The delusions are usually mobile and consist in ideas of grandeur.
The most varied delusions follow each other, modified every instant by external impressions. The patient assumes all the titles mentioned to him: he is in turn pope, physician, and admiral. Occasionally the delusions are referred to the past and take the form of pseudo-reminiscences: a shoemaker pretended to have directed an expedition to the North Pole.
The patient often transforms the surroundings in which he finds himself. A maniac called the head nurse of the service where he was treated the chief of his military station, and the physician the prince of Sagan.
The costume corresponds with the delusions: the patients clothe themselves in fantastic uniforms, cover their chests with decorations, comb their hair in the style of Bonaparte, etc.
Sometimes one delusion persists and remains fixed during the entire duration of the attack in the midst of more mobile accessory delusions: a modest business agent for several months proclaimed himself to be the President of France, and referred to the physicians and nurses as his "grand staff."
The maniac never has absolute faith in his delusions. His conviction is easily shaken. Often he only half believes in the pompous titles that he gives himself; his delusions are a sort of pleasantry with which he amuses himself and with which he mystifies those about him.
Some ideas of persecution, mostly bearing upon the deprivation of liberty, may occur in addition to the ideas of grandeur. In some cases even hypochondriacal ideas may occur. The patient declares that he is afflicted with a grave disease, but that he will cure himself "by taking a trip to London" or by having an operation done by "the greatest specialists of Paris and America."
Hallucinations are rare and fleeting. On the other hand, illusions are frequent and lasting; they often assume the form of mistakes of identity: the patient is apt to believe himself surrounded by his acquaintances and by familiar objects.
In grave forms, during the excited paroxysms, consciousness at times undergoes a certain degree of clouding and the period of illness leaves but a very vague impression, or none at all, upon the memory.
The following case is a good example of delusional mania.
Gabrielle L., fifty-two years old, housewife. Family history unknown. The patient has always been impressionable and lively; intelligence normal. She had five previous attacks of mania, the first at the age of nineteen; all terminated in recovery.
The present attack began with rambling speech, assaults upon others, and tendency to alcoholic excesses; the patient, though usually temperate, began to drink to intoxication. She was taken to the Clermont Asylum, where Dr. Boiteaux issued the following certificate of lunacy: "Condition of acute mania with extreme disorder of ideation, speech, and conduct. Illusions of the senses. Obscene actions. Ideas of grandeur: owns millions, heavens and earth. Excited, difficult to control."
On February 25, 1904, one month after the patient's admission to the asylum, examination was as follows: Medium stature, strong constitution, slight obesity, skin flushed, voice loud, gestures lively, clothing disarranged, hair down over the shoulders. From the beginning the patient showed extreme familiarity. She offered her arm to the physician, whom she took to be the husband of the head nurse, and laughingly asked the latter if she was not jealous. She was well oriented as to place; she knew that she was in the Insane Asylum at Clermont where she had already been five times before. Her orientation of time was somewhat inaccurate: she said the year was 1904, that it was the spring of the year, and gave the date as March 25 (actual date February 25, 1904); on being asked to think a while and make sure of the date, she said: "Why, of course it is March, a few days ago we had a holiday, that was Mid-Lent." (She was evidently referring to Shrove Tuesday.) Later other ideas appeared and it became impossible to prevail upon the patient to reflect properly before speaking.
She had a certain realization of her condition: she said she felt odd, "at times driven to play all sorts of silly pranks." She was very obedient, and always started out with remarkable eagerness to carry out any order that might be given her. But her extremely mobile attention caused her to be each instant distracted from the object to be attained. She was asked to write a letter: "Why, certainly! To whom?" To whomever you wish. "Very well, to the President of the Republic? To the Minister of War? No, I shall write to my husband." Then she began to write: To Mr. L., Gardener in C. . . . Then turning again to the physician: "Because, you know, we have been living in C. . . . for the past eighteen years. I have a house there. The hospital at C. . . . belongs to me. I know Sister Antoinette there. They wanted me to disguise myself as a Sister, but my husband wouldn't have it. He adores me, my husband does!" She was again asked to write, which she did, jabbering all the time and reading aloud everything she wrote. Every moment her attention kept being distracted by the conversation of the persons in the room, although they spoke in a low voice and upon matters which did not concern the patient.
They spoke, in fact, about another patient who helped the nurses with the service in the dining-room. "Good gracious!" exclaimed the patient, interrupting her writing and bursting out with laughter, "that woman is pretty stingy with her bread! One would think she was paying for it! It was I that gave her the money to buy it with!" When asked again to continue her letter she willingly resumed her writing. A minute later they spoke about another patient, and someone made the remark, "She does not sleep." This started the patient again: "Who, I? I don't sleep? Why, I sleep like a dormouse!" It is to be noted that she wrote slowly, seeking for words. Having had but little schooling, writing in her case did not develop into an automatic function. She threw down her pen after having written a few disconnected lines. She was then given a paper and asked to read aloud one of the news items. Her attention was at once attracted by a picture below the news item and she exclaimed, pointing to it: "Here is a pretty woman! She resembles Mrs. P." She was again urged to read. She read the first fine with difficulty, owing to her poor vision, and continued to read on the same level in the next column. Again the above news item was. pointed out to her. It was about some poor old man.
The patient at once stopped her reading. "This is a jolly story! The poor old man! and the veterans! I visited them once, also the buildings for arts and for commerce." With a good deal of urging she was finally induced to read the entire news item; but it made very little impression on her mind; a quarter of an hour later she was unable to tell even briefly what she had read, declaring simply that it was something about an old man. "It is very sad," she added, "sad and humiliating. Thinking of death always distresses me, but I am very fond of flowers. My husband is a gardener in C. ... He buys his seeds from Vilmorin, also his tobacco." Numerous unsystematized grandiose delusions: she is a midwife, she studied for forty years; she is a millionairess, owns mansions; her husband has invented perpetual motion, made the model with nothing but his knife; he has also invented a method for making cheese boxes out of the stalks of rye, which he will sell for ten cents apiece. He is related to the king of Italy and is of noble descent. In her delusions the patient showed marked suggestibility: she was asked, "Have you ever been on the stage?" - "Why, yes, I played in The Chimes of Normandy." Here she began to sing: "Will you look this way, will you look that way?" Her children are also actors.
She played with them at the Castle Theatre, also with Sarah Bernhardt. Here her eye fell upon the word "Minister" printed in large letters in the paper; she said: "My husband has not yet been made Minister, but with his ability he will not have to wait long." She has no hallucinations, but numerous illusions, especially those of vision. She thinks she knows all those about her. One nurse is her cousin, another is her neighbor living across the street. Her motor excitement is very marked. The patient tries to do every kind of work; she makes a few sweeps with the broom, then suddenly rushes to assist a nurse carrying a pail of water, then leaves the nurse with her pail of water to go and make peace between two quarreling patients. Without any intention of malice, she has frequent altercations with other patients who are annoyed by her screams, her songs, and her wild pranks. She picks up all sorts of objects and accumulates them in her clothes: scraps of paper, bits of glass, wood, and metal, pieces of bread and cheese.
She herself laughs when an inventory is taken of all this rubbish, and makes no objection to its being taken away from her.
No noteworthy disorders in her general condition. She eats at all times, abundantly and gluttonously. Sleep somewhat disturbed: she passes part of the night wandering about the dormitory, singing and jabbering.