Gentlemen!

The patient I present to you today is the 32-year-old businessman K. As you see, he is a well-fed man, apparently totally level-headed, who can tell us himself why he has come to the clinic. He came to us in the evening 5 days ago, voluntarily, seeking refuge from alleged persecutors. He lives at the opposite end of the city and is the owner of a grocery shop, connected to a bar. Opposite him lives a watchmaker, who is probably to blame for the whole fracas. He presumes this, because the latter had spoken out shortly before, very unpleasantly, about the dismissal of a clerk by the patient, and because the watchmaker was the main spokesman for ‘the whole group’ [Ed]. While sitting quietly in his room that evening doing his books he suddenly heard their voices, ‘Now he is reckoning the accounts’; then he also heard the total sum, which book-entry he should take in his hand, and what he would write. He concluded that someone was watching all his movements, and knew his thoughts, probably using some form of mirror system, because he believed that he had also noticed a light shining and could see his persecutors—although this was quite impossible because of the location of the windows—and he heard their voices—presumably they were using a telephone, installed without his knowledge. Moreover, since he also heard common swear words, he left the room to find a policeman, who would give him peace of mind. However, since he did not find one in the vicinity he went to a nearby tavern, and ate his supper there. Then he left the bar and met a policeman to whom he made his request. The policeman went with him and said that he saw nobody, nor did he hear anyone making scolding remarks; he advised him to go to sleep. Everything was peaceful as long as the policeman was there. He then went to bed, but soon noticed that the old game was starting up again. He now heard his thoughts repeated; thoughts were even intruding upon him, and indeed the chief of police seemed to want to ‘extract’ from him thoughts whose content was ridiculous, on the basis of which his punishment would be given. It seemed to him as though a telephone led into the garden, and his thoughts were being collected by people in this way. As he lay in bed, he felt as though his face was illuminated. As a result of hearing vulgar swear words, and life-threatening statements such as: ‘The fellow has eaten supper and should be executed’ or ‘People were standing outside who wanted to beat him to death with stones’, he was overwhelmed by terrible fear and got up from his bed to go and seek shelter. On the street he was greeted with ‘Hello’; everybody seemed to know him, everybody ran after him, ‘Here he comes, there he is, the scoundrel, the liquidator, into the Oder with him!’ In his fear, he ran aimlessly through the streets, constantly hounded and persecuted by the crowd behind him, and at length, he went breathless and dripping with sweat into an alehouse near our clinic. There he bought a cognac and asked for a rope to hang himself. As a result, it was recognized that he was sick and was directed to our clinic. He spent the first night here for the most part sleepless. He well knew where he was and felt a little safer, but he could still hear the crowd screaming outside, wanting to drag him to the Oder and throw him in. At one point it seemed to him as though three elephants had come into the room, but he would probably have been deceived. A powder (Phenacetin 2.0) was then given him to sleep. Here in the clinic, he knew well that nothing would happen to him; however, he assumed that he would be handed over if people came to get him. On questioning, he indicated that he would still prefer to end his life in order to escape the fear of his impending fate. He gave clear information about his business affairs, but wished to meet his ‘last orders’, and he stated his intention to ‘follow without resistance’. Fear is suffused throughout his body, accompanied only occasionally by heart palpitations and the feeling of pressure in the pit of his stomach. He explains the fear resulting from the voices, which he hears continually. Literally they declaim expressions such as: ‘For God’s sake. Is not executed. That’s right, the ratbag; now he’s laughing, the doctor is writing. That’s just nonsense, that everything is written down (referring to management of medical history); that’s a malingerer. Insane he may be, but he is also a malingerer. What do we think of such a malingerer? K. is a malingerer. K. you are not listening, you are a malingerer. What does it mean, that everything is written down? The doctor is a good man. The doctor is a fool. The doctor is an ass’. The patient has repeatedly heard the doctor’s injunction: ‘Beware, lest anyone is scolding outside’. Likewise questions were often addressed to him, and his own thoughts were repeated by the crowd of people. Derogatory judgments about doctors, about the Kaiser etc., who were a long way away from him, had been ‘set in his head’ in the first days; later he had heard corresponding voices. The foul language and vulgar words that he had heard on the way here were sometimes individual voices that he recognized, and sometimes were screaming in unison, as if on command. ‘Now he will go in the moat’. But he thought, ‘No, certainly not’. He heard of a dispatch from the Kaiser, ‘Within eight days his head will fall’; saw the telegram handed over to the prosecutor. Several times the criminal bell had rung, as if he were now going to his death.

