MELANC H O L I A, MONOMANIA.

•
M E L A N C H O L I A,
MONOMANIA.
'WO CLINICAL LECTURES, DELIVER-D NOVEMBER, 1885, AT THE
PHILADELPHIA HOSPITAL;
BY
II. C. W O O D , M.D., LL.D.
REPRINTED
FROM THE THERAPEUTIC
GAZETTE,
DECEMBEK 15, 1885, AND JANUARY
15,
E_
DONATES BY
MELANCHOLIA.
p E N T L E M E N : — I propose to-day to call long enough to enable us to determine the
V J attention t o t h e form of insanity known result of treatment.
as melancholia. Of all forms of insanity it is
T h e relation between oxaluria and melanthe one which most frequently comes under cholia is not yet made out. It is rather strange
the treatment of t h e general practitioner, and that those who have large opportunities in
in which we find the most complete series of asylums do not follow out closely this line of
grades between a state of intellectual health clinical research. Clinically we find two sets
and the most intense mental disease.
of cases in which there is melancholia associT h e r e is a condition of the b o d y in which ated with oxaluria. In one class, under the
we find associated with a g r e a t deal of de- use of nitro-muriatic acid, the oxaluria dispression and a certain a m o u n t of weakness, the appears, and the melancholia melts away with
presence of oxalate of calcium in the urine, t h e oxaluria. In the second class nitro-muriand occasionally, although not always, dys- atic acid fails to remove the oxaluria, and at
peptic symptoms. T h i s condition, we know, is the same time fails to remove the melancholia.
largely relieved a n d frequently cured by the What the relation is between oxalic acid in
free administration of nitro-muriatic acid with the urine and the brain-symptoms is unceran occasional purgative. This, so called, ox- tain ; but these two classes do occur clinicaluria ought in my opinion to be considered ally, and it is important to recognize their
existence.
the slightest form of melancholia.
Passing on to fully-formed melancholia, we
As an instance of it, let me describe a case
which came u n d e r m y care two or three weeks have a disease in which the basal condition is a
ago. A young, active business man, about 25 profound emotional depression. In a large
years of age, came t o me, stating that he did proportion of cases of so-called melancholia,
not know what was t h e matter with him', that even in cases found in asylums, there is no
he was exceedingly depressed, had lost interest fully-formed intellectual insanity, but merely
in his business, and that the whole world looked an emotional depression. T h e patient fails
to him as t h o u g h it were going to ruin. I found to be interested in the life around him, not
his urine loaded with crystals of t h e oxalate of because he is incapable of understanding the
problems of life, but because nothing but
calpium.
himself
is of interest to him or occupies his
Very recently I was consulted by a gentleman living in t h e central part of the State. thoughts. In the lighter degrees of the affecIn this case the attack dated from some love- tion the patient will tell you that he is horribly
trouble. As a consequence, the patient had depressed and cares for nothing. T h e man or
become apathetic, had abandoned his busi- woman sits all day in a chair, quiet, perhaps
ness, a n d sat most of the time in a condition with the hands folded, seemingly thinking of
of semi-stupor, paying no attention to his nothing, with an expression of perfect indifsurroundings. I was consulted as to the ad- ference and apathy on his or her countenance.
T h e r e is no interest in business, because the
visability of asylum treatment.
Examination
interest is all the time centred in the man himof t h e urine showed a b u n d a n t crystals of oxself. T h e r e is no interest in wife and family,
alate of calcium. T h i s case was, as you see,
not because the relations are not recognized,
more severe than the first, in which the sympbut because the man is absorbed in nursing
toms were so slight that nothing strange in the
t h e phantom spirit which oppresses him.
man's behavior was remarked by his friends.
Then we go a step further, or we see a
In both cases the urine contained oxalate of
change
come over such a person. Instead of
c l l c i u m . U n d e r treatment the first patient
simple
apathy,
there is wringing of the hands
f_s decidedly improved. In the second case
and
perpetual
moaning
and lamentation, n
; the patient has not been under observation
MELANCHOLIA.
Tor any definite reason that the patient can
assign, but simply because of the depression
of spirits. Under these circumstances it will
be found that all the thoughts of the patient
are tinctured with this emotional depression.
If the man is a business man, he sees nothing
but ruin before him. If he has a conscience
which is not void of offence, the memory of
his past misdeeds, like a Nemesis, forever
haunts him. If his children are ill, they are
going to be swept away to death. The whole
landscape is covered with a black cloud, which
throws everything into the darkest shadows.
Nevertheless there may be even yet no intellectual delusions. When the patient is aroused
he talks well and reasons well. If you can
get him to forget himself for a moment his
intellectual actions are perfect. After a time
delusions make their appearance. They usually develop gradually, and not rarely are the
outcome of some real feeling which the patient
has.
The first case which I propose to show you
illustrates the simplest form of melancholia,
in which at present there is no delusion, although there was at one time a slight delusion
of a hypochondriacal nature. This patient,
A. W., aged 55 years, has led an active, temperate life, and there is no history of hereditary taint. Nevertheless she was admitted to
the Philadelphia Hospital in January, 1885.
She is, as you see, thin and frail-looking.
