Obsessions, General and Sexual—Causes of Obsessions, Predisposing and Exciting—Mental and Physical Conditions in Cases of Obsession — Serious Nature of Obsessions — Prognosis — Prevention
IN 1894, the late Dr. Hack Tuke published in Brain an interesting article on “Obsessions,” which he termed “Imperative Ideas.” He drew attention to the fact that the mental phenomena associated with obsessions had been much more clearly recognised by French and German than by English writers, and asked Dr. Savage, Dr. Hughlings Jackson and myself to discuss his paper, and the subject generally, in the same journal. This we did, and I cited nine cases of obsession I had treated by suggestion: of these, eight had recovered and one bad improved.
I now propose to give a short history of these and some other cases of obsession. Then, with tbis material before us, I wish to draw attention to some points of interest in reference to the stblject of obsessions as a whole. My reasons for doing so are these: (1) The mental conditions involved in cases of obsession have often been misunderstood. (2) Obsessions are of very frequent occurrence; at least half of the patients under my care at the present time suffer from them. (3) As far as my experience goes, treatment by suggestion yields better results in cases of obsession than in any other class of functional nervous disorder. (4) I know of no single instance in which obsessions have been relieved or cured by the use of drugs.
Apart from the obsessions, the patients are often in good mental and physical health. In many instances they suffer from a single symptom, such as a dread of enclosed places, They recognise the absurdity of their fears, and, despite them, often do good mental or physical work. It is as absurd to suppose that a drug can influence such a condition as to imagine, in Sydney Smith’s words, that stroking the dome of St. Paul’s will soothe the Dean and Chapter. What medicine would one prescribe, for example, for an otherwise perfectly healthy and unusually brave man who had an abnormal fear of cats?
No. 31. Mr. --, aged 24, consulted me in May, 1889. Some months previously he had had a number of diseased glands removed ‘from his face and neck, and went up the Mediterranean to recruit. While crossing a plank, he fell and injured his perineum; an abscess formed, which burst externally and into the urethra. When I saw him there was a large, unhealthy wound, through .which the urine escaped. I instructed him to pass a soft catheter regularly, and the wound became more healthy. One day he was impelled to empty his bladder before he could pass the instrument, and water again escaped from the wound. This happened more and more frequently; at last the idea of passing water caused him at once to empty his bladder, no matter where he was at the time. This appeared to be entirely independent of the physical condition of the, bladder, which did not contract because it was full or uncomfortable, but because the idea of urination presented itself to the patient’s mind, and was at once translated into its physical equivalent. He began to sleep badly and awoke frequently during -the night; the instant he did so he thought of his bladder, and was immediately compelled to empty it. Despite all treatment, this continued for several months, and his condition became a grave one.
I had not previously employed “suggestion,” but the mental element in this case seemed so marked that I determined, as other treatment had failed, to try what it would do. After explaining to my patient, an educated man, that I had no practical and only a slight theoretical knowledge of the subject, I proceeded to hypnotise him by Braid’s method. In a few minutes his eyeballs rolled upwards and. inwards and he became lethargic. I repeated this the two following days, and then suggested that he would cease to think about his bladder, should always be able to pass his catheter, retain his urine eight hours and sleep well. These suggestions were immediately fulfilled from that day there was no return of his troublesome symptoms, and the wound healed without operation in about twelve months.
No. 32. Mrs. --. I received the following notes of this case from Dr. ---, the patient’s husband: “My wife had suffered from myxcedema, following influenza; she had low temperature, loss of hair, dullness of intellect, slowness of movement, general irregular swelling of the body, facial disfigurement, alteration of voice and muscular pains. I put her on thyroid extract in January, 1893, and although the symptoms peculiar to myxcedema disappeared, she became utterly sleepless, her limbs trembled after the least exertion, and her digestion remained very bad.
“I brought her to you on March 1st, 1894, to see whether suggestion would procure sleep. At the second attempt you succeeded in inducing very slight hypnosis, and she began to sleep fairly well. For more than a year she had: never had more than three hours’ broken sleep, and often far less. She soon began to sleep thoroughly well and uninterruptedly, and her indigestion, for which I had found drugs and careful dieting ineffective, disappeared after a few suggestions. Her legs became stronger, and her energies restored very nmch to what they were twenty years ago, when she was renowned amongst her acquaintances for her untiring energy. But the fact that strikes me most forcibly is this. Several members of her family are sleep-walkers. She used to walk in her sleep in childhood, and once or twice as a young woman, and the habit is transmitted to my youngest girl. When her first baby was born— sixteen years ago—the thought crossed my wife’s mind,!What if I walk in my sleep and do an injury to my child?’ I endeavoured to persuade her that she had grown out of the habit, but the attempt was wholly fruitless. The idea grew until it assumed the character of an idie fixe, and she always tied herself to the bedpost at night. All attempts to break herself of this habit were failures, and if she went to bed without fastening herself she was never able to go to sleep until she did so.
When we moved into our present house; three and a half years ago, she became alarmed at the great height of the bedroom windows from the ground and their lowness from the floor. She began to suggest that possibly she might undo her own knots during sleep and get out of the window. I pointed out how unlikely it was that she should walk in her sleep, after a score of years’ complete immunity. She granted my reasoning was just, but it did not dispel her fear, and she insisted upon my tying her to the bedpost each night in a very effective manner. In May, 1894, I told you of this persistent dread and asked you to suggest that she should neither walk in her sleep nor be apprehensive of doing so. During that treatment you repeated this .suggestion two or three times, but have not done so since. The effect was magical. She has never asked me to tie her to her bed from that day, and tells me that she has never once thought about it. To me it is all the more remarkable as the hypnosis in her case is so slight and appears to pass into natural sleep if you leave her for a few seconds. She is of a nervous, excitable temperament, but by no means greedy of the marvellous or ready to accord belief to any new doctrine. She had a healthy scepticism of the possibility of anyone hypnotising her, but was anxious for the attempt to be made as she suffered so acutely.”
