Etiology and Potential Causes

But most frequently by far the exaltation in rank concerns the patient himself. He observes that he is being greeted by gentlemen of rank, that sentries show him marks of respect, that he is treated with peculiar distinction; the policeman who travels everywhere after him is appointed by the Emperor for his protection. Someone or other addresses him as Count or Prince; the waiters speak of Highness, of Elector; immediately on his appearance they have a fresh barrel broached; as soon as he begins to eat the lights go up. He perceives that the Emperor is interested in him, that princes also are in the affair, that aristocratic ladies send him letters and presents, which in an infamous way are suppressed; a patient thought that he had himself seen the ladies throwing letters into the letter-box. Someone makes known to the patient that coins with the likenesses of his ancestors are in existence; he hears allusions and learns through the telephone that a patent of nobility has been awarded to him, that at midnight he will be publicly proclaimed a Count of the Empire. It becomes clear to him that he is of high descent, that his ancestors have played a great role, that he possesses great merit and rights. He can display gigantic capacity and knowledge, feels himself a political personage of the first rank, a member of the House of Lords and Vice-chancellor of the Empire, a relative of the reigning House, indeed the rightful ruler of the country himself; a patient said:

Indeed the whole world knows that

He is the “King’s bastard,” son of the Emperor Frederick, step-brother of Prince Charles Frederick, is in communication with all monarchs, will marry Princess Katherine of Russia. A patient declared that he was emperor and pope in one person, ruler of the whole world, later also that he was immortal, that he had driven the capacity of decomposition out of his body by salt, and that he was a unique thing among human beings. A glimpse into this train of thought is afforded by the following fragment of a letter:

Distress, grief, care and doubt make me have the most unrefreshing nights. I cannot be indifferent, and so the dumb, obdurate world is an oppressive burden to me, even though the star of my bliss is as large and glorious as the sun in the firmament. The black spectre of doubt, which often haunted me so dreadfully last year, causes me the question of the whole future, namely, immortality! Dear K. you will also be frightened about it, because no one as yet has remained in the world. But it is also evident and not to be refuted, that also as yet no one has been endowed with my qualities. For this reason it is certainly not absurd to think about it and to talk loud out, consequently even to believe, and the doubt, when it comes upon me, is no wickedness and no sin. I have not called forth this thought; it came upon me suddenly as long as two years ago, in a moment when I went past the well in the garden, and immediately took complete possession of me, so that I was not able to ward it off. … I am already advanced to the half of the usual age, and who has thought of laying down arms and surrendering at discretion? Yes, certainly the world has enough cause to defy the Messiah! Still with the truth it is to be hoped that I shall come out top over all fraud, and that everyone must acknowledge that I am the Lord, as Pharaoh learned. Let it be said, for dying I have not time so soon; I must first beget or create 1000 million children, that is soldiers, and so they may defy. …

In a small number of cases the exalted ideas acquire a somewhat religious content, as already in the example just quoted. The patient is sent by God, is the protestant Joshua, speaks words of divine authority. A female patient declared that she was a saint, she had the insight of a seer, could read the hearts of men, felt beforehand if anyone died, understood all the four faculties, was comforted by God; another was called the bride of Christ. These delusions are often reflected in all sorts of hallucinations. The patient mentioned saw the child Jesus beside her bed; the light of the monstrance fell on her. She heard God’s voice which gave her commands and imparted answers to thought-questions; she felt at night a warm breath and a face beside her, perceived copulation and then heard the child speak in her belly. The patient, from whom the document quoted originates, saw how the pictures of saints nodded to him, how a radiance shone from his forehead; he heard the voice of his guardian angel, felt an invisible hand on his head, the pricks of the crown of thorns on his skull. Other patients hear hints that they are Emperor or Crown Prince, that they are in the middle of a pile of money, are to get one to two millions; a female patient heard “supernatural things”; it was said, “Thou shalt be the lion for the sin.” On the other hand harmless perceptions are interpreted according to the megalomania. A patient asserted that the reigning prince had appeared in a restaurant for his sake disguised as a “field-worker”; another saw a landlord make movements with his fingers and a guest shake his head in reply; he concluded from this that they wanted to signify to him that he should accept the sum offered to him.