This attack, which is the first that she has
suffered, began in May, 1883, at which time
the symptoms were insomnia, depression of
spirits, and restlessness. On admission she
seemed much depressed. She had attacks in
which she cried, lamented, and wrung her
hands. She was careless and untidy in her
dress. Let me say, en passant, the carelessness in dress in melancholia differs from the
carelessness in mania. In melancholia it
grows out of the depression of spirits. The
patient feels that it makes no difference how
such a miserable wretch as he is dressed. He
is untidy, not actively, but apathetically. At
the time of admission the patient answered
questions intelligently. Her memory was
good. No delusions were detected.
One week after admission it is noted " that
the patient has been restless and melancholy;
wrings her hands and sways backward and
forward, repeating constantly the phrase,
'What shall I do? What shall I do?' This
she sometimes continues for hours. She is
unwilling to join in any amusement, and can
give no cause for her grief." This perpetual
repetition of a phrase is very common in mel-
ancholia, but it is also seen in other forms of
insanity.
When asked what troubles her, our patient
always answers, " I worry so, I am not like
myself at all." She sleeps well the earlier
part of the night, but wakes about three
o'clock in the morning, and begins to cry and
lament. You will frequently notice in these
cases that they are more depressed in the
morning than towards night.
After being in the house some months the
patient objected to taking out-door exercise
because, as she said, it was making her as
hard as iron to go out so much. She objected
to taking medicine for the same reason. She
also said that her head, her teeth, and her flesh
were growing as hard as iron. This is the only
trace of a delusion that we can get in the history of this patient, who has been under observation nearly a year. This delusion did not
appear until she had been melancholic for
eight or ten months.
On questioning the patient I find that she
is not at present so sure about the delusion
as she used to be, and appears, therefore, to
be better. As she sits here she talks as rationally as any ordinary person of her class, yet
she is undoubtedly a case of melancholia, and
for a large portion of her time she still sits
and wrings her hands with a perpetual moan
over a nameless woe. This is a purely emotional condition, not an intellectual state.
This patient was well fed before being attacked with the melancholia, and during the
early part of her attack her appetite was good.
This differs from the history of most cases of
this affection. Usually it will be found that
the pulse is slow, especially in the earlier parts
of the attack, that the tongue is heavily coated,
that the breath is foul, that the appetite is
impaired, and that the bowels are constipated. Frequently there is rapid loss of flesh,
in spite of all the feeding that you can give
the patient. Under these circumstances the
patient entirely loathes food, and this for two
reasons : in the first place, because food is
physically disagreeable to him, because there
is such a condition of the prima? viae that
there is no appetite, or worse than no appetite ; in the second place, because life is more
miserable than death. Often there is a suicidal
undertone in the refusal; and again the patient
says to himself, " T h e r e is no use in feeding
such a miserable wretch as I am; I am not
worth feeding."
These cases of simple melancholia reqmr
careful watching, because it is in them
suicide and even homicide are probably
MELANCHOLIA.
frequently committed than in any other form vapors or horridly fetid
of insanity. There may be no distinct hallu- continually oppress them. exhalations which
cination or delusion, and yet the patient beWe find that according to the nature of the
comes so thoroughly miserable and wretched delusion we have different forms of melanthat life is thrown away because death is con- cholia. Thus, there is hypochondriacal melsidered the better fate.
ancholia, in which the delusions relate to some
Such a patient as this is still capable of in- portion of the person's body. It is curious to
tellectual life. Nearly all Americans have a note that in a large proportion of instances
belief in a future world, and frequently you the delusion centres around the sexual organs.
can prevent suicide by working on the fears They are, however, frequently connected with
of the patient. I have had patients whom I the abdominal organs, and more rarely with
was perfectly willing to trust alone, and who, the limbs. I think that where there is a
I am certain, would have committed suicide if hypochondriacal delusion locating itself in
they had not been afraid of what they believed some one organ there is almost always some
came after death. It was the fear of the discomfort in that organ. A man who has a
future that restrained them. If you take a little dyspepsia magnifies that into compjete
person whose education has been such that loss of digestion, and believes that he has no
he has no belief in a future existence, when stomach, or perhaps will insist that food drops
he becomes insane a great preventive of right through him. A man who has a sexual
suicide is wanting. Such cases must be delusion very frequently has a history of maswatched more closely than those who have a turbation or of some trouble connected with
religious belief. In those cases of suicide these organs.
and homicide in which mothers destroy their
Our next patient is one whom I have never
children and then commit suicide, it will seen before, sent here to take the place of one
be found nearly always that the mothers I had selected to bring before you, but who
were suffering with true melancholia or with was taken acutely ill last night. The history
melancholic monomania, and the mother has of this case is as follows :
reasoned that for herself and for her offspring
J. F. was admitted to the hospital two years
death was preferable to a miserable existence. ago. His age at admission was 30 years.
When we go a step further in melancholia There is a marked family predisposition to
we have both hallucinations and delusions. insanity, as shown by the fact that both his
These appear sometimes earlier and some- father and sister committed suicide. Two
times later, but they always take the depres- maternal uncles are stated to have died of
sive type. Hallucinations of hearing are the paralysis. Another uncle died a drunkard.
most frequent. The patient hears voices, but The patient had always been childish, but
these are evil voices. Those who have com- tractable and gentle. He is said to have
mitted murder have sometimes asserted that been of an unsociable disposition, always prethey had two voices in them, one saying, ferring solitude and isolation. He has been
" Kill! kill!" the other voice trying to restrain addicted to alcoholic excesses. Despite the
them. Men have held their hands in the fire statements of early feebleness of intellect, the
until they were burnt black, because they patient can read and write, and possesses
have heard voices telling them that it was considerable musical ability. He is said to
better to enter into the next world maimed have had a violent acute attack of insanity in
than to go with a whole hand guilty of blood 1877, which lasted four months, but of what
or other offence.
type is not known. In 1879 it is alleged that
Sometimes hallucinations of sight occur, he had an attack of sunstroke.