At the end of a year I saw this patient, when she told me she remained entirely free from her morbid fears; and her recovery is confirmed by much later reports.
No. 33. Mr. ---, aged 32. In 18 79, when attending a school of art, commenced to have doubts about his work and lost interest in it. He was making a collection of tracings and copies of various artistic things, but felt this was useless, as it might be destroyed by fire. Later, he commenced to be influenced by every superstition he beard of; he dreaded passing under a ladder, spilling salt, doing anything on, a Friday, or going back to the house for anything he had forgotten. He particularly disliked doing anything in the month of May. Unless he saw the new moon in a particular way, over the right shoulder, he felt something dreadful would happen. He could not sleep unless his pillow was placed in a certain position, and he was always obliged to clean his spectacles in a particular way. He was not naturally superstitious, but yet he was impelled to conform to every superstition he heard of, and gradually these morbid ideas filled his entire mental life and interfered with many of his actions Ultimately, there were so many places he was afraid of going to, and so many things he was afraid of doing, that sometimes he could go nowhere and do nothing. At first he recognised the absurdity of his fears, but in the end they became delusional. He was not afraid that he himself would suffer if he did not conform to his superstitious ideas, but felt that something awful would happen to God Almighty. He was miserable, depressed, and had suicidal ideas. He improved greatly under treatment, but I have not been able to trace his after-history.
No. 34. Mr. --, aged 25, first consulted me March, 1890. Formerly strong and athletic, distinguished football player, bicyclist, etc. Two years previously, after the death of his mother from cancer of the breast, he began to fear that he might contract the same disease. This idea grew stronger and stronger; he became neurasthenic and suffered from insomnia, depression, dyspepsia, etc. Finally, the dread of cancer passed into the firm conviction that his left breast was infected with it. He remained nearly always in one room, and would not go into another without muffling himself up and putting on an overcoat. For some months he complained of difficulty in moving the left arm, and carried it in a sling. I found nothing to justify his fears, but the muscles of the arm were distinctly wasted from disuse. He was easily influenced at the first attempt, and treatment was repeated nearly every day for a fortnight. His morbid ideas disappeared; his general health speedily improved, and a few days after treatment was abandoned I saw him driving a spirited horse. A week afterwards, he told me he felt perfectly well, and was going to train a young horse to jump. Recovery confirmed by later reports.
No. 35. Mr. --, aged 28, first consulted me in April, 1894. His father was very nervous and passionate, and had suffered from chorea. At the age of 14 the patient had many religious doubts and fears, and believed be had committed the unpardonable sin. At 16, while working in a cocoa manufactory, he began to fear that the red lead used in fastening certain hot pipes might get into the tins containing the cocoa, and so poison people. This was the commencement of a folie du doute and claire du toucher, which had never since left him. Instead of going on with his work, he was irresistibly impelled to clean and re-clean the tins. The followhig is taken from a letter of a friend to whom he confided his troubles,:
“On October 1st, 1891, Mr. -told me that he had attempted to commit suicide, as his life was so miserable.” (He bad taken poison.) “He had read of a case of poisoning through eating chocolate, and connected himself with it, though it was five years since he had helped to manufacture any. He now believed he might have been careless with the moulds, and thus have produced a poisoned chocolate, which years afterwards had caused the child’s .death! The grotesque absurdity of the story, as he related it to me, would have made .me laugh, had I not felt how terribly real it was to him. His vivid imagination had pictured every incident of the tragedy: the child buying the chocolate, running home full of happiness, then becoming ill and gradually sickening in awful agony till released by death. The keenness of mind with which he sought to prove the reasonableness of his belief that he bad poisoned the child was extraordinary.
“He wrote: Yesterday I was unscrewing some gas burners in a provision shop and got some white lead on my bands, and I have been thinking that it may have got amongst the food. I found that brooding over this fancy had brought him to the verge of despair, and for weeks his life was a perpetual agony. He worries himself about his work of fixing advertisement-plates to walls, and can never persuade himself that they are securely fastened. He fancies the nails are bad, or the mortar loose, and makes himself ill over it. I have pointed out to him that if a plate fell it would almost invariably slide down the wall. This has not prevented him from painting a most elaborate mental picture of the decapitation of an unfortunate youngster who happened to be playing marbles, with his head against the wall.
“To enumerate all his troubles would take a small volume. I have a great pile of letters before me now, and I suppose they constitute one of the most extraordinary analytical autobiographies it would be possible to find. In reading them I cannot help marvelling at the strange, unshapely wonder of such an imagination. He makes every incident in his life the foundation stone of a castle of fancies; and of late years each castle has become a prison —a torture chamber in which he has dissected his motives and his actions, until he has ceased to believe in himself at all.”
