Hans Förstl


Karl Philipp Moritz

Sonderbare Gemüthsbeschaffenheit eines alten Mannes, der sich einbildete, dass er geschlachtet werden solle.

'The strange mental state of an old man who thought he would be slaughtered'
 -an early report of dementia with delusion

(The ease of a 75-year-old patient with dementia was published in 1785. As well as severe memory impairment, the patient suffered the tormenting delusion that he was persecuted by a tall black man who wanted to kill him and that his flesh would be used to make sausages. There are several anecdotal case reports of dementia and numerous speculative conceptual outlines of dementing disorders under various headings, like 'lethargie' (Cosin, 1592), 'stupidity' (Willis, 1684) or 'insensitivity' (Battie, 1758) before 1800. Detailed early reports of demented patients with psychotic symptoms are, however, rare. Gnothi Sauton (Journal of Empirical Psychology) which was published from 1783 to 1793, was the first journal specializing in psychological and psychiatric issues. Besides theoretical articles it contained case reports on psychiatric and neurological disorders. In 1785 two contributors discussed the case of  Johann Christoph Becker, a 75-year-old man, who suffered from cognitive impairment and delusions:) 

The strange mental state of an old man who thought he would be slaughtered '

Johann Christoph Becker, (this is the name of the man about whose strange mental state I am now tempted to inform you) was born in the year 1710 in Halberstadt of a poor family and still lives in Quedlinburg, where he has been in the service of the abbey there for more than 40 years as messenger to the prior. He has never shown subtle intellect or open-mindedness, as one sometimes finds even in such people. Although always a little simple, he has observed his duties most reliably and honestly, so that I cannot report any unfaithfulness or malice occurring during the seven years he has been in my service. I received the same information from my father, who held my position before and in whose service he had been for more than thirty years. Despite his simple-mindedness he had always understood how to amuse people of his class without being vulgar. He had always read a lot of history books, and from these he kept old stories and anecdotes in his head, which he knew to use at the right time. His was the job of TAX-COLLECTOR, and as he was in charge of this duty for more than forty years, there were hardly any fields in the abbey's wide lands, whose owners or whose landrights he would not have known. Despite this ability, it was not difficult to confuse him, particularly ifhe was distracted from his normal routine in any way. For 12 to 15 years his memory had started to deteriorate and this defect increased noticeably from time to time. One had to give orders more than once for hirn to understand and not to forget them, - but still he often made mistakes in carrying them out. He could not be given more than one instruction at a time without mixing them up. For the past 5 years his memory has finally decayed so that by the time he gets downstairs he has forgotten everything I had just told him in my upper room. Therefore I had to prepare a list and to write down on it everything he should do. But in the end even that did not help any more, because he forgot the context. When he arrived at his destination he could not - in spite of the list - remember what to say or how to proceed. However, even then he still retained his common sense, saw his own mistakes and asked for patience, because there was nothing he could do about it. Under these circumstances he became completely unsuitable for his post and he could not carry out his duties any longer. Her Grace the Prioress, however, did not want to dismiss him, because he, now an old man, had always been honest. Her Grace therefore decreed 2 years ago that he could be supported by his son, but that the old man should keep all the revenues of his position apart from some little incidental earnings, for the rest of his life, and that his son should receive a special payment for this time. From that time, I would say, almost from the very day when he received this benefit which he had himself asked for, and as soon as he was discharged from any occupation, his reason began to fail and a11 his mental faculties decayed noticeably. His memory has abandoned him more and more as each day has passed. It is quite striking that he can still remember those things that had occurred 30 to 40 years ago, especially if they had happened to HIMSELF. He has not forgotten anything about the taxes he had to collect or about any other details. For one year now he keeps the distressing thought in his head THAT HE SHALL BE SLAUGHTERED AND THAT SAUSAGES SHALL BE MADE FROM HIS FLESH. Nobody can take this thought away from him. I am sufficiently convinced that he does not SIMULATE this condition, because he had never had the wickedness nor enough intelligence to play such a role. Furthermore, he looks miserable from fear and anxiety throughout the day, and he cannot find rest during the night.
Very often he gets up at night to prepare for his death. He gets dressed and claims fiercely that a carriage is waiting outside the door, which will take him to his doom. Very often I have encouraged him to come to me and to try and expel his insane ideas by reason. He listens carefully and assures me that he finds much consolation in my ideas. Often he comes back to me on his own to complain about his misery. I then use all my eloquence to comfort him and he is quite calm when he goes away. This relief only lasts for one or two days before the old ideas wake in his mind and all consolation vanishes. He complains that a tall noble man, whom he cannot evade, is after his life. Talking to him requires the utmost care in order to avoid any apparently rough phrase, which would be taken to suggest that one is his enemy, wanting to kill him. He often jumps up at night and goes to the fields to collect taxes. Quite often he wants to beat his wife (whom he did not get along with in former times), but he stops immediately when she says she will denounce him to his master, because he is very timid. The more his physical strength obviously decays, the less peace he finds at night-time (because he hardly ever sleeps). He still has a strong appetite, and eats enormously for a 75-yearold man. His greatest concern, which he often mentions, is WHETHER HE SHALL HA VE BREAD FŸR THE REST OF HIS LIFE. If his foolish phantasies are expelled from his mind, he gets insight into his folly. There are also hours when he will talk about it quite freely complaining of the turmoil in his mind. This, however, never lasts very long before he falls back into his former condition. He has never been very religious, and he has also never been a drunkard. I am not surprised by the fact that his memory failed in his old age. But I cannot think of any reason why he should suddenly hit upon the unfortunate and uncorrectable thought THAT HE SHOULD BE SLAUGHTERED.'
to the mental disease history of
Johann Christoph Becker
'For as long as I have known him, this man has always had a somewhat STARING gaze. When he has had to wait for something for some time, he would sit down, and was able to stare at ONE spot on the floor for half an hour or even longer. He has also always been a little credulous. If he once believed that something was true, no man was able to expel this belief. As far as I know, he has never experienced GREAT MISFORTUNE apart from some little trouble in the education of his children in FORMER DAYS. He has always been a little SUSPICIOUS and DISTRUSTFUL towards other people. Even when the idea that he should be murdered comes to his mind during day or night-time and when he then suffers great fear, he is still afraid that his master might hear about it. When kind people offer him food, but do not look friendly, he will not eat, because he suspects someone is trying to poison him.'

