Nomenclature in Psychiatry. MONOMANIA OR OLIGOMANIA, WHICH? PARANOIA, WHAT? BY Ralph L. Parsons, M.D., Greenmont-on-the-Hfidson, near Sing Sing, New York. Reprint from The Journal of Nervous and Mental Disease, Vol. xiv.. No. 4. NOMENCLATURE IN PSYCHIATRY. MONOMANIA OR OLIGOMAN1A, WHICH ? PARANOIA, WHAT ? BY RALPH L. PARSONS, M.D., Physician in charge of Private Home for cases of Nervous and Medical Diseases at Greenwood on-the-Hudson, near Sing Sing; late Medical Superinten- dent of the New York City Lunatic Asylum, and Physician-in- Chief to the Hospital for Epileptics and Paralytics; Member of the Medico-Legal Society, etc., etc. GREENMONT-ON-THE-HUDSON. NOMENCLATURE IN PSYCHIATRY. MONO MANIA OR OLIGOMAN1A, WHICH? PA- RANOIA, WHAT? THE term Monomania was first adopted by Esquirol as a designation for certain phases of insanity which he had differentiated from the forms previ- ously recognized. His differentiation was in the main good, but the term chosen was unfortunate for the reason that its very definite signification does not correspond with the idea he intended to convey. Hence the term was misleading from the first, so that he was obliged to undertake explanations which would have been unneces- sary if the term had meant what he intended to express, or even if its meaning had been ill-defined or obscure. The term was so misleading, in fact, as to lead Esquirol himself into errors and inconsistencies in the course of his descriptions of the disease ; for while, in reply to the ob- jections that there are no monomaniacs, that there are no insane persons whose reason is sound except on a single subject, that these patients always manifest some disorder of sentiment and will, he replies that if it were not thus monomaniacs would not be insane, he, on the preceding page, after stating that monomania is characterized by a lesion of the intelligence, affections, or will, goes on to say that at one time the intellectual disorder is confined to a single object, or to a limited number of objects, while at another monomaniacs are not deprived of the use of their reason, but their affections and dispositions are perverted, and in a third class of cases a lesion of the will exists, thus limiting 4 R. L. PARSONS. the aberration to a single faculty of the mind, or even to a single delusion of the understanding. And yet his very frequent use of the term partial in connection with this type of insanity, and a study of the cases he adduces in il- lustration, show conclusively that for the most part he thoroughly recognized the fact that the aberration in ques- tion did really extend to various faculties and at least po- tentially to more than one object. If the use of the term monomania was unfortunate and misleading in the first instance, its use has since then be- come still more objectionable for the reason that the term as now used does not even mean what Esquirol intended. He says that the monomaniac is gay, petulant, rash, auda- cious, talkative, blustering, pertinacious, and easily irri- tated; nothing would appear to oppose the free exercise of all his functions. He contrasts him with the lypemaniac as his opposite in the state of his feelings. But the monoma- niac, as now understood by those who use the term, is often- times depressed in mind and hindered in his mental oper- ations. He writes that the course of monomania is more acute, its duration is shorter, and its termination is more favorable, unless there are complications, than in the case of lypemania. This certainly is not true of the typical monomaniac as now classified and described. A monomaniac is generally understood to be a person who is insane in regard to a single subject only, while in all other respects his mental faculties are entirely sound. The obvious meaning of the term tends to establish this belief. As a natural inference, it is thought that mono- mania is not a very serious form of insanity, that the monomaniac is only a little insane. Lawyers and practi- tioners of medicine generally hold this view. The fact is, however, that the mental aberration designated by the term monomania is very grave in character, both in its medical and in its medico-legal aspect. This form of in- sanity is essentially chronic in its nature, and so the pros- pects of recovery are not as good as in cases of acute mania, or even of melancholia. Because of the apparent soundness of their reason in most regards, these patients NO MEN CL A TURE IN PS YCHIA TR Y. 5 are liable to be considered as having a greater power of control over their feelings and acts than is really the case, and so their legal responsibility is liable to be over-esti- mated. A careful study of cases of this form of insanity in which the aberration seems to be most restricted and of the simplest character will serve to show how profound, how fundamental the derangement actually is; and also in what respects certain typical cases differ from the description given by Esquirol. Systematic writers on the subject of insanity express analogous views regarding the grave character of this form of mental aberration. Griesinger writes as follows, to wit: “Thus the excitement of the monomaniac does not pass so immediately towards the exterior ; effort is accom- panied by clear, conscious thoughts and opinions, loses thereby its instinctive character, and becomes actual morbid volition. With far greater, sometimes with per- fect outward calm, there is a more profound internal loss of reason than in mania, because consequences soon result from the general excitation which set aside the essential conditions of healthy mental action.” Maudsley writes as follows, to wit: “ The course of monomania is not often toward recovery. The reasons are plain: in the first place, when it is secondary to mania or melancholia it sig- nifies a chronic morbid nutrition which is a further stage of degeneration of the delicate organization of mind; in the second place, when it is primary, it is the morbid out- growth of a fundamental quality