When I first saw the patient the folic du doute and delire du toucher were constant, and most varied in their manifestations. If he accidentally touched persons in the street, he began to fear that he might have injured them, and exaggerated the touch into a more or less violent push. If the person touched were a Woman, he feared that she might have been pregnant and that he might have injured the child. If he saw a piece of orange-peel on the pavement, he kicked it into the road, but would afterwards began to think that this was a more dangerous place, as anyone slipping on it might strike his head against the kerb-stone; and so he was irresistibly impelled to return and put it in its former position. At one time he used to bind himself to perform certain acts by vowing he would give God his money if he did not do them. Then he was uncertain whether he had vowed or not: owing to this, he gave sums to religious objects which were quite disproportionate to his income. Apart from his peculiar fancies, I found the patient .perfectly rational and intelligent; and, though his claire du toucher hindered him greatly in his work, he generally managed to execute it, but sometimes had to abandon the attempt. I treated him on twenty-four occasions, but apparently without success, and he was then compelled to leave town. He returned on April 2nd, 1895, for a week’s further treatment: he told me that since his former visit his morbid ideas had been neither so frequent nor so marked, and were accompanied by less mental agony. From that date, though the treatment was not again repeated, he rapidly recovered, and six months later stated that he could laugh at his former fears. He has, however, recently relapsed (1909), and writes to say that he is worrying about people whom he believes he might have accidentally killed twenty years ago.
No. 36. Mr. --, aged 33, tall, strong and athletic, was sent to me on March 7th, 1894, byDr. Boating, of Hampstead. The patient stated that he had always been of a sensitive disposition and inclined to be morbidly self conscious. Of late years this had greatly developed and made his life a burden to him. He had the fixed idea that he was constantly making mistakes, and that all those with whom he was brought in contact considered him a. fool. During a business interview he was embarrassed, spoke with difficulty, and felt that everyone must notice this. He had the same feelings in reference to society, and shunned it as much as possible. He also had morbid, and entirely unfounded, fears about his physical condition. He was treated ten times to July llth, 1894, and his morbid ideas entirely disappeared. A year later he told me there had not been the slightest relapse, and that he was now fond of society and at his ease in it.
No. 37. Mr. --, aged 35, was sent to me by Dr. de Watteville, on October 29tb, 1894. His illness had begun six months previously, after the sudden death of his brother-in-law. From that time he slept badly, dreamt of his own death, and was haunted by constant fears about himself and his family. He developed agoraphobia, was unable to cross a road without assistance; dreaded losing his employment, and feared he would find his wife and children dead when he returned from work. One day, when sitting’ alone,. he believed he saw two men bring his coffin into the room. He was utterly miserable, and had strong suicidal impulses. He also had frequent attacks of giddiness, and felt he would fall unless he caught hold of something:,on one occasion he lost consciousness. Be was treated five times up to November 12th: his morbid fears had then almost entirely disappeared; but, as he still had attacks of giddiness, I saw him occasionally up to April, .1895. His recovery was confirmed by later reports. Case shown at Bethlem Hospital and elsewhere.
No. 3. Mr. --, aged 21, was sent to me on November 5th, 1907. He had been nervous from early childhood and could never sleep in a room without a light. He was unable to travel by himself, and could not go into a restaurant, or other public place, where there were strangers. If he were alone in a room, and had the slightest difficulty in opening the door, he suffered agonising terror and felt that he was dying. He dreaded paralysis and other diseases, mid also had religious fears and delusions of persecution; for several years he believed that he was followed by a man in a slouch hat. He recovered after a somewhat prolonged treatment and began work. On November 7th, 1908, the patient’s mother reported that her son was in. good health and interested in the business into which they had put him.
No. 39. Mrs. ---, aged 32, was sent to me by Dr. Forbes Ross, on November 5th, 1907. She had always been nervous, and for four years had suffered from agoraphobia. Then, after a cab accident, she was quite unable to travel in any vehicle. When she came to see me, she was obliged to walk from her home at Hampstead, and back again. After being treated thirty-four times she recovered, and afterwards reported that she had spent a holiday in Paris and had. had no nervousness in travelling. She had also been in a motor accident, but this had not upset her. A later report (March, 1909) confirms her recovery.
No. 40. Mr. —, aged 35, schoolmaster, was sent to me by Dr. Hyslop, of Bethlem Hospital, on January 2nd, 1908. Family history and general health good. At the age of four he commenced to have irresistible obsessional impulses to throw things off the table; these lasted four years. Then, for some weeks he bad an. impulse to push something into his own eye, but this he was able to resist. Since then he had never been free from obsessions, which of late years had been mainly a dread of heights, with an impulse to throw himself from heights, out of windows, and in front of express trains. His classroom was on the third storey, and the obsession about throwing himself from the window became so strong that he had to give up work. He recovered after sixteen treatments. On February 22nd, 1909, Mr. - wrote as follows: “All things have gone well with me since our last meeting, and there has been no return of the trouble I was suffering from before I went to you. I sent up four boys for scholarships in December to Oxford and Cambridge; they were all successful. This you may consider a fairly good criterion that I am in every way fit to do my work. In January, I travelled in an express train (from Ipswich to London) alone—I mean alone in the compartment; it was the first time I had done so for about eight years.”
No: 41. Mr —, aged 56, solicitor, consulted me on January 24th 1906. About twenty years previously he began to. have obsessions in reference to his work; these especially took the form that he had not paid sufficient death dues, etc., on behalf of his clients. His fears were constant, and, as soon as he ceased to worry over one case, another presented itself. The strain and mental agony were so great that he was compelled to give up his profession and lead a very secluded life. Recovered: he now travels, takes an interest in public affairs, etc.
No. 42. Mr. —, aged 40, was sent to me by Dr Ross Sinclair, on October 3rd, 1907. He bad suffered from various obsessions from the age of 23, and for several years these had, been mainly associated with his work. He was secretary to a public company and dreaded having to read any report; his voice and limbs trembled, and he felt unable to control himself. These fears increased and spread to everything connected with business. Before any important interview he had to take several glasses of spirits; and from time to time he deliberately got drunk. His mental agony from bis obsessions was so great that he felt he would become insane unless he could in some way alter his emotional condition. He found that his feelings of remorse after getting drunk took the place of his obsessional ideas for some little time, and thus gave him temporary relief. He recovered after eighteen treatments, and in March, 1909, wrote to say there had been no relapse, and that he enjoyed his work.
