Gentlemen!

The 35-year-old plumber H. (discharged as recovered 8 days after the presentation) who you see before you initially makes an orderly, sober impression. He answers questions put to him promptly and apparently deliberately. When asked, he gives an outline of his life story, talks about his life in the military and where he served, how he fared, the name of his captain, the commissioned officers, a number of his comrades, where he later found civilian work, the company he now works for, when and who he married, how many children he has, their names, and where he now lives. He has ready access to commonly accepted knowledge. He knows the key dates of the last war; knows about Bismarck, Moltke, and the three Kaisers; his participation in the election; shows himself to be well orientated about city streets; can describe the course of the Oder, etc. From his quiet way of speaking and the attentive nature of his answers the only surprise is that he does not know how he came to be here. He believes he has been here only today, whereas he was admitted in the evening, of the day before yesterday. What is this place? An office of the Upper Silesian Railway Station? Does he know me? Yes, I am the chief stationmaster or station inspector. Why is he here? To provide information about his identity and possibly to be put to service. He promises faithfully to do his full duty. Who is this audience? Office assistants, scheduled to start the negotiations. The ward doctor, who has treated him so far, is shown to him: ‘He knows the gentleman very well; he is the station doctor, who treated him for rheumatism some time ago, and had always warned him against drinking’. The patient is made aware of his hospital garb: ‘These are hospital clothes prescribed by the doctor because the smell of liquor permeated his ordinary clothes, which would hinder his working’. On questioning about liquor consumption, he says that he spends 50 Pf a day on drink, but, conniving, he denies that he is a drinker.

Examination of the patient therefore reveals total misjudgement of the immediate situation, his understanding being replaced by terms for the most common ideas in his daily life. Results of the clinical examination so far can be summarized as saying that we are dealing with a patient who, in contrast to near-completely preserved autopsychic orientation—up to the last 2 days—presents severe allopsychic disorientation.

You will notice, as soon as we leave him to himself, how his attentive, collected, and fully alert nature changes: He begins with his eyes wandering about, he stands up, bends down as though he were looking for something, appears to pick up objects, goes to the wall and manipulates it with his hands, braces himself against it; in short, he seems to be completely ‘absent-minded’ [W] and in a delirium. A spoken word suffices to bring him back to an attentive state and makes him return to his seat.

We ask him whether he recognizes the picture on the wall (a portrait of Th. Meynert with his signature beneath); he responds promptly that it is Kaiser Friedrich, and the signature

‘Theodor Meynert (autograph)

Med. Dr. Theodor Meynert.

k. k. Hofrat o. ö. Professor a. d. Universität Wien etc.

gestorben den 31. Mai 1892.’

is read as follows:

“Theodor Mehlquot

Paul Theodor Theodor Mehlquot

k. k. Kauf. u. k. k. Prcesser a. d. Unterurdish in Wunde.

abgeordnenedeten.

gesalbten 31. Mai 1892.”

We encourage him to fixate his gaze again on the wall, and then ask him what he sees: ‘Military, the Kaiser is there, they are at drill’. Does he hear anything: ‘They are shouting Hurrah’. On questioning, and while he continues to fixate on the wall he describes all the infantry formations that should be practised. Suddenly he begins to laugh: ‘Bismarck is riding on a porcupine’. Now we draw the patient’s attention to the floor. He is to see what is moving down there: He bends and begins to collect ants and mites, which he then empties out of his hands and onto the table. Since his attention is now directed to the table top, he claims that there are also horses and Krupp’s cannons there, but in tiny form. From his movements it can be inferred with certainty that he believes in the reality of events he describes. He disregards any contradictions which might occur to a healthy person, with remarkable lack of judgment. Thus, when asked in relation to the military drill how far apart the soldiers should stand, he gives a prompt reply of ‘about eight metres’ [Ed]. He approaches a wall about two metres distant, and on being invited to go up close, he then stops, because he can go no further. About the nature of the obstacle, we can learn nothing more definite from him.

If we want to characterize the singular nature of the hallucinations that we see him experiencing, we recognize at once their similarity to dream experiences. As in dreams, the hallucinations are not limited to a single modality, but combine hallucinations in several senses, such that entire experiences giving a full impression of reality are thereby witnessed, heard, and felt by the patient. We have referred to this type of experience as ‘dream-like hallucinations’ (p. 122) [Ed], because of their similarity to dream experiences, noting that they occur in cases where a sleep-related clouding of the sensorium occurs, which is why they can be summarized under the name of ‘twilight conditions’ [Ed]. Does such a twilight condition exist in our patient? Given the periods when the patient, left to himself, forages, you must answer in the affirmative, despite his eyes being open, and retaining their ability to move; but the answer is very different for those times when the patient, fully awake and attentive, answers every question directed to him and—as he assures on questioning—experiences no hallucinations. In such periods, which can be extended at will, he still completely misunderstands the situation, which, quite logically, leads us to reject the obvious assumption that his disorientation is a by-product of hallucinations, especially when we take note of the fact that his misjudgment of the situation is a very stable characteristic, remaining the same in its content for hours and days, while hallucinations are subject to continual change. One might also think that there is impaired function in the sense organs themselves, for instance, as a detectable disturbance of vision and hearing that could bring about his disorientation. But apart from the fact that we see no analogous impairment in any other mental patients in suitable cases, we are led to a direct proof that no such disorder is present, our patient having normal visual and auditory acuity. So this patient gives us an instructive example of disturbed secondary identification, a relatively rare opportunity to observe, as a spectator, the very process of this identification disorder.

What we see here in uncommonly pure form should be classed as psychosensory anaesthesia or paraesthesia. The allopsychic disorientation can be understood easily as a necessary consequence of the disturbance of identification. His failure to recognize people and situations happens according to principles emphasized earlier (pp. 140, 141), and undoubtedly falls under the heading of optical illusions. However, this failure—his non-recognition—remains as a very remarkable feature, because concepts such as the hospital, the clinic, and the auditorium are well known and familiar to him—as could be shown in a later experiment.

Incidentally, the above features do not exhaust the symptoms of Delirium tremens [W]. In fact, right now, during my discussion of this case you have the opportunity to observe another important primary symptom, namely the peculiar restlessness of this patient. Left to himself, he is constantly doing something: He looks around, fumbles with his clothing, begins to undress, knocks on the wall, braces himself against it, rubs and polishes it, and is constantly busy. All such movements are indeed accompanied by tremors, but they are functional and coordinated, and obviously adapted to certain situations in which the patient believes he has found himself. They stop instantly, as soon as we call him, and with sharp questioning he is brought back to full consciousness. As you know, people tend to designate this physical restlessness as ‘occupational delirium’ [Ed], which is thus fully explained by the ever-changing combined hallucinations. Motor symptoms occurring independently are foreign to typical Delirium tremens [W].