of character, so that to get rid of it would be to undo the very character from its foundation.” The objections to the term monomania are such that many physicians engaged in the care of the insane do not use the term at. all. An examination of the reports of fifty-one asylums for the insane, taken at random, shows that of the whole number of patients enumerated less than two per cent are classified as cases of monomania, while in twenty-four of these reports the term does not appear. In the reports for the Pennsylvania Hospital for the In- sane, thirteen per cent of the patients are classified as cases of monomania, while in the reports of the New York City- Lunatic Asylum only fifteen-hundredths of one per cent are thus classified. If the reports of the Pennsylvania Hospital for the Insane had been left out of the account, the cases of monomania would have been reduced to less than seven-tenths of one per cent. Thus it would appear that even when the term is employed it is done without uni- formity and without any reasonable approach to scientific accuracy, for such cases as were classified by Dr. Kirk- bride as monomania undoubtedly exist in a similar ratio at other asylums. Systematic writers of eminence on the subject of insan- ity also object to the use of the term. Tuke writes as follows, to wit: “We heartily wish ‘monomania’ had never been introduced into psychological nosologies, for if understood in a literal sense, its very existence is dis- puted, and if not, the various morbid mental conditions it is made to include by different writers leads to hopeless confusion. With one author it means only a fixed morbid idea; with another only partial exaltation; while a third restricts it to a single morbid impulse. As we proceed we shall consider its signification, but shall not frequently employ the term.” Dr. Sheppard, in his classification of the forms of insan- ity, writes of monomania (so-called), and approvingly quotes the following from Dr. Maudsley, to wit: “ It is doubtful whether there is ever only one point on which the mind is unsound.” Dr. Maudsley writes as follows, to wit: “ When the monomaniac (so-called) comes under the observation of one who is not only competent to observe, but has suf- ficient opportunities to do so, it will commonly be found that there is a bluntness or loss of his natural affection and social feelings, in consequence of his being so entirely centred in his morbid self; that his character and habits have undergone some change ; and that he exhibits an excitability of mind with loss of self-control in circum- stances which would not formerly have provoked it.” 6 R. L. PARSONS. NOMENCLA TV RE IN PS YCHIA TR Y. 7 Dagonet writes as follows, to wit: “In fine, the term monomania might without inconvenience disappear from science where it becomes a cause of confusion and embar- rassment in the study of pathological facts.” Sankey, as quoted by Spitzka, writes as follows, to wit: “ The popular opinion about the existence of mono- mania, I need scarcely add, is a very erroneous one. The French writers use the term in a much more restricted sense ; but to avoid confusion it is better to avoid the term altogether.” Morel, after quoting Esquirol’s description of mono- mania as pertaining to a single idea or a single faculty of the mind, continues as follows, to wit: “We cannot too strongly invite the attentive reader to reflect upon these peremptory passages and consider whether Pinel and Esquirol, who wrote them, should not have arrived at the conclusion that, through an unfortunate confusion of ideas, they mistook a systematized delusion for an exclu- sive and local delusion. “We affirm the close connection, the solidarity of the ultimate relation between the various acts of the intel- ligence, not only in the home of our observations and of our personal inductions, but also in the name of the history of philosophy. “ This being granted, the question is whether the condi- tion of mental alienation can break this essential law of the unity of intellectual life; for it is clear that if logic and experience constrain us to decide this problem in the negative, we ought also to reject the theory of Esquirol. We could not have a complete idea of the motives which impel the insane to some of their acts, unless we were freed from error in regard to monomania.” But yet, however much systematic writers on the sub- ject of insanity deprecate the use of the term monomania, they rarely succeed. There are manifestations of insanity which are neither melancholia nor dementia, but which differ so much from mania that another designation is required for them, and the objectionable term monomania is the one generally employed. In saying this, it is not 8 R. L. PARSONS. forgotten that there are some modern authors of eminence, as Hammond and Spitzka, who adopt the term without dissent. The latter author even undertakes an elaborate defence of the term, but this defence ought perhaps to rank rather as an apology. He writes as follows, to wit: “ If words were to be eliminated from the vocabulary be- cause they do not literally correspond with their ac- quired and accepted meaning, more than half of those in the medical dictionary, and about nine-tenths of those employed in the special branch of mental medicine, would have to be replaced by new ones.” The objection to the term, however, does not lie in the fact that its literal meaning and the signification attached to it by learned writers on the subject of insanity fail to correspond, but in the fact that its literal meaning is so well defined and so easily understood that it involves within itself an idea 'at variance with its real scientific meaning; and hence that its literal meaning is understood instead of the real one by most persons who see or hear the term. Even alienists, as we have seen, have a feeling that they are unconsciously influenced by its form to a misinterpretation of its meaning, so that many of them are disposed to avoid its use. The misleading of