No. 43. Mr. --, aged 65, first consulted me in May, 1908. At the age of 25 he began to suffer from obsessions, particularly the dread of becoming insane. After some years this passed off; but, later, he felt constantly impelled to repeat mentally a series of proper names. This irritated and worried him, and produced a feeling of great strain. His obsessional ideas were worse at night, and in consequence he suffered much from insomnia. Recovered after a short treatment.
No. 44. Mrs. --- had long suffered from obsessional fears of two kinds. First, she had an intense dread of travelling and could never do so alone. Secondly, if her husband, who is a medical man, did not return home at the hour he had fixed, she always believed that an accident had happened to him. On such occasions she would go, and take others with her, to search for his dead body. Mrs. only received two treatments, and on July 8th, 1901, Dr. sent me the following description of the result:—”First, as .to her fear of travelling. On her journey north, the week after seeing you, she did not show any signs of fear as she used to do. I noticed that she looked out of the window and remarked on things we passed, instead of, as formerly, becoming giddy and sick from seeing .the trees and hedges fly past. For the first time in six years she took a good lunch, and tea three hours later; and did not every half-hour ask for cups of tea or stimulants, and leave them untasted when they were procured. On arrival, she was not worn out and obliged to go to bed at once, but interested herself in the house and her Unpacking till bed-time.
“As regards her exaggerated fears for my safety when away from home. I have been away all day very frequently since our return, and sometimes have not reached home till about 7 p.m., but without her having been upset by my non-appearance at the usual time. On one occasion, when I was delayed for three hours by a cycle tyre bursting and did not reach home till long after I had expected, she was not unreasonably anxious.
“I have no doubt whatever that the improvement is due to the suggestions she received, even though only on one occasion.” (She was only supposed to have been influenced the second time she saw me.) “On this journey she did not appear to require to control herself, her imagination not raising up the usual terrors of an accident.”
,On March 3rd, 1909, Dr. -wrote to say that his wife had never had a return of her unreasonable fears. He also said she was going to travel alone from Scotland to London, and so I could judge that she considered herself cured.
No. 45. Mr. --, aged 31, was sent to me by Dr. Risien Russell, on May 21st, 1908. The patient had suffered from various nervous fears from early childhood, and from the age of 16 these had become progressively worse. He was physically strong and his general health was satisfactory, with the exception that he sometimes slept badly and had night terrors. He suffered from claustrophobia, but his worst fears were suicidal and homicidal. He was afraid to shave, lest he might have an impulse to cut his throat. He dreaded going to a railway station, as he felt that he might be impelled to throw himself in front of a train. He constantly dreaded sudden illness, especially insanity or apoplexy, but his worst fear was tha he might be impelled to murder his wife and children. Result: recovery; confirmed by a later report, March, 1909.
According to Dr. George Savage, “certain associations produce ideas of sexual impotence, or some slight things during the earlier days of marriage set up imperative ideas which produce loathing, hatred, and impotence, which will be dangerous to one or both of the parties. A young married man finds from certain facts (?) that his wife is not a virgin, or he may simply get the notion into his head, and it may dominate his life.” A considerable number of cases of this kind have come under my observation, and most of them have recovered under suggestive treatment. I will give a few examples.
No. 46, Mr. --, aged 35, healthy and athletic, was sent to, me by Dr. Raymond Crawford. He was continent before marriage and had never masturbated. He had been married over three years and was completely impotent, and this had not been improved by medical and surgical treatment. On November 28th, 1898, treatment by suggestion was begun, and continued for a mouth. From Christmas, 1898, his sexual life became that of a vigorous, normal man. There has been no relapse, and he is now the father of three children. In this case the origin of the obsessional idea could be traced to certain emotional troubles that had occurred during his engagement.
No. 47. Mr. --, aged 38, was sent to me on March 26th, 1908, by Dr. Attlee and Mr. Pardoe. He had been continent before marriage, but had masturbated a little in boyhood. He was exceedingly sbyin reference to all sexual matters. He had nocturnal emissions and distinct sexual desire, but erection always ceased when he tried to approach his wife. She bad a contracted vagina and an almost imperforate hymen: this was corrected by operation after marriage. The patient had been married six years, and during this time the impotence had been complete, despite varied medical and surgical treatment. He was treated by suggestion on seventeen occasions, and his sexual life became normal. In February, 1909, he wrote to confirm his recovery and to inform me that his wife was pregnant.
No. 48. In another case, also sent to me by Mr. Pardoe, the patient had no difficulty in having intercourse, but in no single instance had this been followed by emission. After a short course of treatment by suggestion his sexual life became entirely normal. Recovery confirmed by recent report (April, 1909).
No.49. In one still more striking case, sent to me by Sir Victor Horsley, on October 31st, 1903, the patient’s sexual instincts from earliest boyhood had been homo-sexual, and unnatural sexual connection had frequently taken place. He married, hoping this might cure him, but when I saw him there bad been complete impotence, as far as his wife, or any other woman, was concerned, during the whole of his life. The attraction of his own sex was a veritable obsession, while the idea of touching his wife was as repugnant to him as the idea of touching his sister. After prolonged treatment by suggestion, he entirely got rid of his morbid ideas, and his sexual relations with his wife became normal.