On admission he-appeared to be in wretched
but these are less common than hallucinations of hearing. Troops of demons pass physical health. He was continually thinking
before the patient. Spirits from the other and talking about himself, looking at himself
world come before him, but it is never angels in a glass, and showing every evidence of inor spirits from heaven, but always sights of tense anxiety and alarm. His predominant
delusion was that he had hydrophobia, and ocsorrow and of woe.
casionally
he showed a disposition to bite his
Delusions of touch are rare, and delusions
fellow-patients.
This delusion remained in
of smell are still more uncommon. I do not
full
force
for
about
one year, when he sudrecall a case in which I have seen a patient
Wch delusions of smell. They, however, are denly imagined that he had poisoned himself
occasionally present. The melancholic never with carbolic acid. Since then this has been
mell pleasant odors. It is always sulphurous his main delusion.
JL
ft
MELANCHOLIA.
"Well, John, did you think you had hydrophobia?" " Y e s , sir."
" How did you get it ?" " A dog bit me on
the arm."
" How did you feel then ?" " Felt bad."
The resident (Dr. Henry) tells me that
there is an old scar on his arm, and he believes that the man was bitten by a dog.
" What did you do when you had the hydrophobia?" " I stayed in bed five days."
" W h a t cured you?" " I took medicine
and got well."
" What is the matter with you now ? Tell
us about i t " " I got poisoned with carbolic
acid I put my fingers in carbolic acid when
we were washing the floors, and I put it on
my tongue, and it burns all inside. I got two
drops on my finger."
" Does it burn anywhere else ?" " It burns
around the heart and in the stomach."
" H o w long since you got this carbolic
acid ?" " Two years ago."
Our conversation with this unfortunate
shows that he reasons so much about his delusions that I am uncertain whether we ought
not to consider him as rather suffering from
depressive monomania than from melancholia.
His delusions are somewhat systematized, but
this is a matter whose detailed discussion I
must postpone until my next lecture, the subject of which is monomania.
I learn that our patient did get a very small
amount of carbolic acid solution on his tongue.
The delusion consists in taking a small fact
and magnifying it until it overshadows the
whole life of the individual, being incapable
of receiving evidence about it.
This reminds me to speak of a condition
which is very common in melancholia,—that
is, micromania. This does not belong exclusively to hypochondriasis ; I have seen
it in incipient sclerosis of the brain cortex.
in senile dementia, etc. It is a condition in
which a small thought is magnified by the
patient until it becomes his main thought.
Matters of importance sink out of sight, while
the most trivial things become the basis of an
incessant stream of talk.
Another form of melancholia is the so-called
religious melancholia, in which the delusions
are connected with matters of religion. Under
these circumstances there is nearly always in
the past history a devotional, or what might,
Without any irreverence, be called the re'
ngious temperament.
This patient is Bridget M., 46 years of age,
who was admitted to the hospital about thfee
months ago. She is a healthy-looking Irish
woman, fairly well nourished. The attack of
insanity began about three months before admission. At that time she showed marked
symptoms of melancholia. She thought that
she had taken communion without perfect
faith that the bread and wine were the body
and blood of Christ, and that her soul was
lost on account of this. For seven months
previous to .the attack she complained of
buzzing in the left ear. There is now some
impairment of hearing on that side. When
admitted she was much depressed in spirit,
and went about exclaiming that she was lost,
that she was doomed to perdition. She says
that she is not insane, and that nothing ails
her except want of faith. She has led an active, industrious life, and there is no history
of insanity in the family. In good weather
she spends most of her time out of doors,
where she will sit for hours, rocking herself
back and forth, wringing her hands, and crying, in a singsong tone, "Why was I born,
and what will I do ? Why was I born, and
what will I do ?" She seems utterly miserable,
and thinks that she is lost beyond redemption.
During the past month she laments much less
than previously, and her belief in the delusion
appears to be not as strong as formerly. This
is a typical case of a religious melancholia in
an improving condition. In the fully-formed
affection the patient sits, constantly wrings
her hands, and cries, and has no thought for
anything but her own woe.
I wish, in the next place, to show you a
patient who illustrates a form of the disease
known as melancholia agitata. It is, however, not a typical case. There are cases of
melancholia in which the patient, instead of
being apathetic, is excited and continually in
motion, and perhaps tears his clothing and
becomes very violent.
This melancholic
frenzy may closely simulate mania, but it
may be readily diagnosed by the past history
of the patient. Moreover, it can usually be
made out that the individual is violent from
fear rather than from aggressiveness.
The history of this patient is as follows:
Alice 1$., 25 years old, single, was admitted
one month ago. The patient is a slender,
delicate-looking woman, fairly well nourished.
No history of her attack can be obtained.
