Gentlemen!

The patient I present to you today is a typical example of slowly emerging ‘allopsychic falsification of consciousness’ [W]. She is a 45-year-old agent’s widow, Frau Reisewitz, whose illness developed gradually over the last 5 years, from barely noticeable beginnings, and is expected to develop further. She has already surprised you as she enters, by her measured and somewhat dignified bearing, and her facial expression is similarly rather solemn. She says, when asked, that she had lived in Dalldorf, from where she was brought here, and that her surroundings there must have been brought with her here to Breslau. She does not recognize the building where she is as a hospital; these are ‘sacred places’ [W], a ‘house of God’ [W], all bearing the stamp of religious solemnity. The purpose of her stay is probably to prepare for a future important position; she is still very unworthy, and great honour falls on her by her being included here. Possibly she owes it to a high priest, to whom she turned in her misfortune. The fact that she has been through a great deal of misfortune and suffering is well known; her name is known throughout Breslau. Apart from the interpretation she conveys of elevated self-assurance, she is persistently submissive by nature; she rises at each salutation and bows, doing this to every fellow patient, even to a very feeble-minded female paralytic patient. She often apologizes that she has not behaved in a seemly manner, and begs that her words not be taken as too sharp. She regards her fellow patients as men of the cloth, usually high-ranking clerics who are here in part for repentance. The doctor too belongs to the clergy, although he may previously have been a physician. She declares a 13-year-old girl to be the Duchess Arco, chief wardress to His Majesty Kaiser Friedrich, and others as guards for certain princes. All of these people had been around her in Dalldorf but would have made changes in their appearance since then. She alone remains unchanged.

Gentlemen! The information we have just obtained suggests a so-called systematic delusion based mainly on recurring religious themes, and an autopsychic falsification has developed, leading the patient, having now survived the examination period, to play the role of a priest or prophetess. Particularly striking to us however is her reinterpretation of people and the whole surrounding to fit this religious delusion. Given the apparent prudence and the peaceful behaviour of the patient, we cannot assume that her senses have deceived her, such that she could not observe objects and events in the outside world correctly; yet everything is identified in a reconfigured manner to match certain prevailing notions, and, as is often the case, within just such a religious framework. And so she presents us with a striking example of disturbed secondary identification resulting from delusional content of consciousness altered by mental illness. I intend to return later to the amnesia very characteristic of such cases. With regard to her current mental status, it was noted only that she was not entirely free from sensory deceptions. Very few auditory hallucinations seem to occur, whereas olfactory hallucinations and subjective skin sensations are fairly common. The former are interpreted as audible blessings, perhaps the voice of God; in the latter two sensory domains, the ‘vaporization’ [W] of chloroform and the ‘electrical treatment’ [W] are usually accepted patiently as tests, and leave behind bodily weakness; but sometimes they provoke outbursts of anger and energetic ranting. A prolonged conversation is perceived as stressful; but nevertheless you can obtain accurate information about personal details of the patient right up to the time of onset of her illness; memory deficits do not exist; attention and memory are approximately normal.