It is almost impossible to exaggerate the amount of family unhappiness dependent upon sexual disabilities. In some of my cases, the wives had strong sexual feelings, while in others there was an intense desire to have children. These wives were not only unhappy themselves, but made the lives of their husbands a burden to them by their reproaches.
No. 50. In another case, a girl of about 25, the sexual obsession was of an extraordinary character. Before puberty, sexual feeling was excited by reading or hearing the words “myopia “and “myopic,” and also by seeing anyone wearing myopic spectacles. The patient used to look these words up in the dictionary and gloat over them. At a later date, she quite accidentally learnt to masturbate, and when doing so always thought of myopia or myopic spectacles. She was very innocent and prudish, and quite ignorant about sexual matters. One day she told an older woman all about this, and was horrified and brokenhearted when it was explained to her that she was committing a “dreadful and degrading sin.” Recovered. Later reports satisfactory.
The cases I have cited are simply illustrative ones; I could quote many more from my own practice, and supplement,them by numerous other successful cases reported by Continental medical men.
Predisposing causes of obsession.—Savage says:
“In my experience, the most common predisposing cause has been hereditary predisposition of some kind, some neurosis, or a tendency to nervous degeneration present in the patient’s parents, or other marked evidence of nervous instability in brothers, sisters or cousins. There is a close relationship between obsessions and the neurasthenic condition. Neurasthenia depends to a great extent, if not entirely, on faulty association of ideas.”
Obsessions are usually regarded as being typical of degeneracy, and especially of hereditary degeneracy Many of my cases seem to confirm this view; the patients were weak mentally and physically, and had unsatisfactory hereditary antecedents. In several instances their obsessions had become insane delusions; many of them had suicidal impulses; some had attempted suicide and others had hallucinations. On the other hand, some were physically far above the average, while many of them possessed mental endowments of high quality, and their morbid ideas did not prevent them from doing good work. Most of them, it is true, were of an emotional, nervous type; but is the sensitive, mobile brain necessarily degenerate? May not the accidents to which it is liable be the result of its higher and more complex development? The thoroughbred is more emotional and nervous than the cart-horse, but is this necessarily an evidence of hereditary degeneracy? The term “degenerate “is applied so freely and widely by some modern authors, that one cannot-help concluding that they rank as such all who do not conform to some primitive savage type, possessing an imperfectly developed nervous system. Further, in some of my cases the family history was good, and the patients, before the obsessions appeared, were free from all symptoms of nervous, trouble or degeneracy. In one instance, the disease followed an attack of typhoid fever; in others, influenza appeared to be the starting point.
Savage says “I believe that these imperative ideas are very common, and that nearly everyone has some. . . I have the feeling, which is -common, I believe, about walking along a pavement: I have an inclination to avoid the cracks; and at the same time I have a tendency, I own not irresistible, to touch the iron railings with my stick when I walk along a street.”
Exciting causes of obsession.—With regard to these, Savage states that he has “met with many cases in which the obsession appeared to be a steady morbid growth, which had been for longunder the surface, but through some accidental cause had been brought into sight. Shock may produce the effect—it may be one sudden shock, a repetition of shocks, or the result of a prolonged state of expectancy and anxiety: thus a person who has been in imminent danger for some time may become so affected that the dread is never overcome. Allied to this, I have met with instances when a dream of unusually vivid character has been enough to start the whole train of morbid ideas, and has fixed them for ever. There is no doubt that the nervous system, under certain conditions, is more prone to take these impressions and to retain them. It seems as if, through certain surrounding conditions, an impression is made which reaches the more fixed and automatic part of the nervous system, so that it is no longer merely stored for use when it is called for by consciousness, but it appears as a reflex act, one impression bringing it up without any will being exercised.”
In nearly all my cases the condition appears to have had an emotional origin. The shock of the sudden death of a relative caused one patient to fear his wife would die; another dreaded travelling after being frightened by a drunken man in a railway carriage, etc. Although in some instances the emotional element changed its character, and in all became greatly intensified, it was certainly generally associated with the commencement of the original trouble.
Marcé says: “In a predisposed person, feeble of character, endowed with keen sensibility, a word, an emotion, a fear, a desire, leaves one day a profound impression. The thought, born in this mariner, presents itself to the mind in an importunate way, takes possession of it, does not leave it, dominates all its conceptions during this time the individual maybe conscious of all the absurdity, unreasonableness, or criminality of this idea; the acts themselves soon conform to these unhappy preoccupations, and become absurd or extravagant.”
The niental and physical conditions existing in cases of obsession.—I do not propose to discuss the obsessions of the neurasthenics, although, as far as my experience goes, in every case of neurasthenia there are obsessional ideas. These are generally varied, but all have reference to the patient’s supposed mental or physical condition. In extreme cases these ideas are ever present, always talked about, and control or excite the patient’s actions.
The transition from the normal state to obsessional ideas is frequently almost insensible, in some instances the repetition of insignificant sayings being, according to Ribot, the slightest form, and preoccupation, such as anxiety about an examination, a degree higher. Further, Ribot says: “In every sound human being there is always a dominant idea which regulates his conduct; such as pleasure, money, ambition, or the soul’s salvation.”
One class of obsessions, then, may be said to have their origin in the affections, and to be simply an exaggeration of natural anxieties. For example, a father, devoted to his children and anxious about their well-being, gradually became abnormally fearful until, ultimately, he suffered agonies when they were out of his sight. If he gave them permission to go for a walk, as soon as they passed out of the avenue in front of his house, and Le was unable to see them, he was obliged to send for them to be brought back. In many other instances the not unnatural anxieties associated with business became so acute that the patients were forced to retire.
