Case CL

Madame D., daughter of a celebrated physician, well educated, gifted with a sound judgment, a very good musician, and never having had any disease in the ear, has, for many years, had an hallucination of hearing, which consists in the repetition of a musical phrase for several consecutive hours. This lady has frequently noted these musical airs, but has never found them worth the trouble of preserving. They are at times regular melodies, but presenting nothing original, and yet nothing popularly known; at other times they are only incoherent notes.

This lady is conscious that she is the sport of an hallucination; she is no way influenced by it, but yet cannot rid herself of it. The musical airs having continued for a time, cease, to return at intervals.

M. Meniere, to whom we are indebted for this case, has on several occasions examined the lady; he has not found any defect in the ear. In a word, the characteristic remains decided and pathognomonic, which, to our minds, irrevocably settles the question of the inutility of an external impression in hallucination; whilst in illusion it is indispensable. There can be no illusion, without an image; whilst the blind and deaf have hallucinations. We might add that the conduct of the hallucinated may be consistent with reason, and that the false sensation may long exist unperceived, whilst illusion will not escape notice, and will finally place any one exhibiting its symptoms amongst the insane.

The form of alienation may render its diagnosis uncertain. Thus, with maniacs, it is sometimes impossible to recognize the kind of hallucination, or to distinguish it from illusion, because the sensations of the patient are all internal. His actions can alone guide the judgment of the physician.

Prognosis. - Hallucinations are regarded as a very unfavorable sign in insanity; those which are material and simple offer, it is said, a less chance of cure than those which arise as a symptom of another form of delirium. These general principles require some development. Solitary hallucinations, which appear suddenly in individuals who have no sign of insanity, are quickly cured; so it is with those consequent on the abuse of strong drink; they cease with the cause. Hallucinations dependent on a febrile state without mental alienation, pass away with the disease. Hallucinations occasioned by narcotic substances, are dispelled when the action of the substance ceases.

The prognosis differs with mental diseases. In active and recent monomania, the hallucinations have but slight influence; it is not so in melancholy monomania, especially if characterized by the idea of a bad action, the fear of damnation, or any cause of alarm; they add to the evil, and often provoke to suicide.

The hallucinations of mania may be rendered dangerous by the resolutions which they induce, often driving the alienated to inconsiderate acts; so that a maniac, hearing a voice calling to him from the street, may throw himself out of the window. There is no doubt that suicide, in this kind of madness, has often been caused by hallucinations; and when combined with illusion, as is often the case, the madman may become a homicide. At other times, he gives way to transports of blind rage; tears, destroys, and knocks down any one who opposes him; because he incessantly hears evil and taunting voices. The duration of hallucinations is generally short and fugitive in acute mania; and often, in chronic mania, they are as versatile as the ideas of the maniac

Puerperal mania may be combined with hallucinations; but this species Of madness being, in general, rapidly cured, the symptom is very unimportant.

The hallucinations of acute dementia are rare and of little consequence.

Hallucinations in dementia have but a relative influence; they become weaker and disappear with the progression of the disease. It is, however, not unusual for hallucinations in maniac and monomaniac dementia to last for several years; we have noticed them in cases of this character for six or seven years after their first appearance. Their importance in this form of alienation depends on the recrudescences, which give more intensity to hallucinations and aggravate the condition of the patient They are sometimes a bad symptom when connected with mournful ideas, because they agitate the patient, disturb his repose, and deprive him of sleep. The hallucinations remarked in some cases of general paralysis with dementia, adds but little to the severity of the alienation, but they contribute to distress the sufferer, by giving fresh impetus to his deadened impressions.

When hallucinations have existed for a great length of time, the prognostic becomes more serious, and the difficulty of eradicating them is increased. Whatever may have been their origin, they must necessarily have produced a modification in the cerebral texture, a faulty direction of that organ; and it is more difficult to discover a remedy, because the modification itself is entirely unknown to us. We do not dispute that hallucinations of long standing have been cured; but these cases belong to the catalogue of chronic diseases, the cures of which are reported, but from which it is not possible to form a doctrine. We have read of more than twenty cases of persons who have been insane for seven, eight, ten, and fifteen years, who have been suddenly cured by a wound, a fall, or a sudden immersion. These are exceptional cases, which cannot serve as rules for conduct. Their authenticity, however, prevents a too absolute assertion of the incurability of hallucinations of long existence.

The prolonged duration of hallucinations produces besides a psychological phenomenon which accounts for the difficulty of their cure. In fact, hallucinations haying been fixed and distinct for years, tends, by the constant repetition of the same act, to become confused and volatile, and to transform itself into another, or even to pass into a state of general hallucination.

A simple hallucination is more readily cured than when it is combined with others. If an hallucination of all the senses occurs from the commencement, the prognosis is serious, because it announces a deep and intense cerebral disorder.

When the hallucinated are conscious of the falsity of their impressions, the prognosis is unimportant; the remark applies equally to those who, in giving credence to their hallucinations, do not act under their influence; but when hallucinations are prolonged, and above all exist in individuals predisposed to madness, or of weak, superstitious, and ignorant minds, they are frequently of extreme tenacity.

Hallucinations observable in hypochondria and epilepsy increase the severity of those diseases; they are often dangerous in epilepsy, by the actions to which they excite the patient. Hallucinations combined with illusions of taste, touch, and smell are often very obstinate, particularly when the patients think that their food is poisoned, and that their death is being compassed by pestilential odors, etc.

Recapitulation. - Progress and duration. Hallucinations may be remittent, irregular, diurnal, nocturnal, intermittent, or periodical. They are more rarely constant.

Different causes may diminish the intensity of hallucinations, or even suspend them.

The progress of hallucinations vary, according to the form or character of the madness. The same occurs with the type.

The duration of hallucinations is very variable; some last only a few hours - others during a whole lifetime.

The forms of insanity influence their duration.

Diagnosis. - The difficulty of the diagnosis exists when the individuals keep silence.

In a doubtful case, the conversations, actions, and writings must be examined.

The characteristics of nocturnal hallucinations, somnambulism and ecstasy, differ from hallucinations.

Hallucinations are distinguished from illusions under certain relations.

Hallucinations are sometimes difficult of discovery from the different forms which insanity assumes.

Prognosis. - Single hallucinations which appear suddenly; those uncombined with insanity; the hallucinations of delirium tremens, and of febrile delirium, are, in general, very easily cured.

The hallucinations caused by narcotic substances disappear so soon as the substance ceases to act on the system.

Monomania of a lively character, and of recent occurrence, is only slightly influenced by hallucinations; it is otherwise in that of a mournful character, which frequently receives from them the most unfortunate impulses.

The prognoses are varied according to the form of insanity. Hallucinations may be dangerous in mania by the acts which they incite.

The hallucinations of puerperal mania, of acute dementia, and of dementia, possess only a relative influence, excepting in some rare examples. It is the same in dementia with general paralysis.

Hallucinations of long existence add to the seriousness of the prognosis. The fact that some very prolonged hallucinations have been cured cannot alter the rule.

The nature of hallucinations is modified by their prolonged duration.

The prognosis of simple hallucinations is more favorable than those of general hallucination.

The prognosis of hallucinations compatible with reason is of slight consequence, especially when they last but a short time.

Hallucinations of nervous diseases other than insanity, such as hypochondria and epilepsy, augment the serious nature of these affections. In acute inflammatory, chronic, and other diseases, hallucinations are in general transient, but they should not be the less carefully watched. It is often difficult to eradicate hallucinations which are combined with certain illusions.