Part 2 (1/2)

No objective alteration in cutaneous sensibility in any of its forms is discoverable on examination of O., but he bewails a long array of subjective sensations, painful or disagreeable as the case may be.

Certain abdominal pains in particular occupy his thoughts: after being in bed about an hour he begins to suffer from pain in the abdomen and across the kidneys, so acute that he is forced to rise and walk about his room, or sit on one chair after another; at length it moderates enough to allow return to bed and permit of sleep. During these crises there is no sign of any local pathological condition, no distention or tenderness or evacuation of the bowel. They usually last for some days at a time and disappear suddenly, as when, after several nights' and days' uninterrupted suffering, his pains vanished as by an enchanter's wand once he set foot on the boat that was to take him to England.

We have had the opportunity of observing our patient in the throes of one of these attacks, and while we did not doubt the genuineness of his sufferings, we could not but be struck with the dramatic exuberance of his gestures. He wriggled on his chair, unb.u.t.toned his clothes, undid his necktie and his collar, pressed his abdomen with his hands, sobbed and sighed and pretended to swoon away. Such excessive reaction to pain is characteristic of a nervous and badly trained child, not of a man of his years. Notwithstanding his humiliation at these exhibitions of weakness, he can no more control them than he can his ordinary tics; in fact, the tics run riot during the crises of pain.

On several occasions the reflexes have been the object of examination.

The pupillary reactions are normal, as are the tendon reflexes of the upper extremity; but the knee jerks are much diminished, and one day we failed to elicit them at all, though we noted their return a week later.

A careful search for further signs of possible cerebro-spinal mischief proved negative, if we except a slight flexion of the knees when walking and a tendency to a shuffling gait.

Notwithstanding this absence, in O.'s case, of any definite indication of organic disease, we cannot afford, in our examination of patients, to overlook any symptom, however fleeting or trivial it may appear, since it is only by painstaking investigation both on the physical and the mental side that we can ever hope to determine the characters and fathom the nature of the affection, apart from the value of such an investigation as an aid to diagnosis, prognosis, and treatment.

With charming spontaneity and frankness, but critically withal, O. has furnished us with a picture of his mental state. Nothing could be truer or more instructive than this piece of self-observation, even though his obvious pleasure in hearing himself talk is a little weakness of which, to tell the truth, he is the first to accuse himself:

In childhood and at school my accomplishments were ever on the same dead level of mediocrity. I was neither brilliant nor backward; in the drawing-room or in the playground, I was good at everything without excelling in anything; the astonis.h.i.+ng facility with which I learned to sing, play, draw, and paint, was linked with inability to distinguish myself at these pursuits.

Each new study, each new game, attract and captivate me at first, but I soon tire of them, and once a fresh enterprise has taken their place, indifference to them changes to disgust. If I am amused with a thing, I do it well; if bored, I throw it aside. I suppose it is characteristic of people who tic to be fickle and vacillating.

The versatility which is so fundamental an element in O.'s nature has not been prejudicial to his business career. He has managed and still manages important commercial undertakings, demanding initiative and decision, and, so far from sparing himself in any way, he has exhibited a combination of caution and audacity that has stood him in good stead.

It is more especially in the conduct of urgent operations that his alertness is displayed. His comprehensive grasp of the situation enables him to put his machinery at once into action, with eminently satisfactory results, if we judge by his prosperous and a.s.sured position.

His mobile and impulsive temperament is revealed in his every deed, but he shows at the same time a curious disposition to alternate between the pros and the cons of a question. It is the outcome of his extremely a.n.a.lytical and introspective mind.

I find myself seeking a knot in every bulrush. I experience a sensation of pleasure only to tax my ingenuity in discovering some danger or blame therein. If a person produces an agreeable impression on me, I cudgel my brains in the attempt to detect faults in him. I take it into my head to ascertain how anything from which I derive enjoyment might become an aversion instead. The absurdity of these inconsistencies is perfectly patent to me, and my reflections occasion me pain; but the attainment of my ends is accompanied with a feeling of pleasure.

In regard to my tics, what I find most insupportable is the thought that I am making myself ridiculous and that every one is laughing at me. I seem to notice in each person I pa.s.s in the street a curious look of scorn or of pity that is either humiliating or irritating. No doubt my statement is a little exaggerated, but my fellows and I have an overweening self-conceit. We wish to be ignored, and yet we wish to be considered; it is annoying to be the object of sympathy, but we cannot bear to become a laughing-stock.

Accordingly our goal is the dissimulation of our failing by any means feasible; yet nine times out of ten our efforts are abortive simply because we invent a tic to hide a tic, and so add both to the ridicule and the disease.

Alike in speaking and in writing O. betrays an advanced degree of mental instability. His conversation is a tissue of disconnected thoughts and uncompleted sentences; he interrupts himself to diverge at a tangent on a new train of ideas--a method of procedure not without its charm, as it frequently results in picturesque and amusing a.s.sociations. No sooner has he expressed one idea in words than another rises in his mind, a third, a fourth, each of which must be suitably clothed; but as time fails for this purpose, the consequence is a series of obscure ellipses which are often captivating by their very unexpectedness.

His writing presents an a.n.a.logous characteristic.

It has often happened that I have commenced a business letter in the usual formal way, gradually to lose sight of its object in a crowd of superfluous details. Worse still, if the matter in hand be delicate or wearisome, my impatience is not slow to a.s.sert itself by remarks and reproaches so pointed and violent that my only course on reperusal of the letter is to tear it up.

By way of precaution, therefore, O. has adopted the plan of having all his correspondence re-read by his colleague. Strangely enough, to his actual caligraphy no exception can be taken. The firmness of the characters, the accuracy of the punctuation and accentuation, the straightness of the lines, are as good as in any commercial handwriting.

With the aggravation of his head tics writing has become a serious affair. Every conceivable att.i.tude has been essayed in turn, and at present the device he favours is to sit across a chair and rest his chin or his nose on the back; in this fas.h.i.+on he can write all that is required.

O.'s every act is characterised by extreme impatience. In his hurry he comes into collision with surrounding objects or breaks what he is carrying in his hand, not because of defective vision or inco-ordination of movement, but because of his eagerness to be done.

In spite of the fact that I know my recklessness to be absurd, that I see well enough the obstacles around and the danger of an encounter, I am conscious of a paradoxical impulse to do exactly what I should not do. In the same instant of time I want what I do not want. As I pa.s.s through a door I knock against the door-post without fail, for the sole reason that I would avoid it.

There is impatience in his speech. His volubility makes him out short his own phrases or break in upon the conversation of others. If an idea suggests itself, he must give it expression. Perhaps the word wedded to the idea is not at once forthcoming, yet he does not hesitate to invent a neologism, which is often amusing in spite of or because of its oddness, and if it please him he will enter it in his vocabulary and use it in preference to the other.

To wait is foreign to his nature. The least delay at table exasperates him; any order he gives must be executed instanter; no sooner has he set out than he would be at his journey's end. An obstruction or difficulty in the way is the signal for a fresh outburst; his irritation soon exceeds all bounds; his language degenerates into brutality, his gestures become increasingly violent and menacing.

It is not with any surprise, then, that we learn in O.'s case of incipient homicidal and suicidal ideas.