She seems to be depressed in spirits, and cries
frequently when talking. She answers questions rationally, but is apt to become incoherent and excited. She has various delusions of a depressing nature. She thinks tha
she is surrounded by enemies, and that sh«^
is suffering for her father's sake.
MELANCHOLIA.
Let us see what we can learn from the
patient herself.
"Tell us when you heard from your father
last." "I can't; I am too excited. Bring
Dr. Richardson forth. Correct. That will
do. No, sir."
"Alice, did you see your father last night ?"
"He was sick. He was in Milwaukee, Wisconsin."
"Did he get well ?" " He died. He went
to purgatory, certain."
"Is he there still ?" "Certainly not. No,
sir. He got out because I suffered for him."
"Have you heard from him lately?" "I
saw his ghost plenty of times, and heard him
talk. Hain't that enough for yees?"
"What did he say?" " He said he was in
purgatory, sure."
"Did he have a good time?" " H e suffered. That was for what he did to my
mother. He was a drupkard. He suffered
for his sins."
This case illustrates another point,—that is,
in some cases, especially where melancholia
is associated with frenzy, the patient is not
always depressed. There are intervals in
which the condition resembles mania rather
than melancholia. Melancholiac frenzy is to
be distinguished from mania by the undercurrent of fear and depression, and by the
fact that the delusions are of a depressing
nature.
A man who is suffering from acute mania
perpetually changes his delusions. They are
unstable. They are fixed in the sense that
he believes them at the time, but there is a
continual change in the delusions. It is about
one thing one minute or one day, and something else the next minute or the next day.
In melancholia the delusion continues the
same for weeks at a time.
Observe the appearance of this woman now.
A moment ago her face was lit up with agitation and excitement, but now that has passed
away, and you see the expression of depression
and of melancholia.
"Are you sure you saw your father?" "I
saw his head the other day. I heard him
swear."
" Does your father ever touch you ?" " No,
sir. I was not crazy. I saw my father. My
brother's trouble made me crazy.
John
Brown, come forth ! Student of the medical
department, come forth ! Now swear him in.
Hurrah !"
" I s your brother dead?" " N o , sir. He
Is married and got a wife."
You see that this woman has delusions of
hearing and of sight, but she has no delusions
of touch or of smell.
I shall occupy most of the few remaining
moments of the hour in speaking of the termination of melancholia, and narrating certain
cases which have come under my observation,
which throw light, or rather which cast a shadow
upon the question of the nature of the change
in this disease. In most cases of melancholia
the recovery is slow. The prognosis in melancholia is much more unfavorable than in mania;
and while in the majority of cases recovery,
when it does take place, is gradual, yet there
are cases in which the patient gets well almost
at once. It is these cases which to my mind
show the great improbability of our ever understanding the pathology of melancholia.
The first case that I shall relate is that of a
lady with whom I was thrown in almost daily
contact for many years. At the age of 45
she was taken with religious melancholia of
the most pronounced character, which for
many years was accompanied with agitation,
and sometimes with frenzy. This persisted
for fifteen years. There had been in all this
time not the slightest wavering of the mind
of that woman in regard to her future life.
She firmly believed that her soul was irretrievably lost. At the same time her general
emotional nature had undergone a retrograde
change ; she had become exceedingly jealous
of attentions paid to other persons, and she
had lost many of the peculiar traits of refinement which had been her especial characteristic. After being in an asylum for some
time she recovered intellectual power sufficient to take charge of her husband's house
with the assistance of an attendant, but there
was no wavering in her delusion or let-up in
her misery.
One night the attendant noticed this lady
on her knees at the bedside. This was the
first time in fifteen years that she had been
known to kneel in prayer. The nurse, being
a wise woman, did not disturb her, and there
she remained all night. In the morning she
came together with the family, and said that
she had found Christ, and that she was perfectly well and happy. Her old disposition
had returned, and her peculiar jealous sensitiveness had disappeared. The woman that
had been buried for fifteen years had emerged
in one night without even the grave-clothes
about her. This continued for o n e ^
Then the old cloud came on her, and for days
she was in the old condition; but sudd n7
the sunlight again broke through the d o ^
and she remained well for three or four days,
MELANCHOLIA.
to relapse, and after some hours again to
regain her sanity. These attacks continued
to recur at gradually lengthening intervals.
Finally she had been perfectly sane for several consecutive months, when suddenly she
was seized with a serous diarrhoea, causeless as far as could be ascertained, and hopeless as far as relief by remedies was concerned. In forty-eight hours she was dead.
I believe that the cause of that death was the
same obscure something which had so potently affected for years the emotional life,
but which we cannot comprehend ; that which
for so many years had dominated the nervecentres of higher life attacked and paralyzed
the lower centres of animal life, and death
came speedily.
'
Another case of melancholia was that of a
lady who had been apathetic for a number of
days, and could not be induced to speak a
word to any one. Her husband, who was a
Friend, took her with him to a Friends' meeting. She sat in the carriage, while he went
inside. There had been no change whatsoever in her condition. While sitting here an
old acquaintance, well known in the society
of Friends, came up to her and offered to
shake hands, but she refused. Then he repeated the well-known words of Peter in the
temple, "Silver and gold have I none, but
such as I have give I thee. In the name of
Jesus Christ of Nazareth, rise up and walk."