Much doubt has existed, and still exists, in reference to the mental conditions involved in obsessions. Dr. Ladame, for example, in referring to the different opinions expressed about folie du doute and dêire du toueiter by Magnan, Krafft-Ebing, Marcus, Jules Falret, Morel, Lasegue, Ball, Meynert, Kraepelin and Scholz, says that folie du doute is regarded by contemporary writers as a symptom of the most varied mental affections, sometimes as a psychopathic episode of hereditary degeneracy, at others as a special form of psychosis, or as a simple elementary trouble dependent un the general pathology of mental alienation. Thus doubt, he says, not only exists amongst the patients: it has passed into science, and could equally be called folie du doute on account of its uncertain place in the chart of mental maladies, as because of the strange symptoms which characterise it.
A clear distinction between these diseases and recognised forms of insanity was made for the first time by Morel, in 1886. He stated that patients suEring from obsessions did not interpret them after ‘the manner of the insane that they had neither hallucinations .nor illusions, nor underwent those transformations which change the personality of the insane and make them radically different from what they were before. According to Westphal, also, the obsession never becomes a true idée fixe delirante, but always remains a stranger to the patient’s ego, while the insane conform logically to the deductions of their fixed ideas. This scientific distinction between insane ideas and obsessions has long been recognised by the Church, which has always made a difference between possession and obsessions, saying, for example: “This man is not possessed, he is only suffering from obsessions.”
,Ribot applies the term “fixed ideas” to the states we are discussing, and regards them as “chronic hypertrophy of the attention”; the fixed ideas being the absolute, attention the temporary, predominance of an intellectual state or group of states. The fixed idea is attention at its highest degree, and marks the extreme limit of its power of inhibition. There exists, he says, both in normal attention and in fixed ideas, predominance and intensity ‘of a state of consciousness; this is more marked, however, in the fixed idea, which is permanent and disposes of the important psychical factor—time: In attention this exceptional state does not exist long; consciousness reverts ‘spontaneously to its normal condition, which is a struggle for existence between heterogeneous states. The fixed idea prevents all diffusion: there is no antagonistic state that is able to overthrow it; effort is impossible or vain: hence the agony of the patient who is conscious of his own impotency.
The following is Ribot’s conception of the probable physiological condition associated with fixed ideas: “In its normal state the entire brain works; diffused activity is the rule. Discharges take place from one group of cells to another, which is the objective equivalent of the perpetual alterations of consciousness. In the morbid state only a fewnervous elements are active, or, at least, their state of tension is not transmitted to other groups. Whatever may be their position in the cerebral organ, they are, as a matter of fact, isolated; all disposable energy has been accumulated in them, and they do not communicate it to other groups; hence their supreme dominance and exaggerated activity. There is a lack of physiological equilibrium, due probably to the state of nutrition of the cerebral centres.”
Ribot refers to Westphal’s recognition of the difference between fixed ideas and insanity, and his statement that “the fixed idea is a formal alteration of the process of ideation, but not of its content.” The “formal” perturbation consists, says Ribot, in the, inexorable necessity that compels the association always to follow the same path. “There is alteration, not in the nature or the quality of the idea, which is normal, but in its quantity, intensity and degree.” Thus, it is perfectly rational to reflect upon the usefulness of bank notes, or the origin of things; and this state differs, widely from that of the beggarwho thinks himself a millionaire, or the man who believes himself to be a woman.
According to Pitres and Regis, it is the emotion which is the essential condition in obsessions; the constant and indispensable one. If you take an obsession, no matter of what kind, and suppress the fear or anxiety which is associated with it, the obsession no longer exists. On the other hand, if you abstract from the obsession its axed idea or impulsive tendency, and only leave fear or anxiety, you -still have the essential part of the mental disturbance left. For example, you can have a state of generalised fear and anxiety, or even a fear of having a fear. Thus, these patients have no fixed idea, no specialised obsession, but yet have a constantly recurring dread of something they cannot define. Further, there are many cases of obsession in which the obsession is multiplex, or, having commenced with one special obsession, passes into a totally distinct one, or several different ones may be present at the same time. The intellectual phenomenon, the sentiment or idea, varies, but the emotional phenomenon, the anxiety or fear, is always present.
The following is the description given by these authors of the origin of acase of obsession:— A sensitive young man blushed, for example, under circumstances more than usually painful, and this produced a moral shock. From that date, under certain definite conditions, particularly in the same circumstances and before the same people, the same phenomenon of involuntary blushing was produced, more and more painfully in proportion asits appearance was feared. Up to that date it was only a systematised fear, with purely intermittent manifestations, but little by little the dread of this infirmity took possession of the mind of the patient, and dominated it so thoroughly that the memory alone of an attack of blushing made him blush. From that time he always thought about blushing; a “fixed idea “was grafted upon the original emotional phenomenon, and the fear became a true obsession. Thus, an obsession is often a morbid fear which has lost its character of simple emotional trouble in order to take, through the course of its natural evolution, the characteristics of a trouble at the same time emotional and intellectual.
Amongst my own cases, the most noticeable fact has been the mental agony of the patients. Fear has been the predominant element. Generally, they dread that something is going to happen to them, such as sudden illness, death or suicide, or they fear that they have actually injured others or mayyield to an impulse to do so in one way or another.
When the obsessions have been more purely intellectual— as in the case of a woman who worried about the Creation, and put all sorts of questions to herself and sought in vain for their answers—these fears have been neither so acute nor so specialised; but still, in all the cases I have observed, they existed to some extent and arose from, though they were not directly connected with, the obsession. For example, a patient suffering from insoluble self-questionings, such as the origin of things, etc., is not in the same frame of mind regarding this as the patient who dreads cancer, suicide, or an impulse to injure others. On the other hand, she may develop a more or less intense fear that these questionings may injure her own brain. Again, the impulse to touch certain objects, to do certain things, or to conform to certain superstitions, is generally associated with fears, either as regards the patient himself or others. Thus, in the case of the man who was influenced by all superstitions, he felt, if he did not conform to them, that something dreadful would happen to the Almighty.
