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this case, and to suggest in what respects it seems to afford us some insight into the processes of delusional formation as a whole, and to indicate some reasons why patients believe in the reality of their phantasies.


The history of the case is briefly as follows: Mr J. is a married man, aged 38. He was the youngest child in a large family and his mother's favourite. The parents belonged to the artisan class and lived in one of the poorer London districts. The father was somewhat addicted to alcohol, but the home was respectable and the children brought up as well as the means of the parents would permit. Mr J. grew up a shy, seclusive, dreamy and clever boy. His studious tendencies enabled him to acquire a good secondary education, and he eventually gained a position in the Civil Service. His industry has enabled him to raise himself above the station in which he was born, and he has achieved a position of moderate comfort. He is happily married and has two nice children.

The first signs of mental disturbance occurred in 1915 when he developed 'neurasthenia' attributable to worry and over-work. Some time later he created a good deal of friction in the family by making ridiculous assertions in regard to the morals of his mother-in-law, and subsequently a paranoid attitude developed. As Mr J. himself describes it, "I gained a general impression that people were against me; a kind of excitement was stirred up against me; nasty insinuations, suggestions and remarks were made; there was a sort of under-current when I appeared." All this time he kept on with his work, but after some trouble with a friend whom he imagined had made reflections of the morals of his (the patient's) mother, he broke down for a time and was sent to hospital. He appeared to recover, however, and resumed his work until shortly before coming under my care. He had then been sleeping badly, had alarmed his wife by muttering to himself and gazing strangely about him, had been sitting about for hours with a vacant expression, and had complained of going into trances and having visions.

The patient was an intelligent and pleasant man who talked freely of his case, but he tended to be solitary and seemed more interested in his own thoughts than anything else. And this was actually the case; he explained that he was constantly disturbed by visions of his past life and he could not concentrate on reading or the ordinary affairs of life because these experiences were so compelling. He did not merely think

of the past; the memories came freely and of their own accord and they were not like ordinary thoughts because they were forced into his mind. and he could not control them. They were so vivid and real that it was just as if he were at the cinematograph. It was as if he were actually living his past life over again; he felt surrounded by the whole atmosphere of the past-the same sights, smells, voices and feelings. He was vague as to whether these experiences were actually due to external influence or not; he thought it all very strange and inexplicable, and though his memories were very amusing, exciting and interesting, he wished he were not troubled in this way because he could not carry on his work.

When asked whether these memory visions referred to any particular experiences of the past the patient replied in the negative, and asserted that anything which had happened to him might be revived in the manner described. This reply was somewhat disappointing because I had come to believe that hallucinatory experiences were associated with some particular theme or trend, and that they were not general and indifferent in content as the patient told me they were in his case. One day, however, I asked him how far back his memories extended and received the astonishing reply that, while until his illness in 1919, when he was in hospital, he could only remember events in his life from the age of four years, since then, memories had come back to him from the age of two onwards. He then explained, with some hesitation, that the memories that were now coming to him in the form of visions referred to experiences that he had entirely forgotten and which had been obliterated from his mind altogether. The experiences, he said, were of such an extraordinary character that he had hitherto refrained from describing them as he feared they would not be credited and he would be regarded as insane. He had no doubt whatever that the visions actually referred to events in which he had taken part; he felt they were his own experiences; they seemed to belong to himself, as it were, and made everything clear in his past life that he had not previously understood. His personality had been a dual one, he said, and the memories which had been driven from his mind were now being restored.

The nature of these 'memories' may now be briefly described. His first recollection was of being, at the age of two, at Balmoral. A group of persons including King Edward, himself, and his real parents (the Earl and Countess of X-) was being painted in the garden by a famous artist. The patient now remembers that this picture was reproduced in a weekly paper though he did not recognize when he saw it that it included himself. In the next vision he sees himself at Windsor. He

was behind a tree with a nurse and King Edward and his parents rode by on horses. The whole experience is so vividly and faithfully reproduced that he can see and actually feel himself stumbling over a branch as he walked forward to watch the distinguished group ride past.

At the age of three the patient now remembers having been through a series of highly dramatic and complex experiences, all of which he can describe with a wealth of detail. He journeyed to Egypt with his parents; met Gordon and was in Khartoum when he was killed (chronologically impossible); travelled over great mountains, sometimes on camels at others on elephants; explored Central Africa; was attacked by fierce hordes of barbarians but escaped; nearly died of thirst in the Sahara, but managed to survive by drinking camel's blood; and eventually after tremendous adventures reached England. The next 'recollection' is of being handed over to those whom he had always regarded as his real parents until these obliterated 'memories' had emerged. He was taken to London by Queen Alexandra in a cab, submitted to a process by his enemies which served to blot out all memory of his past, and handed over to his foster parents.