He then passed on, and nothing more was
said. When her husband came out she met
him with a smile, and said, "Good-morning,
John. Let us go to Friend
*s for dinner."
At last accounts this woman continued rational.
Gentlemen, can you conceive of the nature
of that structural lesion which for fifteen years
had held the grip of death on the nervous
centres, and then suddenly let go its hold ?
The fact is that .when we come to study the
ultimate nature of disease we are as ignorant
as babes. We take the ovum or the male germ
and look at it under the microscope, but we see
nothing but an irregular transparent speck of
protoplasm ; and yet the records of past generations are written in that little formless mass,
in which also are enwrapped the potentialities
of future generations untold in numbers. You
can understand when so much can be within
that which is so little and so structureless, how
hopeless it is to expect that we shall ever understand the infinitely delicate changes which
take place in the complex protoplasm of the
brain, and to be able to say why these waves
of emotion and these waves of mental and
physical paralysis sweep over the individual.
I believe that the changes are physical, but I
also believe that it will never be within human
power to recognize their nature. We consider the microscope the embodiment of delicacy and of precision. It is merely a coarse,
blundering tool, which fails utterly in the
hands of the man who attempts to fathom
mysteries of this character. Not until we get
the power and knowledge of the infinite can
we hope to understand the ultimate changes
of nervous protoplasm gone mad.
In conclusion, gentlemen, allow me a word
in regard to one or two points concerning the
treatment of melancholia.
In the first place, permit me to say that we
have now tested in this hospital the hydrobromate of hyoscine upon a sufficient scale to
enable us to speak with authority. When
given hypodermically in doses of ^ to ^ of
a grain it acts almost invariably in melancholia with agitation as an invaluable soporific and calmative. I have used it myself,
also, in a number of private cases, and in the
University Hospital service, and there seems
to me no doubt as to its great and peculiar
value. When administered by the mouth it
acts with much less certainty; and as its hypodermic use is never followed by any local
irritation, and as it is often much easier to
give a hypodermic injection to a violent
maniac than to get him to take medicine, it
is best administered hypodermically. Although in most cases larger doses are required, it is not safe to begin with more than
T ^ of a grain.
Some months ago I received a telegraphic
dispatch from a very prominent Western specialist, asking if we had any cases of melancholia upon which he could demonstrate the
almost specific action of cocaine. I replied
in the affirmative, but heard no more about
it. I have not sufficiently tested this alkaloid
in melancholia to come to a fixed belief in
regard to it, but have tried it in two cases,
one without and the other with agitation. In
the quiet melancholic no effect was produced
by the largest doses of it administered by the
mouth. If my memory serves me right, we
gave as high as 3 grains of the alkaloid a day.
In the other case half a grain administered
hypodermically increased so markedly and
alarmingly the physical excitement that we
were afraid to try it a second time.
A
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which might be included under monomania
would sometimes pass from this condition of
excitement to one of depression The term
has been used by different alient*ta with under h» pillow, livery day be had trawled
almost every conceivable meaning. In the*e out of bed ewrtv m t h * laiwnin* _BM! hid Ibis
lectures I shall use it to cover a very large t—# of gold in a certain pan of lite ftMMbMMl
class of chronic insanities in which the insane A sf e _r # a fea^ st___-it _s _h_tl a^^^^^^^ ^^^^^^e^^ ^^^^^^fc^B jNUMasMfS
condition is limited, at least in it* marked hack and pet ti endee the ptHow- fieewrttie*1
manifestations, to certain portions of the were also fotttwl aiwniimieM to headfede of
brain-functions. The term monomania, thus thousands of doUar* Avarice had hicowt
limited, covers those cases which are com- so overweening thai it wa* bsyoad th* powwr
monly termed cases of partial insanity, in
which one function of the mind is either parallel to the appetite erihidk te aagMtftNril
almost solely or most markedly affected. The
best scientific definition of monomania that 1 the will; bat there f reqoently doe* dseetop a
know of is that given by Sptuka. He says, condition of the nervous system ia nrbidi tlft
'Monomania is a chronic form of insanity,
based on an acquired or transmitted neuro- enced by the long continued HabH ibet the
degenerative taint, and manifesting itself in man is a monomaniac as regards drink. The
anomalies of the conceptions! sphere,—#".#,» thirst for alcohol absolutely dominate* him,
the sphere of thought,—which, while it does and is entirely beyond his power to control,
not destroy entirely the mental mechanism, lt it, of course, a very difficult matter,—
dominates it." This definition is, I think, and it may be in individual cases impossible,
scarcely wide enough. I believe that the —(or us to draw the line between sanity and
term monomania should include not only insanity,—i**., between the condition in which
those cases in which the intellectual or e x - the patient could, if he would, control the apceptional .sphere is involved, but also those petite, and that in which the power of self-conm which the emotional condition is affected. trol is really lost; but assuredly the difficulty
There are, as you know, certain passions, of drawing the line ought not to cause us to
such as avarice, envy, vanity, and so on, reject these cases of emotional disorder aa
which are really as much cerebral functions belonging with the insanities. Did we not at
as is the reasoning power itself. There are our last lecture on melancholia learn that a
cases in which these emotions become so general depression of spirits may" be for a
magnified in their power that they dominate time the sole evidence of an insanity ? And
the whole individual. As an example may be if what may be considered a generalized emotaken the miser, in whom that portion of the tional disturbance marks general insanity,
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8
MONOMANIA.
surely a particularized emotional disturbance,
such as exists in the miser, may mark particularized insanity,—i.e., monomania.
