Gentlemen!

Learning about hallucinations, which we merely touched on in previous discussions, is probably the most important topic in the general pathology of mental illness; and we therefore have to know about their basic features before we can proceed to studying examples of the various clinical pictures seen in acute psychoses. Since the time of Esquirol [1], sensory perceptions have been differentiated into two major groups: hallucinations and illusions. Hallucinations are sensory perceptions that occur without excitation of the relevant sense by any external object or external stimulus; illusions are false perceptions—misconceptions in perception of objects that are actually present. For the purposes of our schema, hallucinations belong to the group of psychosensory hyperaesthesias (p. 13); that is, they represent a pseudo-identification produced by aberrant stimuli; illusions are attributable to psychosensory paraesthesias; that is, they represent a falsification at the level of secondary identification.

We must consider how far primary identification is involved, when we come to discuss the theory of sensory perceptions.

The main experiences of hallucinations are to be found in the sense of hearing; so let us start with these, especially since they can claim, by far, the greatest clinical significance. Here again I limit myself to essential points in clinical experience.

Auditory hallucinations take two different forms, namely voices (or phonemes [W]) (p. 80), and auditory perceptions of a different kind. The latter, also called acousmata [W], can show up in the widest variety of ways, so that, for example, sick people hear slamming, banging, clattering, knocking, thunder, drums, shooting or chirping, hissing, boiling, howling, barking, neighing, or roaring. Such noises are seen particularly in very acute disease states, often accompanied by severe morbid changes in the general condition of a patient. If there is a dry tongue and oral cavity, the mucous membrane of the Eustachian tube and inner ear may also be affected, so one cannot exclude the possibility that hallucinations classed subjectively as tinnitus are of peripheral origin; and this is particularly true for simple, elementary sounds. You would have heard of the group of hallucinations arising from peripheral irritation of the inner ear, singled out by Kahlbaum [2], the Phenazismen [W], to be classed as disorders of primary identification. This type of acousma is apparently very close to an illusion, since the fact that it originates peripherally does not prevent its being interpreted and used by a patient in a fantastic way. This manner of origin draws on occasional experiences of every healthy person of a subjective tinnitus, and also on inner ear peripheral irritation. It is also known that pure tones can arise in this way. Acousmata such as distinct melodies, an orchestral piece, or other auditory impressions of more complex nature, such as groaning, moaning, whimpering, or screaming children—these cannot be explained in such a way, and must have some other origin.

The ‘voices’ [Ed]—or phonemes—also occur in two different forms, namely when they are expressly identified as ‘voices’ [Ed], which a patient himself perceives as something special and different from ordinary experience, or when they are attributed to another person who is actually present, or to a person nearby. The first case is a clear instance where a patient himself creates his own form of expression to describe it as a symptom. If you ask such patients to say whether they hear voices, they usually affirm it without hesitation, conveying also that they fully understand the question. Other patients also will come out with the description of ‘voices’ [Ed], without any external prompting with this term. This clearly indicates that auditory hallucinations made up of words seem to be inseparably linked to a very specific vocal quality. Patients can usually specify with certainty whether the voices come from known or unknown persons; in the former case they can name them, and distinguish men’s, women’s, and children’s voices. The terms ‘angelic voice’ [Ed] and ‘voice of God’ [Ed] occasionally issue from an unusual, alien tone of voice. The voices seem sometimes far away, and sometimes nearby; often they come from close-up, so that it seems to the patient as if someone were whispering, speaking, or screaming into their ear. Usually the direction from which voices appear to come can be precisely specified; and patients often develop, in this regard, quite striking ability to localize, found only in cases of illness. The source of the voices is indicated not only by the direction, but even by the very precise location and distance from the ear. It also happens quite often that the voices seem to change their location independently of each other. The patient thereby acquires some form of personification of a voice: He complains that the voices fly or buzz around him; he looks for them under his pillow and hunts for them as if they were an annoying insect. Our engineer K. heard them, among other places, in his food bowl. At other times, it is not so much the abnormally fine localization, but the vivid perception that the voices are accompanying the patient, for example when he changes his location, or on a walk, and this leads him to conclude that the voices can also change location.

In the case of unilateral hallucinations, which occur quite often, the direction from which the voices come changes with the patient’s own position, a manifestation that under favourable circumstances can lead to our investigating the subjective nature of the symptom. In such cases we usually succeed in detecting either a high level of deafness or reduced acuity in one ear. Hallucination in these cases may be encountered sometimes on the side of the healthy ear, and sometimes on that of the damaged ear. Perhaps there is some regularity in this respect, which is apparent if we pay attention in a medical examination to the localization of ear impairment. Our patient K., who is hard of hearing in his right ear as a result of old middle-ear catarrh, reported a voice that had been so loud and so close to the ear that the ear began to bleed and in fact he once found a small bleed in the external auditory meatus.

Hallucinations can force themselves upon a patient’s attention, even if erroneous sensory perception is not understood. So, by way of example, indefinite noises precede distinct phonemes; and quite often the phonemes fade out in such a way that patients no longer speak clearly but hear only a whisper. In both cases, patients give a clear indication that they need to listen to the sound, even though they do not understand its meaning. Even with the new patient K. it was the same. Like many others, he felt a compulsion to listen, as a physical torment, to an intrusive act of abuse.

Under reflex hallucinations [W] Kahlbaum includes those produced either by actual perception or by another hallucination, whether these are brought about by the same or a different sensory modality. For example, one of Kahlbaum’s patients heard, every time, on first catching sight of strangers, the nickname ‘Uncle August’ [W]. A patient under my observation, in early stages of delirium tremens [W], heard with great fear, from the ticking of a clock, and from the swirling sound of a water outflow, the words ‘Mangy dog’ [W] and ‘Go hang yourself’ [W]. When a patient who had behaved very badly for a long time became highly motivated, because I usually made an insulting comment at the end of a conversation with him, this also probably indicates a reflex hallucination. Some patients, at the sight of the meal set before them, hear every time quite contradictory instructions—‘eat’ [Ed] and ‘don’t eat’ [Ed]—and this is probably also based on reflex hallucinations. In their inner disarray only a resolute command by a physician can tip the balance and motivate them to eat.