It is true, as Morel says, that, -in typical cases of obsession, the patients fully recognise the absurdity and .unreasonableness of their ideas, and constantly fight against them. On the other hand, obsessions have undoubtedly tendency to become insane delusions. Thus, in one case, the dread of acquiring cancer passed into the fixed belief that it existed. In other instances, fears of having injured others became delusions that such injury had been done. In another case, where the patient had many abnormal conscientious scruples, and fears of committing various sins, these ultimately passed into insane delusions. She believed, for example, that her umbrella was not her own, that she had taken it from someone else, that she had stolen the money in her Purse, etc.
As far as my experience goes, none of the patients who dreaded yielding to their impulsions to injure others ever gave way to them, and I have observed the same thing in reference to–their fears of committing suicide in some particular way, such as throwing themselves before train jumping from a height, etc. On the other band, I have known of cases where the dread of being forced to commit suicide in one way has indirectly led to the patients doing so in quite a different manner, i.e. the agony of striving to resist their fixed ideas has caused them to take their lives in order to escape from the obsession: Further, one of my patients attempted suicide because his life had become absolutely miserable through his delusions that he had caused the death of others by poisoning them.
According to Dr. Gélineau, a crowd of sentiments of repugnance, etc., which the laity group as aversions, closely resemble the conditions we are discussing. Henry the Third, for example, who showed his bravery at the siege of La Rochelle and elsewhere, could not bear the sight of a cat; the Duke of Epernon fainted at the sight of a young donkey; Ladislas, King of Poland, got frightened and ran away when he saw apples; and Favoriti, a modern Italian poet, could not bear the smell of a rose. Montaigne says: “I have seen more people driven to flight by the smell of apples than by arquebuses, others frightened at a mouse, made sick by the sight of cream, or by seeing a feather bed shaken.”
Similar observations have been made by Savage, who says: “The body has its imperative ideas—one person being unable to stand the presence of a cat, while another is affected by a rose. The senses, in fact, give -us valuable aid in considering the question, for not only can we see that these imperative nervous influences may be primary, as with the cat smell, but they may be secondary or associated; thus in the so called photisms, certain persons have associations with a sensation which has no real relationship\ to them. For example, one man hears a vowel sound and sees a certain colour at the same time whereas another, perceiving a certain smell, also sees a certain colour arise with the olfactory sensation. These sense-relations are very imperative, and are so firmly established that most of those who have them cannot go back to any moment when they were free from them.”
The fact that an obsession remains a stranger to the patient’s ego distinguishes it, according to most authorities, from an insane delusion. This rule has its exceptions; One of my patients commenced to be “inhibited” by various superstitions. Many people, by no means insane, actually believe in, and are influenced by, similar superstitions, but it is just their belief in them which prevents the condition being one of obsession, with its inseparable mental distress. This patient, however, did not believe in them, at all events for some years, and keenly resented their interference with his actions. Thus, the non-assimilation of the obsessional idea sometimes constitutes the morbid element, and this apparently depends more upon the individual than upon the idea itself. The patient who made herself miserable about the Creation might, under other times and circumstances, have taken pleasure in discussing the number of angels who could stand upon the point of a needle, or whether, in passing from point to point, they had to traverse the intermediate space. The imperative idea to discover the site of ancient Troy only differed from those we are discussing in the fact that it was assimilated by its possessor; but this did not constitute insanity.
The serious nature of obsessions.—Berillon thinks the professional character of these nervous troubles has not been sufficiently noticed, and he draws an analogy .beLween them and the different functional spasms which show a tendency to professional localisation. In illustration of this be cites the following cases:—A young priest, not timid in the performance of his other religious duties, suffered agony on entering the pulpit; another was affected in the same way when he received a confession. A medical student suffered extreme agony at the sight of a few drops of blood. A chemist made up a prescription which caused the death of a customer: he was able to prove that it was dispensed exactly as ordered by the doctor, but, as his existence became a veritable torture from constant fear of making a mistake, he sold his business. A notary only had morbid fears when he had to give a professional opinion. A hairdresser noticed that his hand trembled one day, and then constantly dreaded that this would reappear when he shaved his best customers
the same anxiety did not exist when he had to shave a poor or unknown customer.
Dr. Frémineau reports the case of an actor who abandoned his profession on account of extreme stage fright; this condition only appeared after a successful career. Dr. Bérillon reports several similar cases.
Riegler has noticed a morbid dread amongst railway mechanics, to which he has given the name of siddrodromophobie; this is-characterised by an extraordinary aversion to their habitual occupation, and the sight of a train or the whistle of an engine is sufficient to revive their disgust.
Grasset mentions that a distinguished Parisian surgeon commences to be anxious the moment a patient leaves hisconsulting-room with a prescription. He anxiously asks himself whether he could have written centigrammes instead of milligrammes, and only recovers his mental calm when his servant, sent to seek the patient, brings back the prescription and he can see that it is all right. Another doctor, Grasset says, is rendered perfectly miserable by the fear of microbes.
