Massachusetts Medical Society: A Discourse on Mental Philosophy as Connected with Mental Disease

A Discourse on Mental Philosophy as Connected with Mental Disease

Annual Oration 1830

By Rufus Wyman, M.D.

You had expected, at your last meeting, an address from Dr. John Gorham. From him you had hoped to receive instruction and delight. This expectation, and this hope were disappointed by his death. He was suddenly cut down in the vigor of manhood and season of usefulness. Another departed slowly, full of days, and covered with honors, and learning, and virtues of the steady growth of a hundred years. Other fellows, within the same year, went down to the grave in unusual numbers. And again during the last year, they were followed by others to be counted with the dead.

Of the dead, many were your active and useful officers. They were cultivators of sound learning, promoters of the public good, guardians of the public health, ornaments of human nature. Of these time will not permit me even to repeat the names. But the name of Gorham is too intimately connected with the services of this day, too much honored by the fellows of this society, too much known by the lovers of medical science, and too dear to the friends of virtue, not to be mentioned, on this occasion, with the greatest respect. I am not to attempt his eulogy. It was pronounced over his mortal remains, by his learned and distinguished friend. It issued from the pulpit, and the press. It came spontaneously, and universally from the hearts of the people of this extended city. He was learned, and wise, and good. He was, therefore, valued and loved while living; honored and respected when dead.

The nature of the change, produced in man by death, has ever been a subject of anxious inquiry. The funeral ceremonies of the ancients clearly indicate a belief in them, that their deceased friends continued to exist beyond the grave. Unless the dead had been supposed to have knowledge of the actions of the living, these ceremonies would have been a senseless show. Whether this belief were derived from early revelation, transmitted by tradition, or from an induction from facts without us, or from a peculiar consciousness or feeling within us, it has existed among the learned, and deep thinkers of almost every age. It has generally been believed, that the substance, to which consciousness, knowledge, and feeling belong, is totally distinct from the body, which we commit to the earth, there to be decomposed and to enter into new combinations, according to chemical laws. But the determination of the question, whether consciousness, thinking, and feeling be attributes of matter or of spirit, seems not to be important in determining the question of man's future existence; for whatever substance it may be, which has existence, knowledge, and feeling here, the same may exist, and know, and feel hereafter.

The brain is admitted to be an organ, by whose agency we have connexion with the external world. By this agency sensations are produced, and volitions are executed. We have no difficulty in believing, that an impression upon an organ of sense may be transmitted to the brain; because in this case we can trace a continuity of organized matter. But that there should arise in the brain itself, thus affected, any consciousness or knowledge, is a fact so entirely distinct from, and so destitute of analogy to other affections of matter, as to indicate the existence of some other substance, possessing different properties, or susceptibilities. So in the execution of our volitions, there is for a similar reason, no difficulty in believing, that a change or motion, existing in the brain, may be transmitted to the voluntary organs. That the brain should originate voluntary motion, is to me wholly incomprehensible. But a review of the arguments, advanced by the materialists and immaterialists, would be of little interest on this occasion. Avoiding then the discussion of a question, in which so many have been bewildered, it will be sufficient to notice the phenomena of nature.

Powers, faculties, operations, functions and states of mind are terms which are frequently used. Nothing more is expressed by them than bare phenomena, made known to each individual by his own consciousness; and consciousness itself merely expresses a fact, which can be explained only by reference to the experience of its subject.

We learn then by experience, that man is a being that thinks and feels. Each individual being himself conscious, that he is at different times in different states, is so constituted as to infer from this fact, that others have a similar experience in regard to themselves. These different states, such as perceiving, remembering, comparing, and discerning, and also the different states in anger, joy, hatred, &c. constitute the phenomena, which are called mental. They are as closely connected with each other in one clearly marked group or assemblage, as the phenomena, which are common to vegetable and animal life, are connected in another. They are as distinct in their character from the organic phenomena of vegetables and animals, as the organic are from the physical. Nor are the organic actions more interesting to the physician, than should be the mental operations. There is a natural and fixed course of each, which is denominated perfect health.—‘Mens sana in corpore sano.’

There is a difficulty, and perhaps an impossibility of defining disease of mind; yet the difficulty seems not to be greater, than in disease of body. The state of perfect health is taken as the standard for each. Every deviation from this state is, strictly speaking, a disease. The deviations in the organic functions, however, are not usually considered diseases, unless they should be attended with pain, uneasiness, or other inconvenience. Neither are the deviations in the mental states or operations of one man to be considered as amounting to disease, unless they be obviously inconsistent with the feelings, judgment, or belief of other men, who are competent judges; so that the mutual adaptation, by which one mind is fitted to act in concert with others, is destroyed. It may be objected, that there are no mental diseases. That it is an ‘unphilosophical notion, which supposes an immaterial principle, the soul, sick or deranged.’ It is admitted, that an immaterial agent cannot have organic disease; because it is not composed of material organs. But that the operations, functions, or states of such an agent cannot deviate from their established course, and usual order, is contrary to obvious facts, of which, I think, every individual must at times be conscious.