T h e difficulty of decision exists in all forms
of monomania. Let me cite you a case from
my experience.
Several years ago I was called to a palatial
mansion, and I was met in a boudoir by a
handsome young wife, quiet, perfectly ladylike, and self-restrained in her manner. She
said to me, " Doctor, I have sent for you
under very painful circumstances, because I
feel that I must confide in some one." She
then went on to say that she had syphilis,
and that this had been given to her by her
husband, and that she had had a child born
in a certain watering-place, and that it had
died from hereditary syphilis. She further
told me in detail of having personally detected her husband's infidelities. I examined
the woman thoroughly, but could not find
the slightest evidence of specific disease. I
finally wrote to the physician who had attended the woman at the birth of the child.
We at once replied that the child was well
formed and perfect, and that it had died from
an ordinary acute infantile disease. I then
assured the woman that she had not had
syphilis. She expressed herself as much relieved, but was unrelenting towards her husband, who she said kept a mistress, and frequently annoyed her by communicating with
said mistress at places of amusement where
they were together, and by having said mistress to drive immediately behind them in
the park. She had detectives employed to
watch her husband, and had a, well-known
lawyer engaged to superintend the detectives.
After this had gone on for some weeks, I
began to suspect that there was something
wrong with the woman's brain, and to watch
her. .
To make a long story short, my patient
watched her husband more and more closely,
spent hundreds of dollars, and at last one night
at a theatre pointed out as the paramour of her
husband a lady who was well known and entirely beyond suspicion. The whole of her
story was undoubtedly invented, although she
herself believed it. Her husband, however,
believed that she was full of the devil and
wanted to torment him. She was all the time
acting against her own interest. She could
have obtained anything from her husband if
she had acted in a decent manner towards him
There was nothing to be done in the case. The
couple were sent to Europe, but the same condition renamed, and they finally separated
This was undoubtedly a case of well-formed
monomania, in which the woman's intellectual
powers, except in this regard, were perfect
She mingled in society, reasoned well, and
did everything well, but she had this delusion,
by which her whole life was altered. I found
in that case, as is found in most cases of
monomania, that clear back to childhood there
had been evidences of something not quite
right with the cerebral functions. The woman
had always been extremely vain, wildly ambitious to shine in fashionable society, and
with a marked excess of egotism. These are
characteristics which frequently precede the
evidences of monomania. This was well exemplified in the history of Guiteau.
Although Esquirol used the term monomania as belonging to those cases in which
there was an excess of animal spirits and of
the emotions, such as ambition and anger,
which are related to aggressiveness and power,
there can be no doubt that there are two distinct classes of monomaniacal persons,—those
in which there is a condition of emotional
exaltation, and those in which there is a
condition of emotional depression. In other
words, precisely as in general insanity we have
two types of cases, represented by mania
and by melancholia, so do we have in this
monomania, or partial or limited insanity,
two classes of cases, the one corresponding
to general insanity with emotional exaltation,
and the second corresponding to general insanity with emotional depression.
I have already expressed the opinion that
monomania may exist without the presence of
a delusion and be purely emotional. At the
same time, in most cases, sooner or later
there comes a distinct delusion. Some writers
say that the character of the delusion is dominated by the character of the emotional disturbance. Others say that the character of
the emotional excitement is the result of that
of the delusion. For instance, a man who
imagines that he is the Czar of all the Russias
is, by the very belief itself, kept in a perpetual state of exaltation, while a man who
believes that he has committed the unpardonable sin is by his belief thrown into a state of
deep depression. I do not believe that the
delusion produces the mental state always, or
that the mental state produces or dominates
the character of the delusion. It seems to
me that all that can be said is that these two
things are correlated, and that a condition of
mental depression tends to delusions of persecution and delusions of a depressive type
and that in a condition of emotional exalta-j
MOKOMANIA.
tion the delusions partake of this general
character.
The delusions of monomania, like the delusions of ordinary general insanity, often
grow out of something having a real existence. A melancholic or hypochondriacal
monomaniac may have some bad feeling,
which is increased in his mind until it dominates his whole life: thus a dyspeptic symptom leads him to the belief that he has no
stomach. These cases are to be distinguished
from the cases of hypochondriacal melancholia by the fact that the delusion is " systematized." The systematized delusion, you
will remember, is one said to be characteristic of monomania, and is one about which
the patient reasons, and which he defends.
As an example of this let me cite a case
which recently came to my notice,—that of
a gentleman, now dead, who was at the time
a colonel in the United States Army. This
case also well illustrates how closely monomania relates itself to sanity, and how difficult it sometimes is to draw the line, and to
convince others, especially those who have no
medical training, where the line is to be drawn.
This man was, at the time I speak of, stationed
at one of the frontier posts of the country, and
was performing, with satisfaction to all, the
duties appertaining to his rank. One day he
said to a friend, " My life in this frontier post,
from its monotony, would be absolutely unsupportable if it were not for my daily mail
which I get from my dead friends. I had a
letter from your brother last week, and every
morning I live in expectation of receiving a
letter from some deceased friend or relative."