Brochin reports the case of a doctor who fears no contagious malady except diphtheria, and who shows proof of veritable heroism every time he sees a diphtheritic patient. A case has recently been reported from abroad in which a medical man, dreading that his fees might be the means of contagion, invented elaborate methods of sterilising them; and I know of similar cases in this country. I could quote numerous cases from my own practice, in addition to those already cited, where the obsessions have interfered with occupation or entirely prevented it. In many instances the patient’s livelihood has entirely depended on whether he could, or could not, be cured of his obsession.
In some instances the patient’s obsessions interfered with the usefulness of others. For example, a lawyer’s wife had the obsession that something dreadful would happen to her if she allowed her husband, to be an instant out of her sight. She followed him everywhere, and even insisted upon going into court with him, and also remained in his office whenever he was there. I also know of several cases where the wives of medical men were almost insanely jealous of pregnant women, and tried everything in their power to prevent their husbands attending confinements; none of them showed abnormal jealousy in any other direction.
Prognosis.—Savage says: “As to the curability of these imperative ideas, I can only say that if they have existed for a year or more, I do not think there is any prospect of cure, If they are acute and associated with any special cause, or if they are associated with a period of life, such as adolescence or the menopause, there is some slight hope. Few of these cases need to be permanent inhabitants of asylums, in fact, many of them need never be there, if their friends can afford to keep them out of asylums.”
This opinion was expressed in 1895, before Savage was acquainted with the results obtained by myself and others from suggestive treatment.
In no class of functional nervous disorder have I had better results than in the treatment of obsessions. In every instance where the malady has been of recent origin the recovery has been rapid and complete. Undoubtedly my percentage of -recoveries would have been higher had it not been that, in most instances, the patients had been suffering for many years before they consulted me. In one case, recently sent to me by Dr. Risien Russell, the patient, aged 84, had been unable to cross a road without assistance for sixty-four years. During this time he had had varied treatment, including “dietary,” under the late Sir Andrew Clark. After talking the matter over with me, he not unnaturally concluded that it was rather late in the day to begin anything fresh.
Prevention.—This is rapidly becoming the age of preventive medicine. The bacilli of different diseases are being discovered, and knowledge is being gained, in reference to their origin and development, which is daily becoming of more value in the prevention of disease. But how are we to prevent the entrance of a morbid idea into some sensitive nature at the psychological moment? This can only be done by gaining a clearer insight into the mental condition of nervous children, and by taking measures to develop their control of emotional states.
Most children have suffered at one time or another from obsessions. This, as a popular writer has justly remarked, appears to arise from an exalted sense of the importance of what they say and do, and also from an exaggerated fear regarding the notice taken of them: by others. He says: “How miserable we make ourselves over some silly remark we have made. Some of us even keep a little store of foolish things we have said or done at various times—and take them out, occasionally and blush over them. As a child, I blushed for years at the thought of having piped out a response in church in the wrong place, before the clergyman’s turn was over. I felt as if the whole congregation turned and gazed at me with scornful ridicule. As I walked away, I was sure that everyone who glanced at me was thinking, ‘There goes the child who made that extraordinary squeak in church.”
Few people seem to recognise the vividness of imagination in childhood and the sensitiveness to criticism. Many parents frankly discuss their children’s failings with others in their children’s presence, and in this way a morbid selfconsciousness is often developed which is never lost in after-life and entails endless misery.
A faulty religious training often plays an important part in the development of these morbid mental states. One of my patients, when a small boy, was taught to examine his conscience when he ought to have been playing marbles, and thus acquired habits of self-analysis and introspection which practically ruined his life. In another case, a sensitive child was constantly frightened by his parents’ talk of Hell, the Day of Judgment, and the approaching End of the World—the latter event, especially, being made forcible and convincing by the quotation of various prophetic utterances, and the production of weird diagrams, which apparently put its early arrival quite out of doubt. This same boy’s parents had dismissed a servant for telling him ghost stories, but were quite incapable of seeing that the terrifying pictures they themselves drew would seriously influence for evil the child’s future.
Another way in which parents frequently injure their children is by undermining the child’s confidence in himself. If they think the child is conceited, they will carefully point out to him how mistaken he is in reference to his supposed powers and this, in more than one instance that has come under my notice, has led to morbid lack of confidence in after-life, and even to the obsessional idea that the patient was making a fool of himself in every business interview, and that this was noticed by everyone he came in contact with.
As a boy, I remember being amused at the story of the old Scotchman who was said to have prayed: “Lord send me a good conceit of myself.” Now, I recognise the true philosophy of it, for those who are sensitive and proud are self-conscious, and suffer in consequence, while the only truly happy ones are the conceited. They are always self-satisfied, always confident, never self-conscious and never troubled by doubts.
As a whole, children at the present day are much better treated than they were in Elliotson’s time, but what he said about them might still be read with profit. According to him, their faults resulted from bad management, and could be corrected by good example and advice. Dullness and crossness were often the result of over-fatigue, and the poor child was punished when he ought really to have been sent to bed. Many little things made us cross, but no allowance was made for the young. Convulsions sometimes arose from overwork, and terror was no uncommon cause of nervous affections, but these maladies were often not recognised, and were punished as obstinate faults. St. Vitus’s dance, local twitchings and the like, were often supposed to be due to bad habits or obstinacy. Momentary tits of epileptic unconsciousness, little paroxysms of insanity, causing absurdity or anger for a few minutes, were frequently mistaken for bad conduct, and the child was punished accordingly.
In recent years, the importance of medical examination of school children has become more and more recognised. This ought not, however, to be from the physical side alone: the mental side is equally important, and slight deviations from the normal, which might easily be corrected at an early age, may show themselves sometimes in afterlife as obsessions, or mental disturbances of a like nature. Fear and self-analysis are the things, above all others, most likely to be mentally hurtful to a child.
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