Ideas of exaltation and persecution frequently come into a certain relation to each other. Their conjunction is here, as in several other diseases, so frequent that it can hardly be doubted that there is an inner connection between the two. It is usual to represent it in this way, that the elaborate arrangements which are made to injure them cause the patients to think that there must be some special reason connected with their person, or that the opposition, which stands in the way of the realization of their delusion of greatness, engenders ideas of persecution. Sometimes indeed the patients give utterance to ideas which seem to point to such trains of thought. People are trying to get them out of the way, in order to be able to take possession of their great inheritance; people wish by “court intrigues” to hinder them from making an aristocratic marriage; they are to be made willing by the traps laid for them to marry their persecutor. A female patient thought that her relatives wished to hinder her from marrying till she could no longer have children, in order that she might become a rich old aunt; a patient who considered himself the rightful King of Bavaria stated that the plebs were hostile to him; others are persecuted in order to prevent them from making known their just claims. Meantime the attempts at explanation proffered here by the patients, which moreover often completely break down, are hardly more than reasons thought out after the event; otherwise, indeed, they would come to the surface much sooner. As we shall see later in the delusion of pardon in prisoners, a profound emotional disturbance lasting for a very long time engenders by itself the tendency in some measure to take flight from inexorable reality to a world of pleasing illusions, a process that surely signifies a certain weakening of the psychic power of resistance. As it has to do with a progressive morbid process, it could be understood that the exalted ideas as a rule do not usually appear till the patient has become prepared in the hopeless struggle against hostile powers.

Perception

The perception of the patients is never disordered. They are clear about their surroundings and their position, if the misinterpretations caused by delusions are not considered. Understanding of the disease is completely absent, though a certain morbid feeling appears often to be present at least at the beginning. The substance of the hallucinations of hearing point to that; it is not infrequently related to psychic disorder: “That’s where the silly woman lives,” “We’re going to take him to the mad-house.” Many patients feel themselves “driven to madness,” made to have brain disease, made stupid, their enemies are to make them lose their understanding; others try all sorts of experiments to find out whether it is a case of hallucinations or real perceptions. In the end, however, healthy deliberation is invariably overpowered by the morbid influences, and the patient remains completely deaf to reasoning. A patient declared:

I ride my nag and I do not give the reins to anyone else

A woman said:

If I imagine everything, then I admit that I am a regular fool

But in spite of this she was not able to correct her ideas of persecution; she looked on the supposed bad treatment in the institution as a sort of method of cure by which she should become accustomed to the persecutions outside.

Pseudo-memories

Memory and retention do not in general exhibit any disorders, but delusional pseudo-memories not infrequently come under observation. The patients report that already in their youth they were persecuted, that their experiences were already made public previously in the newspapers, were made known to them, usually with all details; formerly they had not paid any attention to it, but it now occurs to them. A female patient asserted that she had repeatedly been hypnotized and assaulted, but had no idea of it till it now came into her mind again. The validity of their claims has formerly been confirmed to many patients. A patient reported that already in school he was addressed as Prince; his grandfather said to him of William I., “Joseph, that is your grandfather.” Later in the year 1886, he met the Emperor Frederick, who had a cannula in his throat; it was said to him that was his father. It was made very plain to him everywhere; his mother spoke of the Crown Prince; in his sponsor’s letter there was a large sum of money; his aunt wrote to him on the death of the Emperor Frederick; in the tramcar someone said, “That is the German Emperor.” It was said, “Two emperors at the same time, that was a difficult birth,” from which he concluded that he must have had a twin-brother.

Exactly those kinds of delusional experience which one would at first be inclined to trace back to hallucinations often prove on more exact examination to be pseudo-memories. A patient narrated that many years ago a strange man had strewn poisonous powder on his forehead through the crack of the door; at the same time he heard a gold piece jingle as a sign that the man was hired by his enemies. Another patient affirmed that solemn promises were made to him in Parliament from the ministerial bench; a third repeated a host of long conversations, which were connected with his claims to an inheritance, word for word with such detail, as is never possible in real hallucinations, but for pseudo-memories is characteristic. I quote here an example from his numerous notes of the conversations alleged to have been heard by him relating to his claims:

On the 2nd February I was at the funeral of A. at the Auerfried Cemetery. It was half-past two o’clock when I arrived. South from the old mortuary four people preceded me. Furthest to the left there was Joseph R., then his wife, beside her Mrs S., and furthest to the right a man unknown to me with his brown cloak. I was walking only a few steps behind them, and heard every word that was said. Mrs S. said, ‘Oh, how P. (name of the patient) looks; it’s a veritable pity, and he was once such a capable workman; how they have ruined him; that is an abominable injustice.’ Mrs R., ‘And now they want to keep back his money from him too, and he is so much in need of it; just look at him, how he looks, so pitiable!’ R., ‘Of course they would not want to give him the money; they say he does not need it, but they must certainly give it to him; but it will still come to light; then they will be well punished.’ The man on the right, ‘Then doesn’t he know anything of the business?’ Mrs S., ‘He does know something but not rightly.‘

