J.E.D. ESQUIROL

Jean Etienne Dominique Esquirol (1782-1840) wrote the first detailed medical description of a compulsive symptom. The patient, a 34-year-old woman, consulted him for help in overcoming her compulsive rituals, which Esquirol called "reasoning monomania."

Mad'lle F., thirty-four years of age, is tall, with auburn hair, blue eyes, flushed face, and sanguine temperament. She is of a gay disposition, and mild temper. Trained to a knowledge of commercial affairs from her earliest youth, she feared to wrong others.... She was accustomed to make frequent visits at the house of her aunt, without her hat, and with an apron which she was accustomed habitually to wear. One day, at the age of eighteen, without any known cause, on going out of the house of her aunt, she is seized with disquietude, lest she might unintentionally carry away in her apron, something belonging to her relative. From henceforth, she makes her visits, without wearing her apron... At a later period, she spends much time in completing the accounts and invoices, being apprehensive of committing some error; of substituting one figure for another; and consequently, of wronging purchasers....

After many periods of remission and exasperation,...after having tested the inadequacy of the advice of her relatives and friends, as well as her own reason, she decides to come to Paris.... [S]he comes to commit herself to my care at the close of the year 1834....

In order to render [her condition] more perfectly understood, I will trace her manner of life for a day. She rises at six o'clock, as well summer as winter. Her toilet usually occupies her an hour and a half, and more than three hours during the period of excitement [i.e., during a flare-up of her symptoms]. Before leaving her bed, she rubs her feet for ten minutes, in order to remove whatever may have insinuated itself between the toes or beneath the nails. She afterwards turns and re-turns her slippers, shakes them, and hands them to her chamber-maid, in order that she, after having carefully examined them, may assure her that they conceal nothing of value. The comb is passed through the hair a great number of times, with the same intent. Every article of her apparel is examined successively, a great number of times, inspected in every way, in all the folds and wrinkles, and rigorously shaken. After all these precautions, the hands are powerfully shaken in turn, and the fingers of either hand rubbed by each other. This rubbing of the fingers is performed with extreme rapidity, and repeated until the number of rubbings, which is enumerated in a loud voice, is sufficient to convince her, that nothing remains upon them. The close attention and uneasiness of the patient are such, during this minute exploration, that she perspires, and is almost exhausted by the fatigue of it. If, from any cause, these precautions are not taken, she is restless during the whole day....

She is never irrational; is aware of her condition; perceives the ridiculous nature of her apprehensions, and the absurdity of her precautions; and laughs at and makes sport of them. She also laments, and sometimes weeps in view of them.... She is fond of amusement; goes to the theatre, and visits public walks. She makes parties for the country, and every evening joins a social assemblage. Her conversation is gay, humorous, and sometimes mischievous.... She attends to all the medical suggestions that are proposed to her, but is opposed to baths, in consequence of the precautions which she is obliged to take, before entering the water, and on coming out of it. It would be impossible at any time, to discover the least disorder in the sensations, reasoning faculties or affections, of this interesting patient.

Reasoning monomania [Esquirol's term for Mad'lle F.'s illness] ought to be studied with the more care, since those suffering from it know how to deceive the most skillful physicians; because they dissemble their condition, in presence of those who notice them, and have authority to decide on the question of their isolation; [and] because they impose upon judicial magistrates in their legal capacity, when about to administer upon their persons or fortune[.]