In addition to these revived 'experiences' which refer to the life of the patient before the age of four, a mass of 'memories' have emerged which refer to his life until quite recently. Thus in vision he sees himself in Paris learning to fence under the tuition of the most famous fencing masters in Europe. One of them fences with great fierceness and the patient realises that an attempt is being made upon his life under pretext of giving a lesson. In another 'memory' the patient sees himself killing this man at Osborne. At the age of 14 he 'remembers' being attacked by three bulls and a woman with a poisoned dagger. He killed the three bulls and made his escape. A wealth of such 'memories' might be given but these will suffice for the present purpose.

As the outcome of these forced 'memories' the patient now exhibits a delusional attitude similar to that occurring in so many asylum cases. He is hostile to his wife whom he believes to be in league with his enemies to deprive him of his rights, he is repellent and haughty to those around him, he writes letters to cabinet ministers on familiar terms as if they were old friends, and signs himself "Rex Imperator, Swordsman, Aga Khan." He believes himself to be the son of exalted parents and the heir to the throne. Having been abducted in childhood and been brought up by foster-parents, he is under the impression that from time to time he has been rendered unconscious and taken from his humble home in order to resume his rightful position. During these periods he has been

the hero of a number of fantastic adventures from which he has emerged victorious, but all the experiences he has been through have been obliterated by a magical process and it is only recently that he has been made aware of them in the manner described. During these forgotten periods he has been trained and educated as a prince; has had numerous attempts made on his life; and has been closely involved in matters of high political importance. In states of unconsciousness he has been brought back to life by sexual intercourse with a number of princesses, and his children born as the outcome of these unions are now ruling in various countries. Thus indirectly he has control of vast territories, and though apparently only a civil servant he exerts an influence all over the world. He is the man behind the scenes- -a hidden source of energy. Thus the patient is a typical paraphrenic with the conventional delusions assuming the forms of megalomania, persecution and eroticism.


In this case the familiar foster-parent phantasy in which the real parents are replaced by imaginary ones of exalted birth finds expression in a delusional form. Otto Rank has shown how frequently this theme occurs in mythical stories and also in the day-dreams of children; here it occurs in an intelligent adult and not merely as a phantasy, but as something believed in and acted upon. The manner in which this delusion developed may now be considered.

Amongst older psychiatrists it was customary to regard the megalomania of paranoid conditions as secondary to delusions of persecution. Thus ideas of greatness have been described as following on ideas of persecution in consequence of the abnormal exaltation of self-feeling which results from protracted conflict with imaginary persecutors; or, more crudely, it was suggested that a person comes to the conclusion. that he is great because of the unwelcome attention he receives. The foster-parent delusion itself has been ascribed to a process of rationalisation. Thus a person who believes himself to be a king finds his admittedly bourgeois extraction is incompatible with his delusion. The notion, therefore, grows up that his parents, as he supposes them to be, are really only foster-parents. This process in which subjectively assured data are transformed so as to harmonise with an incompatible delusion has been described as "retrospective explanatory insanity."

A superficial knowledge of the psychoses suffices to show that such explanations are inadequate to account for the occurrence of delusions. Apart from the fact that megalomania is not necessarily preceded by

ideas of persecution, insane delusions do not develop by processes of reasoning and deduction; a patient does not "come to conclusions" about himself but conclusions are forced upon him. Though comparisons between the mode of development of every-day beliefs and extravagant beliefs of the insane are not without value, the beliefs of the latter cannot be understood by regarding them as merely an exaggeration of the normal. When an otherwise sensible person (as in the case described) entertains grotesque and untrue opinions about his personality, we may be quite sure that the processes of which they are the outcome have but little or no relationship to those occurring in the normal person. Even though modern psycho-pathology, based as it is in a great measure on the study of the psycho-neuroses, has enabled us to understand our insane cases in a manner which was previously impossible, there has perhaps been a tendency to over-emphasise the resemblances between the psychoses and psycho-neuroses, and to neglect the very important differences between them.

A child or neurotic might indulge in a foster-parent phantasy similar in structure to that exhibited by our patient; and in all three cases it would be correct to describe the phantasies as instances of wish-fulfilment. Here, however, the resemblances cease and a vital difference emerges, namely, a difference in attitude or feeling towards the phantasy on the part of its subject. In the child or neurotic the phantasy, though lived-through intensely and thoroughly enjoyed, is known to be imaginary, whilst in the insane it is believed to be real. Why should a phantasy be invested with a belief-feeling as to its reality in some cases (psychoses), and not in others (psycho-neuroses)? The subject is obscure, but we may proceed to consider it in the light of the facts observed in the case of Mr J.

As has been shown, the patient now believes himself to be Thomas Rex, Swordsman, Aga Khan, though he is actually Mr J., a civil servant, a fact of which he is at the same time equally cognisant. The problem to be considered is why he should believe himself to be, rather than merely picture or imagine himself to be, these personages. Fortunately we are not here hampered by a patient who confined himself to dogmatic assertions; he was able to give some description of the manner in which his delusions developed, and he made it clear that they were the product of false-memories. Why then should the images which surged into the mind of the patient have been regarded by him as a revival of episodes in which he had personally taken part-as actual events in his lifehistory. The question is all the more difficult because normal memory has never yet been completely analysed or explained. The most recent

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