(translated by Hans Förstl, Robert Howard, Alitair Burns, and Raymond Levy; a complete version was published in the “Journal of the Royal Society of Medicine” 1991:
The term and the concept of 'dementia' had been in use long before 1800. It was, however, not before the Age of Enlightenment that the term and subject were well defined and it was not until the end of the 19th century that relevant neuropathological evidence for the underlying diseases was diseovered1. Due to the lack of clear concepts and terms and due to the low life expectancy up to 1800, dementia had not been a favourite topic. Therefore the in-depth description of this single case deserves particular interest as it addresses issues which gained paramount importance more than a century later. The original authors of this report presented a detailed account of the patient's pre-morbid personality4,5; how at the age of 60 he began to experience deterioration of his short-term memory with preserva tion of his long-term memory and character. At 74 he developed the delusional conviction that he was to be killed and made into sausages. He became restless at night, episodically aggressive, and lost weight despite a good appetite. Neither religion - the great foe of many authors of the Enlightenment - nor alcohol could explain his disturbance, The first author stated that he was more puzzled and attracted by the delusion than by the presumably age-related cognitive decline. The anonymous first author dismissed the possibility that the patient could have simulated the disturbance. 'Vesanic dementia', a psychotic defective state appears quite unlikely in few of the prominent memory disorders. In general paralysis, neurological symptoms and grandiose delusions would be expected. However, the symptoms closely resemble the symptoms of dementia as delineated in modern diagnostic criteria. The phenomenology in this case fulfils the definition of delusion as it is firmly fixed and impervious to evidence to the contrary. Alzheimer's original description was of a patient with hallucinations and delusions, yet the majority of research has focused on the cognitive deficit. Presumably this is because disorders of cognition were considered the primary manifestation and the psychiatric disturbance was therefore secondary and hence of secondary importance. )