Gentlemen!

As you can see from such examples, it is beyond doubt that we interpret this as a psychosensory disturbance of identification in organ sensations, although it is difficult—even impossible—to establish whether it is hyperaesthesia, paraesthesia, or anaesthesia which is present.

At a certain stage, emergence of these two different initial localizations comes to the same thing, that is a feeling of repletion or ‘surfeit’ [Ed] of food: on one hand, starting with food that is either laboriously swallowed or artificially introduced and accumulates in the stomach area; on the other, a faecal mass backs up from below, eventually right up as far as the pharynx. The most common and most important of these abnormal sensations is refusal of food, which in such cases almost always requires force-feeding by oesophageal tube. A heavy feeling of dolour is always present, quite understandably so, given the feeling of severe physical illness which predominates. This also affects patients’ outlook on the future: They always believe themselves to be lost and quite without hope. In pure cases of this sort, actual perceptions of anxiety are restricted to the autopsychic area, often in a quite limited way, in that patients blame themselves for having brought about or aggravated their illness through neglect of medical advice and medical planning. In the case of a 60-year-old, unmarried woman, after a long career in nursing, combined with a sad Affective state, she quite suddenly she fell ill with this form of intestinal somatopsychosis and severe food refusal. After about 6 months of illness, the abnormal sensations in her pharynx diminished. However, the dolour and autopsychic focus of her anxiety remained, as did the somatopsychic perception of anxiety about having no bowel movements, and the illness eventually led to her death.

A 57-year-old female patient, who had struggled for years with severe food problems, was subsequently diagnosed as having sensations of intestinal obstruction. Six months later, at the height of her illness, she claimed to be full to the top with faecal matter, and unable either to breathe or to move. When her illness began, she had repeatedly expressed her fear of starvation, with despairing restlessness; but after an intercurrent bout of influenza she veered towards a severe state of fatigue, in which she also complained about slowness and difficulty in her thought processes. Subsequent infiltration of the upper lobes of both lungs seemed to make the prognosis totally hopeless; nevertheless, after several weeks in this condition, she started to convalesce, and after about a year was discharged to family care as improved. The disease trajectory in this case can be regarded as purely extensive, and the akinesia then corresponded to a peak in that curve. This case was interesting in that her anxiety, which focused on the heart, was always stated to be a separate phenomenon, and suggestions of ideas of autopsychic anxiety taking the form of self-recrimination were quite short-lived.

Even clearer than in the previous case, the worsening behaviour of a hypochondria with initial localization restricted to the genital organs was demonstrated in the case that I presented a few semesters ago. This was a 23-year-old Jewish lady, who had suffered psychotic attacks on several previous occasions, sometimes more melancholic, sometimes more manic in nature; her sister had been mentally disturbed in a similar way on two occasions. She had lived with her brother’s family, and looked after his very sick child with utmost devotion. At the beginning of her own illness she complained of feeling a solid body in her genitals and was treated by the gynaecologist. The symptom was combined with a burning sensation, urinary tenesmus, and pressure, with failure of menstruation. There were no objective findings. When the sick child died about 2 months later, she began to take on the hardest work, in spite of which she soon declared that she was no good, could not work, was superfluous, and was a burden to her brother. About 2 months later she attempted suicide with chloroform and was unconscious for several hours. A foiled attempt at drowning provided the occasion 3 months later for her being transferred to the clinic, where the patient’s delusions of belittlement have been intensely managed up until very recently. In the last 2 weeks prior to admission, and during the first months of her stay in the clinic, her physical ailments intensified to an extremely desperate state. She said that as a result of unsatisfactory stools, her food had accumulated inside her—not faeces, she explicitly stated—and had been transformed into a solid mass. This solid mass had penetrated every part of her body, disfiguring it; only her skin remained in its natural state. The patient had convinced herself of this because of feelings of internal heaviness, and from palpating herself with her hands. Her body felt dead, as if it had expired, and there was no longer any blood flowing through it, although the patient could feel her pulse and also hear her heart beating. This ‘solidification’ [Ed] extended also to her sense organs: Although she could hear with her ears, her eyes remained fixed within her head; she could not move them, nor open her eyelids. When she made eye movements during the examination, she assured us that this would not otherwise have occurred, and that she had to turn her head instead. She doubted whether she could smell, feel, touch, or taste; she tried it with milk, and found it to be so. However, she could swallow and move her tongue. The patient constantly refused food during this time, and had to be tube-fed. As for bowel movements, she claimed that they were insufficient, even though infusions or laxatives—which she willingly accepted by the way—had had an effect from which she felt instantly relieved. She constantly felt severely ill, with a sense of absolute hopelessness, and a correspondingly desperate mood in relation to her physical condition. However, she complained of anxiety only transitorily, at times of extreme excitement and despair, the anxious feelings then being localized to her breast.

As for this patient’s motor behaviour, there were periods of outpouring of despair as a result of progressive decline of strength. There was her delusion of having sinned through having eaten too much; she was lost to all eternity; she deserved all the most severe punishments awaiting her, such as being consumed by fire. Similarly she regarded her stay in the clinic—where perforce she had to be kept at the monitoring station—as a well-deserved albeit minor punishment. Moreover her intelligence was intact, her orientation fully preserved; despite physical weakness there was no slowdown, nor hallucinations, nor delusion of relatedness. With continuing weight loss, death ensued after a 9-month stay in the clinic.