You will observe the contrast between this case with such pronounced allopsychic falsification of consciousness and another patient, in whom consciousness of the outside world is in no way involved over the entire course of the illness right up to the present time, while the main alterations are in awareness of physicality, and, in due course, also of personhood. We can take it as an example of residual, mainly ‘somatopsychic falsification of consciousness’ [W]. This is a 46-year-old female cook, Tscheike, who had been treated for 4 months in our clinic 5 years ago, and was then transferred to the asylum in the city of Berlin. She was discharged from there as relatively improved, but after multiple attempts to resume her employment finally came back to our clinic. The period of her first stay could be regarded rather as the most acute stage of a mental disturbance, which up until then had been gradually increasing over a 2-year period and had been accompanied by all kinds of serious disturbances of general health. Currently, she is entirely free of such complaints and presents a healthy appearance; her bodily functions are controlled; she maintains a roughly constant body weight; and her behaviour at today’s clinical presentation shows nothing remarkable. Her answers are prompt and meaningful. She is fully orientated with respect to her surroundings, her current situation and her former illness, and also about all her personal circumstances; namely, she has good memory for certain details of her illness. The sum total of her knowledge is consistent with her stage and level of education; despite a degree of malaise, her mood is elevated rather than depressed. On the ward, however, she does not always behave appropriately and comes only from time to time to her occupation in the sewing room, usually preferring to become involved in all kinds of things that do not concern her, giving advice, and harassing her fellow patients through jokes and childish behaviour. For example she pulls the bedclothes off them, or throws water in their face to surprise them, steals from them, or perhaps steals food she is not entitled to from the kitchen. She is in the habit of disrupting clinical rounds by interjecting. She disobeys doctor’s orders, and if she is sent to bed for disciplinary reasons is unabashed to wander naked in the corridor. So you see, gentlemen, that the patient’s behaviour is in no way normal, but, on the contrary, requires so much patience and forbearance on the part of her surroundings that she can exist only within the special confines of an institution. You will see later that many patients are in the same situation: After recovery from actual mental illness, they prove themselves incapable of living anywhere else than in an institution, on account of their social incompatibility, and their demanding and mainly egotistical behaviour requiring constant supervision. On closer investigation our patient shows that she is also full of a vast number of misconceptions. At the time of her illness she suffered from bronchitis. She was so full of mucus at the time that she felt that a prehistoric man, a bloodthirsty man, or a lancelet—she uses these three terms synonymously—had entered her body. The prehistoric man disturbed her greatly—he had been housed in her body as if a living child was therein. He was originally created in the diaphragm; he has a transparent pink body consisting of phlegm—as might be seen in an aquarium—an angel’s head, and a pointed tail. He lies within her in such a way that the head is in her brain, the body along her spine, and the tail above her anus. He often wanted to get out, forcefully, which she noticed from stitches on top of her skull and below at her anus. He lived on what she ate, but mainly on what she drank, which was why she had to drink so much. Since that time she had doubled everything—double nerves, double heart beat, and even a double brain. From that time on she also had gained a very young face like that of a 15-year-old girl with the head of an angel, and her pockmarked skin had become smooth. (The patient actually has numerous pockmarks on her face.) At the time of her illness the right half of her brain had broken out on one occasion: She had suffered from severe headaches and nausea; the vomit looked like brewer’s yeast; she felt that the right half of her brain had suffered damage. The diseased half of the brain later replaced itself. Through the illness she had also received doubled thought—‘on the one hand the epitome of everything that had been my work, on the other hand politics and science’. In fact, she seems to differentiate between her earlier mental status, which corresponded well to her areas of interest as a cook, and her mental activity since the onset of her illness. She believes that she has ‘genius in everything’, and has apparently read a number of books, which aroused her interest but with no comprehension. She mentions the book by Häckel, ‘Urmensch oder Lanzettfisch’ [W], but believes that Häckel means something like binding, or belonging together. According to her, a person has 27 senses: profundity, combativeness, hygiene, sense of language, word meaning, sense of colour, and artistic sense; the others she just could not recollect. She writes treatises on political conditions, of which I shall read you only the beginning of one: ‘The lowest class of people is used to save the life of the higher. As a consequence, the poor individuals receive an acute or the opposite of it. This stomach ache is related to chlorosis’ etc. She emphasizes that she understands something of medicine, can treat fractures, apply bandages, cure diphtheria, etc.; and it is this that leads her to interfere during ward rounds. Gentlemen! We will talk later about the processes by which such falsifications of consciousness—partly somatopsychic, partly autopsychic—actually arise. I want to emphasize just one point here: That we have observed in these patients the time at which somatopsychic delusional ideas actually originate, and can thus provide evidence of their origin from abnormal physical sensations. If such fantastic ideas could arise from one’s own body, we need to remind ourselves of the peculiar situation in which these patients find themselves: Patients experience morbid feelings which are hitherto quite unknown, totally devoid of any analogy with normal bodily sensations, for which patients lack any vocabulary to describe their experiences. Parables, similes, or analogies are then forced up to conscious levels in distinctive ways for each patient, and are then used as a means of description. During the acute, Affect-laden stage we hear patients complaining all too often how indescribable, unspeakable, and unique are the feelings which afflict them. The bodily localization of these feelings—which may be more or less definite—then provides the main evidence leading to the development of a delusion, by way of explanation, whose building blocks are then adaptations of each individual’s scientific knowledge. Our patient was probably influenced by Häckel’s undigested writings when she conceived her delusional system. A further delusional explanation is based on the autopsychic notion that, due to the illness, she has come into possession of a new way of thinking, extending to politics and science. In this, she expresses her own perception that her mental activity has changed direction, due to alterations in the content of her consciousness, a point to which I shall soon return. The nonsensical, apparently feeble-minded aspect of her thought processes, here associated with elevated mood—a contrast with the way her thoughts had formed previously—can thus be fully explained.