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CHAPTER II

A REVIEW OF THE GENERAL PSYCHOMOTOR STATES

       THE emotional state of the patient was one of great depression and even of anxiety; the face looked extremely sad, anxious and distorted with the mental pain caused by the lumps and the three working agencies,―the worms, the spleen, and the soul. The eyes were lustreless, apathetic; the skin was pale; the whole body was badly nourished and partly bent, as if by the weight of great suffering.

        The feelings of the patient were greatly affected; he lost all interest in everything and in everybody. His whole mental and emotional horizon became narrowed down to the one painful state, to his highly systematized delusion. He became unfit to do his work and he had to give it up altogether. The parasitic delusional system became the predominating one and sapped all the vigor of his affective emotional life.

        The flow of association of ideas became greatly retarded and even seemingly arrested; only what related to the principal delusional system and what therefore met with no obstruction, only that alone flowed with great ease and facility. The patient could hardly be induced to talk of anything else but his woe; when he was induced to enter into conversation his speech was slow and in monosyllables; the thoughts formed slowly, with great difficulty, and tended to revert to the principal delusional system. Only when the conversation directly concerned the dominating delusion, only then did the current of speech and the stream of association of ideas flow with ease and without disturbance.

        While the patient's memory was otherwise bad and unreliable the memories for his delusion were excellent and exact to the last trifling details. Outside his main delusional system the reasoning process was sound and but little disturbed. The trouble was that but little mental material remained outside this delusion; most of it having been drawn into the whirlpool of the general delusional state.

        The attention was impaired in relation to all interests and also to stimuli not connected with the one all­absorbing delusional system, but it was quite strong and distinct to whatever directly or indirectly concerned the focal functioning system constituting the delusion. The loss of attention in regard to things not connected with the systematized delusion, no doubt, explains the fact of the relative loss of memory.

        The patient could not fix his attention on anything. When tested with reading, he could not follow the type,―he became mixed up and understood nothing of what he had been reading. Occasionally the depression became so intense that he was absolutely incapable of appreciating external impressions, or as the patient characteristically put it: "I looked out of my eyes and I could not see."

        The patient was also predisposed to become possessed or obsessed by insistent ideas from which he could not free himself. Thus, one of his friends suggested to him that he seek advice of Dr. N. This suggestion became a fixed idea with him,―he must see Dr. N. come what may. He had no rest and gave others no rest; he implored over and over again: "Will Dr. P. go to see Dr. N.; it is in my head and I must see him: it is always in my mind and it bothers me." It was only by means of hypnotic suggestion that we could rid. the patient of this insistent and troublesome idea.

        In regard to the general motor reactions, no gross motor disturbances were present; the reflexes remained normal, but the voluntary motor reactions were rather retarded; the patient reacted slowly to external stimulations, walked at a slow pace, as if absorbed in one intense, painful grief. The whole motor attitude was decidedly one of dejection. As in the case of memory and attention the motor reaction became quickened with regard to impressions relating to the delusion.

        No sensory disturbances were present. Sensory stimulations were correctly perceived and estimated; no anæsthesia, no paræsthesia, no hyperæsthesia could anywhere be detected. Vision remained unaffected; there was no limitation of the field of vision'; and there was no reversion in the series of perceived colors. Taste, smell, touch, pressure, the thermic sense, and kinæsthetic sensibility were all in good condition and showed not even transient anomalies.

        The patient suffered from bad dreams, which also left him in a state of great depression after awaking. The dreams usually referred to the delusion and seemed to have intensified it. Thus, during the early part of his illness he used often to dream of his spleen, and has seen it in his sleep jumping around and removing lumps. One night he became so terrified that he screamed in his sleep, from which he awoke in great terror; he was afraid that his spleen would jump out through his chest. Sometimes his dreams were determined not by the definite delusion, but by the general indefinite melancholic tone. Once he dreamt, for instance, of two men attempting to murder him and that he called firemen to his aid.

        No hallucinations were present, and the illusions observed were those pertaining to the dominating delusion, which was of a purely central character; no peripheral pathological disturbances could in any way justify it, except possibly the condition of costiveness, which was, no doubt, of a secondary character in the formation of the delusional system.

        Although the affective states were of intense depression, still there was no tendency to self-destruction. The whole attitude was one of quiet, passive dejection, without any violent outbursts, without any uncontrollable impulses.

        It goes, of course, without saying that orientation in space, time, and in regard to social relations was fully and clearly present and as far as it could be ascertained was never gone. The patient could fully realize his environment, he could come to definite places at the appointed time, and could take good care of himself. The central delusion was entirely limited to his inner life, and seemed not to have affected his relation to the external world; it left intact his sense of appreciation of his environment. As far as examination could disclose neither unconsciousness nor subconscious states have occurred in his former normal healthy condition or in the course of his mental disease.

        The intensity of emotional depression, the retardation of psychomotor processes, and the highly systematized delusion of the agencies conceived in his physical troubles would have made it tolerably certain to a psychiatrist that the case closely approximated to typical hypochondriacal melancholia, and some even would have added that the case had a strong tendency to what may be termed" secondary paranoia."

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