In science men may differ—may adopt peculiar, and sometimes very singular opinions; yet they may not be accounted insane. Long after Sir Isaac Newton had proved, that the earth is flattened at its poles, the author of the Studies of Nature, contended that it is there elongated; but he was not adjudged to be a lunatic. After him Capt. Symmes believed, that it was neither flattened, nor elongated. He affirmed, that instead of solid earth, there was a vast hole, forming an entrance into an immense cavern, leaving the earth a mere shell, inhabited, as well on its internal, as its external surface; yet perhaps Capt. Symmes is entitled to a judgment, as favorable as that of St Pierre.

There are mental deviations, however, which relate to the ordinary affairs of life and the daily experience of all, in which no man can depart much from the usual opinions, or conduct of mankind without actual derangement. It is true any man may err from want of information, or experience. But a man of sound mind, will be susceptible of the influence of evidence. He will attend to the arguments against his erroneous opinions, and be willing to correct them.

A deranged man will seldom attend to arguments, or feel the force of evidence against his opinions. He will hold fast a belief, which every rational mind would perceive to be founded on error and falsehood. False belief—delusion is, in view of criminal law, essential to insanity. Lord Erskine, in his defence of Hadfield is most full and clear on this subject, and the court unanimously assented to his exposition. James Hadfield was tried in the Court of King's Bench for shooting at the king in Drury-lane theatre. ‘He imagined that he had constant intercourse with the Almighty Author of all things—that the world was coming to a conclusion, and that, like our blessed Savior, he was to sacrifice himself for its salvation, and because he would not be guilty of suicide, though called upon by the imperious voice of heaven, he wished that by the appearance of crime, that his life might be taken from him by others.’ His delusion consisted in his belief, that he was under a special command of God—in his belief, that the end of the world was at hand, and in his further belief, that his death would procure its salvation.

In this city, a man believed himself to be King Charles II. He wore a long beard, as was the fashion in the days of that prince. He spoke in the royal style, and required of all persons to address him in language suited to the royal presence. He assumed great dignity of manner, and deemed the touching of his beard the greatest insult. These singularities in conduct did not constitute his derangement. They were indeed proofs of it. His belief, that he was a king, was his delusion. His actions were perfectly consistent with his belief. It would have been unreasonable in him to have conducted differently. His belief, founded on error, did as really govern his conduct, as does the belief of other men, founded on truth, govern theirs.

Last winter an intelligent gentleman believed, that various evil minded persons, who were strangers to him, had often attacked him in the streets with chlorine gas, and had contrived to throw it into his chamber; that it produced pains in his head, and soreness of his nose. He made the doors of his house doubly secure with additional bolts, and caulked the windows, and kept pledgets of lint in his nostrils and ears. This man was the only proper judge of the existence of the pains and soreness. They were feelings, of which he alone could be conscious. But in assigning causes of these feelings, others were equally competent judges; yet contrary to the unanimous opinion of numerous friends, in whom he had great confidence, he continued in the same belief, and frequently and secretly changed his lodgings to escape the annoyance. He said to his friends, ‘I know that it appears to you unreasonable, and imaginary, but to me it is a reality; to you it is a proof of insanity, to me it is a source of suffering.’

Lawyers may trace insanity to delusion, and proof of delusion may always be necessary in courts of criminal law to establish the existence of actual derangement. But physicians should extend their inquiries further, and endeavor to ascertain the difference between a state of delusion, and a state of sound mind—to ascertain how a state of delusion or false belief is produced. This inquiry is not less important in the investigation of mental diseases, than is the accurate discrimination of the healthy and disordered states of the organic functions in the investigation of their diseases. A knowledge of the mental functions in health can be derived only from the history of mental operations. This history of facts, with the laws and principles deduced therefrom by the aid of a sound logic, is called the philosophy of mind.

Mental philosophy, then, is an indispensable study of an accomplished physician. Such are the mutual dependencies and influences of the mental and organic functions, that diseases of either cannot be well treated without a knowledge of both. But I would not go back to the vagaries of the ancient metaphysicians. It is sufficient to begin with Locke, and proceed with Brown, Stewart, and Reid. If the reading be confined to a single volume, it may be Payne's Elements of Mental and Moral Science. These writers have been guided by the precepts of Bacon. They have taken facts and sought for their connexions and dependencies. They have labored to become simply the interpreters of nature. Whoever will turn his thoughts within him, and attend to the operations or different states of his own mind, will find in their works a record of mental phenomena, of which his own experience will afford the fullest confirmation. An acquaintance with their writings will fix the philosophical import of many terms in popular and scientific use, concerning which there is much confusion and ambiguity in medical books. The faculties of the mind, for example, are usually considered as distinct agents. This is erroneous. The faculties are not parts of the mind. The mind cannot be divided. There is but one agent acting in different ways, or performing different acts. This is the doctrine of the immortal Essay Concerning Human Understanding. The same doctrine is taught by various authors. Mr. Locke, speaking of the understanding and will, says the word faculties must not be ‘supposed, (as I suspect it has been,) to stand for some real beings in the soul, that performed those actions of understanding and volition. For when we say the will is the commanding and superior faculty of the soul, that it is or is not free, that it determines the inferior faculties, that it follows the dictates of the understanding, &c. though these and the like expressions, by those who carefully attend to their own ideas, and conduct their thoughts more by the evidence of things, than by the sound of words, may be understood in a clear and distinct sense; yet I suspect, I say, that this way of speaking of the faculties has misled many into a confused notion of so many distinct agents in us which had their several provinces and authorities, and did command, obey, and perform several actions as so many distinct beings. Which has been no small occasion of wrangling, obscurity, and uncertainty in questions relating to them.’