The patient showed that he was perfectly orientated, knew the doctors, each of the warders, and the other patients, and had never projected the voices onto any of these people known to him. It was always the crowd of people ‘out there’ [Ed] of whom he spoke. On questioning he stated that he had often seen the people outside, with the watchmaker included amongst them, who was always there. He was surprised that the people sometimes remained even during his meal times and did not keep their distance. He has heard voices: that there is poison in the food; that he should not eat, but nevertheless he did eat, admittedly in the hope of escaping a worse death in this way. The patient is uncertain that he has had sensations of taste and smell to match this content. When he was given paraldehyde in the evening as a sleeping aid, he heard a voice saying, ‘This will please him, that he still gets cognac’. As for abnormal sensations, this patient declares that it often happened that he felt himself to be electrified; he also believes that there must be a powerful electrifying machine somewhere. Several details of this patient’s auditory hallucinations are interesting. He complains of continual ringing and buzzing in his ears. These are joined by rhythmic ringing as soon as his head rests on the pillow, in the ear of the same side. He has repeatedly stated that the rhythm of the ringing has synchronized his pulse; and he then hears voices in the other ear. As for his behaviour on the ward, you often find him kneeling at the side of his bed; he offers up his last prayer, as he is soon to be ‘taken away’ [Ed]. He also often leaves his bed and stands listening at the doors. He never loses his focus, and encouragement always rapidly succeeds in calming him. Sleep is brought on only with a sleeping draft, or, as in many similar cases, a dose of 2 g of Phenacetin.

Let us summarize the essential features of the clinical picture: We have here a physically well-nourished, prosperous man, who is probably in a position to give information in a level-headed way. However, from his manner of speaking, he conveys restrained Affect; he is ‘focused’ [W], as he says himself, yet is tormented by perpetual fear. Also, his speech is sometimes hasty, and his vocal tone a little shaky. His outstretched hands soon start to tremble. The main symptom we know about are phonemes, whose content, corresponding with his anxious state, is partly of a threatening nature and partly expresses his reduced personal status (that is, part allopsychic part autopsychic notions of anxiety). He hears the most defamatory claims about him personally, shameful insults, and threats; he describes how he is being hounded to death, and even now awaits an ignominious death. He makes most definite comments about the fact that his medical condition has become very acute, and within a few hours has risen to a high level; furthermore, he has heard voices, and, as a result, is overcome by anxiety. When he first met all those people together on the street, and when, as though by agreement, he heard shameful suspicions screamed at him, that fixed in his mind the first comprehensive anxious idea: that it might all be over, for his business, if these people made him out to be so bad. The severe anxiety only came later, when he was chased down the street. Attempts made by the patient to provide an explanation are remarkable. He is convinced that a telephone had been placed in his home; he talks of a ‘mind reader’ and describes a corresponding apparatus that he has allegedly seen: a lamp with a mirror above it, trailing electric wires. He assumes that there is a specific starting point for these persecutions, where he refers to the watchmaker as the ‘people’s stirrer’ [Ed], and implies that the latter’s motive is wanting the patient to suffer for the dismissal of a clerk. In all these situations we see attempts to systematize towards a uniform explanation of the phenomena that frightens patients, and this, just a few days after the acute onset of psychosis. We shall soon see that this rapid systematization is quite characteristic of the current illness. It is based undoubtedly on the relative intactness of formal reasoning ability, as we have since seen; and that during the demonstration the patient was free from voices and was never distracted by them. Visual hallucinations take second place, appearing preferentially in combination with auditory hallucinations, and have a delirious quality. Other sensory delusions, with the exception of those of skin sense (as electricity!), did not occur. This patient is firmly convinced of the reality of his perceptions, although there is no loss of his orientation, and he assesses his current situation properly, while confined to the clinic. The contradiction arising from this is not lost on the patient, as is revealed even in the form of a phoneme which he tells us. Namely he has heard, ‘If he were in prison, he could be taken by force; but because he is in the hospital, one must wait until he comes naturally’.