He was asked how the letters came, and it
was learned that they were received through
a certain living medium in the eastern part of
the United States. This lady would almost
daily write a letter to this man, which was
received by him with absolute credence as
coming through her from the spirit world.
We come right here upon the delusions of
spiritualism, and we come to a class of cases
in which it is very difficult to say where sanity
ends and insanity begins. In matters of religious belief, every man who believes strongly
in a certain faith might consider every other
person who believes in a different faith to be
insane. Profound belief in the daily presence
of spirits may coexist with great scientific or
business acumen.
Although it seems impossible to fix a line
which shall separate a sane from an insane re'ligious trust or belief, it can hardly be doubted
|that many of the devotees of spiritualism
ought to be considered as monomaniacs. Let
me refer again to the colonel I spoke of a
moment ago. On one occasion he said,
" There is one thing that gives me great comfort, and that is that I am a descendant from
the Virgin Mary." Some one intimating a
doubt of that genealogy, he continued, " I
know that T am a descendant of the Virgin
Mary, because I had a letter from her, and she
says so, and she certainly ought to know."
Can we hesitate in deciding that here was a
delusion which was thoroughly systematized
and logically defended by its holder? The
first premise, that he received letters from the
spirits, was false, but his reasoning based upon
it was sound.
Another case which came under my notice
a year or two ago was very interesting, and
also illustrates the difficulty sometimes met
with in drawing the line. It was that of a
lady who saw visions. If a person sees a
vision, and recognizes that it is a vision and
does not believe that it has a real existence,
that person is not insane ; but when a hallucination so takes hold of the mind of a person
that he is convinced of its reality against the
evidences of touch, that person is insane.
This lady of whom I have spoken sat in my
office, and, pointing to a particular part of the
room, said, "There is a stick rising u p : it
grows out, and now it has on it the head of a
big bull-dog." She then went on to describe
its heavy, sensual, hanging jaw, vicious expression, etc. She said that she knew that there
was no bull-dog there, that she simply saw it
as a vision. Then she went on to state that
she knew what this meant, that the vision was
sent from the other world as a symbol of
something that was past. She said, " That
bull-dog is given a resemblance to a certain
doctor, now dead, whom I once knew. He
was a coarse, heavy, sensual man, and this
vision is sent to me to show that his disembodied spirit still holds to the mould of its
earthly tabernacle." That woman understood
that the thing which she saw had no real existence, and you would at once say that she
was sane, but yet she evidently was insane,
because she believed that the vision was sent
to her as a symbol of something else. She
also had all sorts of ideas about a presence at
night. She would be awakened out of sleep
with a horror and fear that a spirit was behind her. She would at times get out of bed
and pray for hours that she might be rid of
this presence, which she believed to be the
spiritual essence of the devil sent to torment
her. She was clearly over the line.
MONOMANIA,
I shall now bring before you some patients
suffering with monomania. T h e first patient
is Miss P.
" I understand, Miss P., that you have had
a remarkable life. Will you tell us something
of your past history?'" " Do you mean my
personal history ?"
" Yes. Tell us something about your life."
" W h e n I was brought here I was kidnapped.
I was not examined at all. Ever since I was
poisoned, which is seven years ago, I have
been trying to earn my own living, but there
have been parties determined to ruin me. I
have not succeeded in getting work because
somebody always opposed me. I look upon
it as the work of political parties on account
of my father's belief."
" What about your ancestry ?" " That is
what they want to find out. My father was
a Stuart, but there are different branches and
they are not sure which house it is. There
was a mistake made in raising the children
and bringing them up among others. This
was r during the Revolutionary War.
My
parents lived about the time of the War of
181a. As far as I can make out, both my
grandparents lost their lives in this war, and
the children were raised among others. T h e
cousins wanted to force me to become one of
them, especially one of the Martha Washington descendants. She is determined that I
shall live with her, and I can recall many
things that she has done with this object."
throne. That is a delusion of exaltation. She
also believes that she is persecuted because
of her greatness : thus she has the delusion of
persecution grafted upon a delusion of exaltation. T h e woman's mental functions, disconnected from her delusions, are fairly well
performed.
I shall now have a patient brought in who
believes that he is Melchizedek the high-priest,
and prophet.
"Well, C , how are you feeling?" "Firstrate."
"You look healthy." " I should like to
travel around ; I would not mind taking a
trip to Harrisburg."
" I see that you have lost your sight; how did
that happen ?" " I was born with cataracts."
" Does that interfere with your seeing
visions ' " " Not as I know of. I don't think
so. I expect to see a vision of the Lord tonight."
" Have you had such a vision lately?
" Yes. A few nights ago."
" Tell us about it." " T h e Lord appeared
to me in great splendor, in a fiery flame, with
a shining face. Take, for instance, that young
man sitting up there. What kind of an establishment is this ?"
" This is the lecture-room." " Is that so ?"