Mood

Mood is at first for the most part anxious, depressed, even despairing, but then becomes more and more suspicious, strained, hostile, threatening. Later, when the exalted ideas come more distinctly into the foreground, the patients become self-conscious, haughty, scornful. They withdraw themselves from the people round them, avoid intercourse, go lonely ways, appear sometimes brusque and unapproachable, sometimes formally polite and dignified, but from time to time may also, where the delusional attitude to their surroundings does not come into consideration, be pleasant and accessible. In their spoken or written statements they are usually skilful and ready, give a connected and reasonable account of things, refute objections, and in doing so readily become impassioned and excited, or they are repellent, will not admit any explanation, declare that it is superfluous, everything is already known without it.

Activities

The activities of the patients are influenced in the most decided way by their delusions. It is true that many patients may continue to live for many years in their usual circumstances without specially severe disorders, but at the same time their whole conduct very soon shows the deep-reaching morbid change which has been accomplished in them. Apart from the fact that they shut themselves up and become gloomy and taciturn, they fall sooner or later into all kinds of disputes. They carry on loud soliloquies, they drum and knock on the furniture in the room, are irritated without recognizable cause; they are abusive, they threaten, they make a noise at night. Many patients defend themselves in despair against the voices, stop their ears, whistle or scream loudly to drown the sound of them. The voices said to a female patient that she should just be violently abusive; she was so aloud or in thought; that helped. A patient was forced by the voices to continual answering by the remark, “Silence gives consent.”

Often there are sudden attacks of anxiety. A patient called loudly for help at night, barricaded himself in his room, and passed a motion on the floor because he did not dare to go to the water-closet. The patients frequently change situation and place of residence; a female patient for years moved from town to town and always after a few months made the discovery that she could not continue in her new home because everyone was already initiated. A patient tried to lead his persecutors astray by giving a false destination aloud on going out.

Sometimes it comes to wholly nonsensical actions probably caused by delusions. A female patient stood for hours in the sun, washed herself in the water-closet, picked the skin off her face because small grains of sand-soap had penetrated it. A physician left his faeces on the table-cloth and gargled with his urine. Very commonly after some time the patients apply to the police, beg for protection against the annoyance, ask for an explanation of what they are accused of, put advertisements in the newspapers to defend themselves against supposed slanders, appeal to the public with a cry of distress. A patient ran through the streets in his shirt in order to force admission to an institution for the insane for the verification of his mental state.

An idea of the struggle which the patients go through is given in the following fragments from letters which a patient threw over the walls of the institution in order to call the attention of passers-by to his circumstances:

When I came to Munich in the year 1875, I was brought by force to the institution for the insane here, for fear I might bring a complaint before the court, although according to a medical certificate and my certificate of service I was physically and mentally perfectly healthy and fit for work and no one could complain of me. As appears from my letters, complaints, and so on, my freedom is taken from me in this institution here principally for the purpose, though hitherto without success, of destroying in every possible way my mental and physical health, for which unprecedented crime the persons who took part in it are responsible. The institution for the insane is wrongfully used for the greatest crimes and serves especially the particular interests of unscrupulous physicians. I live here among wholly demoralized people, who for the most part avoid work, of whom several, as also the so-called attendants, gain their living by continually annoying and disturbing me by all sorts of misconduct and noise. … The superintendent of the institution avoids less and less every day the worst means to disturb me continually in my peace and where possible to get opportunity to have me still more under his power. Every human feeling and decency are here trodden under foot. The physicians often pretend to be insane and to confuse me with some other person. In the interest of order and justice I beg everyone to interest himself in my affairs and to bring them to public discussion.

Self-defence

As the inward tension increases, the patients who see themselves helpless and abandoned to persecution, often undertake self-defence. They call the offending individuals to account, or in petitions to the Emperor explain the whole of the mean fraud which is being carried on with them, or try by deliberate attempts to escape from the detention in the institution for the insane. They overwhelm a policeman with invective, suddenly box the ears of a harmless neighbour at table, by whom they fancy they are abused, throw stones at the passers-by, and finally make dangerous assaults on their supposed persecutors; they become, as the French alienists call it, “persecuteurs persecutes.” A patient shot his landlady from behind as she was passing, without further consideration, because he was convinced that she was going to put him in prison and incite others to murder him; she had rattled with the keys in the morning, carried on a lively conversation with some neighbours who were sick nurses, made signs and laughed sarcastically, so that he thought he was in the greatest danger. Some patients perpetrate attempts at suicide in order to escape from their persecutors.

The exalted ideas may lead to all kinds of morbid actions. The patient goes to the bank to take out the sum standing to his credit,