the term is liable to be of especial disadvantage in courts of justice, where the correct definitions of the learned counsel and of expert witnesses on one side may fail to enlighten the intelligent jury in opposition to the interpretations of counsel on the other, aided by the evident, implicit mean- ing of the term. Now, it being granted that the term monomania is open to serious objections, the question arises whether it has become so identified with the subject of insanity that it must be retained as a sort of necessity ; or, if this is not the case, what suitable term can be best used as a substitute. It is evident that the term is not an absolute necessity from the fact that so many discard its use, although there are certainly strong reasons in favor of a suitable sub- stitute. It is believed that such a substitute is available. In the annual reports of the New York City Lunatic NOMENCLA TURE IN PSYCH I A TR V. 9 Asylum, the term monomania does not appear, although up to and including the year 1878 one thousand nine hundred and forty-five out of ten thousand one hundred and thirteen patients are classified as cases of mania par- tial. The designation mania partial, or partial mania, is a very good one in some respects. But it lacks certain requirements which a term suitable to designate im- portant and well-marked characteristics of the disease should have. Such a term should consist of a single word, in order that it may serve as a basis for the classification of sub-varieties. In addition to this, the term should not have a well-recognized meaning of its own at variance with the idea it is intended to express; and it should not be already in use for some other purpose. The term oligo- mania is believed to fulfil all these requirements. More- over, it is believed to be especially suited to replace the term monomania in the nomenclature of insanity, and hence it is proposed as a substitute for that term. The derivative meaning of oligomania is so obvious that no ex- planation is required in this regard. Its technical mean- ing, however, should not be too strictly inferred from its literal meaning, but should depend also, as in the case of other scientific terms, upon the definitions, distinctions, illustrations, and explanations attached to the term. Within the past few years, the term paranoia has been used to a considerable extent as a' substitute for the term monomania, especially by the younger writers on the sub- ject of mental diseases. This fact is a still further illus- tration of the prevailing tendency to avoid the use of the term monomania. But the objections to this substitute are hardly less weighty than those which apply to mono- mania itself. If the meaning of monomania is too narrow for the purpose required, that of paranoia is too broad, and it may be added, too definite for the designation of some thing different from its evident meaning, which is simply distraction, craziness, insanity. Griesinger writes that Heinroth has described a form of monomania in great part under the name of ecstasis paranoica, but does not adopt the term. Feuchtersleben A. L. PA A'SONS. mentions the following as synonyms of folly, or insanity in the more restricted sense: “ Insanity, according to Hein- roth ; dementia, bewilderment, according to Ideler ; poly- mania, according to Fantonetti; paranoia, according to Weiss; and says that it proceeds from delirium as its highest degree.” Feuchtersleben further says Reil seems to me to have given the best description of this form, as it occurs in nature, without pretending to state its essence. ‘ Fools,’ says he, ‘ have no ruling idea ; they change with their con- ceptions, and combine, in all sorts of ways, follies and eccentric tricks. Besides their general craziness there is a remarkable weakness of all the powers of mind, espe- cially of the judgment.’ ” Paranoia as the synonym of folly here retains its'original signification, and has nothing in common with the meaning to be conveyed by the term monomania. Hughes makes use of the term paranoia as a synonym for primary monomania, Kiernan as synonymous with monomanie systematise, monomania of Spitzka, primasre Verruecktheitof the Germans; Mills as synonymous with delusional monomania and also with moral insanity, thus giving a new and not very well defined meaning to the term, albeit one not in accordance with its derivative mean- ing and its classical use. The term paranoiac has also been employed, especially to designate what is popularly understood as a “ crank.” In fact, the general idea of a partial and ill-defined subdivision of oligomania would seem often to be in the minds of those who use the terms paranoia and paranoiac. Even in this case it is submitted that oligomania would be a better term, with such quali- fying additions as might be required to express the exact idea intended, as primary oligomania, secondary oligo- mania, delusional oligomania, moral oligomania, mysopho- bic oligomania, systematized oligomania, oligomania of suspicion, or such other modification as might be needed. In conclusion, then, with the assumption that monomania, as defined and explained by certain writers on psychiatry, designates phases of insanity of sufficient importance and well enough differentiated to require a place in the general NOMENCLA TURE IN PSYCH I A TR Y. 11 classification of mental diseases; and with the farther assumption that the reasons adduced in this paper are sufficient to justify the substitution of the term oligomania for monomania, it only remains to apply the proper mean- ing of the latter term to the former, to wit: A form of insanity which, although potentially affecting all the mental faculties and operations, apparently involves only a part, as the intellect, the emotions, or the will, or certain manifestations only of a faculty of the mind originates in the intel- lectual faculties rather than in the feelings ; and the manifes- tations of which are well-defined, persistent, dominant, and systematic in character.