" What did the Lord say to you ?" " The
Lord appeared unt.o me and said, • I am the
Lord, thou art my servant.' The institution
authorities think I have given up what they
" W h o was it that tried to poison you ?" call foolishness ; but I am still a prophet. I
" Ihe party that was implicated said that they would not object to taking a trip to Harriswanted to destroy my intellect, but not my burg for my health."
life. Something was said about an insane
" Are you perfectly well ?" " Yes, I believe
asylum. That was the woman Morris, who is so."
a descendant of one of the parties born on
" A r e you perfectly happy?" "Not at
the American side. She is really one of the present time. I want to be where I can hear
Marys, and is one of the Jersey links. It is the conductor say, ' T h i s train for the east.
just a fight between some of the American Change cars for Harrisburg,' or some other
links and the other links. I am a connecting point."
link between two contending parties. They
" Do you really see the Lord, or do you only
both have about equal rights." .
imagine it ?" " It is as true as I am sitting
"Are you happy or unhappy?" " I am
here."
naturally buoyant and spirited, but I have
" Does he ever touch you ?" " No. The
passed through a great deal of trouble."
Lord
does not treat people that way. He
(The patient was now removed.)
stands
at a distance, in human form ; someGentlemen, you there see an example of
times
just
a fiery flame." (The patient was
what I mean by a thoroughly systematized
now
removed.)
delusion. That woman argues and reasons
There you see the condition of exaltation
about her delusion. You see also that the
with
no depressive delusions. You see also
delusion is not dominated by the emotional
that
the
hallucination goes as far as hearing
condition. She has a mixed delusion. She
and
seeing,
but does not affect the sense of
has a delusion of persecution and a delusion
touch.
of exaltation. She believes that shl 1 1
The next case illustrates a depressive deluhino- rrrsat ^ i
"cucves m a t she is somemng great, and even has a chance for a sion. It is of the melancholic type.
1
MONOMANIA.
•
}., where were you born ?" * At Argyle, not by virtue of great brain-power, but beEngland."
cause his brain takes a certain limited direc"Are you married ?" " Yes ; I have been tion. A man who is dominated by his imagithirty years."
nation is always in danger of being swept off
"What is your business ?" " Bricklayer."
his feet by the rush of his imagination. A
"Do you think that you could lay bricks genius is recognized as a man not practical.
now?" "Yes, I could work, although I have By a man not practical is meant one lacking
been badly used."
in common sense; and common sense is, after
* "What have they done to you ?" " I have all, nothing more or less than the term used
been strangled four times in my sleep. They to express good judgment in the ordinary
were trying experiments on me, for what matters of life. A man who has great imagireason I do not know, unless it is because my nation usually lacks reasoning power, and is
wife has been here. There are other parties not practical, because of his great imaginaconcerned in it."
tion. One of the best examples of the rela"Have you seen your wife ?" " Yes, I saw tion between great imaginative power and
monomania is John Bunyan, the author of
her and three others."
" When did you see her \ast ?" " It is about " T h e Pilgrim's Progress," which, according
three weeks since I saw the one I took to be to any standard that we have a right to set
my wife. I hear her frequently down-stairs. up, is one of the five or six greatest books in
She has been detained. I hear her sometimes the English language. It is certainly more
un one side of the hospital and sometimes on read than any other book, with the exception
the other. Before I came here somebody got of the Bible. No one who reads the history
into my house and chloroformed me and got of Bunyan's life can doubt for a moment
at my wife." (The patient was now re- that he suffered from monomania with depressing delusions. He, however, finally removed.)
covered.
This man probably could work as well as
ever, except as his attention was drawn from
Another remarkable instance of the close
his work by his delusion. He believes that relationship between insanity and genius is
his wife is perpetually attacked by people, and afforded by the famous Victor Hugo. His
that she is confined down-stairs. This man uncle died insane; his brother, Charles Hugo,
represents a very dangerous class. His mental in his late boyhood gave promise of remarkfunctions are sufficiently perfect to carry out able talent for literature, but before twenty
any scheme which may come from his delu- he became insane, and finally passed into a
sion of persecution. He may fasten his de- condition of complete dementia. One of the
lusion on some one and make a violent as- daughters of Victor Hugo is now and has
sault on that party. If this man believed that been for many years living in an insane
it was John Jones who had chloroformed him asylum. According to the London Medical
. and ill-treated his wife, he would be very Times, there are in many of Hugo's finest prolikely to assault John Jones. This is prac- ductions numerous passages which could only
tically the most dangerous class of lunatics, have been conceived by a diseased imaginaand it is the class which is, perhaps, least fre- tion, and are indelibly stamped by madness.
A remarkable fact in the mental history of
quently recognized as crazy.
In concluding this lecture I want to say a the great French poet is that along with his
few words in regard to the relations between great imagination there was a shrewdness
this form of insanity and high intellectual almost as remarkable. No banker could
power, and especially with reference to ge- have more carefully managed his fortune; no
nius. There can be no doubt that a large politician could have more tenderly nursed
proportion of those who are considered as the his popularity. He who had amassed over a
most pronounced examples of genius are cases million of dollars died the idol of a comwhose intellects are forever on the border of munistic democracy ; he who had played at
insanity. To say that an individual is a fast and loose with all political parties was
genius usually means that he has a certain buried amidst a tumult of universal sorrow.
The prognosis in monomania is exceedfunction of the mind exalted high above the
ingly unfavorable. This is because the conother functions. A man whose imagination
dition is so often the result of a faulty formais developed out of proportion to his reasontion of some part of the brain. There is a
ing faculties is apt to be a poet or a novelist,
peculiarity of the cerebral organization which
»nd produces works which may live through
shows itself from the very first.^
'jenturies. Such a man is above his fellows, |