A modification of intestinal somatopsychoses, which is not rare, occurs in cases in which the aberrant sensation is localized more towards the airways. In one such case the nasal passages were the main site of this abnormal feeling, associated with fear of suffocation; in another case there was a feeling that the throat had dried up and the trachea was overgrown, although swallowing and nourishment continued undisturbed, and without any respiratory distress. Nevertheless, the patient, a 42-year-old farmer’s wife, experienced a localized feeling of severe loading in the epigastrium, as if from a stone, which was so severe that she described it as a ‘death feeling’ [Ed]. Apparently this feeling climbed only gradually up to the pharynx. The patient tossed and turned with internal unrest, whined incessantly, and had most pronounced tendencies to suicide. Multiple attempts had already been thwarted. At the time of observation she had already been ill for a year and it was learned that during the first half of the year she had spoken in self-accusatory terms, and of fears for her family, with even more vehement anxiety. Her husky voice and occasional bouts of coughing led us to examine her larynx, and it turned out that, in addition to catarrh that had led to swelling of her vocal cords, one vocal cord was completely paralyzed. Although suspicion of tuberculosis of the larynx had arisen in this case, clearly this did not explain the paralysis of the vocal cord; and you could even ask whether it was more of a direct consequence of the hypochondriacal sensation arising in the laryngeal innervation, in other words, an effect of abnormally altered sensation in an organ which at the same time serves motility, in the sense of comments made earlier (p. 132). The possibility was then considered that the catarrh was only a consequence of deficient motor activation, as the end result of morbid sensation. I submit that the unilateral nature of the vocal cord paralysis does not support this explanation, and a different view of this rare condition is closer to the truth. Vocal cord paralysis and catarrh were perhaps the common outcome of a latent, undetectable cause, and only the paraesthesia of abnormal organ sensations was the starting point of circumscribed—and in due course, clearly symptomatic—intestinal somatopsychosis.

Gentlemen! In light of the above comments, symptoms of paralysis in cases of circumscribed bladder hypochondria are much more likely to be understood as psychosensorily induced akinesia. These cases mark a transition between hypochondriacal psychosis and neurosis, in that they encroach even less than the previously described ones on the rest of mental life. Moreover, treatment in our institution can often be avoided, the more so since the numerous subjective complaints associated with paralysis of the sphincter muscles are usually limited to certain times of the day, the rest being symptom-free. Particularly burdensome is the feeling of urinary pressure sometimes connected with a tendency to involuntary ejaculation: The latter are also able to occur without erections. Patients are therefore in constant fear of causing embarrassment; besides this, localized feelings of anxiety can exist in the epigastrium. Outside the spasm, the patient may appear mentally normal; however, during the attacks they suffer from more or less severe autopsychic notions of anxiety and despair to the point that they become tired of life, with a tendency to suicide. These patients usually organize their way of life so that incidents of the type described cannot arise; professional activity and dealings with other people suffer as a result. In one such case, treatment with several hours of warm baths, in which the patient felt relieved of every concern over unexpected moments of embarrassment, had a sustainable, long-term success. I need not emphasize that these cases are distinguished by absence of any local changes, and of any symptoms arising in sensory nerves or the spinal cord, while the patients’ history of persisting cystitis or gonorrhoea is not without significance.

Certain cases of defaecation hypochondria are related to hypochondriacal neurosis in a similar way: The main burden on patients, and likewise the fear, with its sequelae, is similarly eliminated by controlling production of stools.

Gentlemen! Not unexpectedly, circumscribed intestinal hypochondria can also be localized in the female genitalia. A typical case of this kind, who I presented in the clinic, concerned a 22-year-old serving girl who, before her illness, was of normal intelligence, but always easily excited, and inclined to outbursts of anger; her brother was mentally ill when he died. After bouts of anger, she was said to have had repeated seizures of an unspecified nature. At the time she presented here, she had been suffering for about 2 years—though with several long intermissions—from a burning sensation, which was not directly painful but was yet described as quite unbearable, in the genitalia and internally in the lower abdomen. This burning was not continually present, but recurred persistently. It was worse towards evening, and was simultaneously associated with low back pain, headaches, dizziness, and nausea. At the same time she complained of anxiety in the epigastrium. The illness was accompanied by unhappiness, low mood, and hopelessness; and her facial expression, and her apathetic behaviour altogether, conformed to this mood. At the time of her menstruation, there were fewer complaints; before and after it, there was lower back pain and some discharge. Special mention must be made of the patient’s motor behaviour. While she usually stayed in bed, depressed and apathetic, occasionally there were outbursts of totally unmotivated, senseless rage, when the patient screamed, lashed out, bit, and scratched, quite unaware of her surroundings. The patient subsequently had no recollection of these instances, which did not last for hours; and each time, they were initiated by an increase in abnormal sensations in her genitalia; then came, like a type of aura, a feeling as if the body were dying, with consciousness fading. These motor expressions bear the stamp of senseless rage, and would be correctly understood as a type of reflex response to violently-increased organ sensations, and thus as hyperkinesia induced by psychosensory means, via a short circuit. At the time of observation she was suffering from ulceration of the cervix and vagina. The beginning of her illness was allegedly related to a delivery and subsequent metritis. As a result of her tantrums, this patient had to be transferred to a nursing home. Although the reported symptoms are close to the clinical picture of epilepsy, typical epileptic seizures were never observed.