The very learned Dr. Good says of the faculties, ‘we sometimes, however, are apt to speak of them as distinct and separate existences from the mind, or as possessing a sort of independent entity, and as controlling one another by their individual authorities.’ Again, ‘The faculties of the mind are so many powers.’ ‘But the power to do one action is not operated upon by the power to do another action.’ Yet he says, under the genus Ecphronia, and not very consistently, ‘a sound mind supposes an existence of all the mind's feelings and intellectual powers in a state of vigor, and under the subordination of the judgment, which is designed by nature to be the governing or controlling principle.’

That the study of mental philosophy is a necessary part of a medical education, will be more apparent by attending to the description of insanity by any approved author. Diseases, affecting the intellect, are placed by Dr. Good in his fourth class, under the first order, Phrenica, in which they are thus described; ‘Error, perversion, or debility of one or more of the mental faculties.’ The import of these terms must be understood, or the description will be of no use. From this description we learn first, that there are several mental faculties. Then arises the inquiry, what is their number, and what is the character of each? We next learn, that there may be error, or perversion of one or more of these faculties. Then comes another inquiry, what is their sound state? for unless this can be ascertained, it will be impossible to know when there is error or perversion. When we have acquired accurate knowledge of the sound state, we can, by comparing the two states, learn in what respects the diseased states deviate from a state of health.

The same learned author proceeds in his description, and remarks, under the genus Ecphronia, or insanity, that there is ‘diseased perception with little derangement of the judgment,’ &c. The medical student would certainly inquire, what are the mental functions or states, intended by perception and judgment. Unless he do this, he cannot understand the description. Dugald Stewart observes, that ‘in ordinary language we apply the same word, perception, to the knowledge, which we have by our senses, of external objects, and to our knowledge of speculative truth; and yet an author would be justly censured who should treat of these two operations of the mind under the same article of perception.' In the definite and philosophical use of the term, perception denotes that mental function, which refers to an external object as its cause, the impression made upon an organ of sensation. Thus when we have a certain impression upon the ear, followed by a sensation, we refer it to a man cutting wood with an axe. But there is another use of the same term, perception, when we speak of the perception of the agreement or disagreement of two ideas, or of the perception of the relation of the successive steps of a geometrical demonstration, &c. Dr. Good has adopted both uses of this word in the proem to his fourth class. In his description of the genus Ecphronia of the same class, I think, it is nowhere pointed out in which of these senses, or in what sense it is to be understood.

Writers on mental philosophy arrange the mental operations or states under two heads, one of which regards our knowledge, the other our feelings. The former includes the functions of intellect, or the intellectual powers or states. The latter includes the affections, emotions or passions, or the pathetical powers or states. Pope, in his Essay on Man, has very happily pointed out this distinction. “Two principles in human nature reign, Self-love [passion] to urge, and reason to restrain.” “Man but for that no action could attend, And but for this were active to no end.” “On life's vast ocean diversely we sail, Reason the card, but passion is the gale.” “Love, hope and joy, fair pleasure's smiling train; Hate, fear and grief, the family of pain. These, mixt with art, and to due bounds confined, Make and maintain the balance of the mind.” This division of the mental states or functions has suggested a corresponding division of mental diseases—diseases of the intellect and diseases of the passions. The same division is the basis of Dr. Good's arrangement of the mental disorders, which is clear and comprehensive, and should be thoroughly studied. He has, however, made many subdivisions, more important, perhaps, to a systematic work, than to the treatment of mental diseases.

In diseases of the intellectual functions there may be perversion, diminution, or augmentation of one or more of the intellectual states or faculties.

1. It has already been observed, that delusion or false belief exists in all cases of insanity, in the legal meaning of the term. True belief is founded on some intuitive knowledge, some original principles, some self-evident truths, from which, by the process of reasoning, conclusions are derived, to which assent is given. Thus my belief, that the sun will rise again, is an inference from a confidence in the permanency of the order of nature. My belief of the existence of an external world is derived from my sensations. My belief, that Dr. Holyoke lived in Salem, A. D. 1828, arises from my confidence in the evidence of memory. My belief, that he was then one hundred years old, arose from my confidence in testimony.

If there be perversion in the original principles of belief, all consequential belief will be false. If these foundations of intellect be overturned, the superstructure will be in ruins. The physician and patient cannot meet on common ground. Reasoning will be vain. They are at variance about first principles, which are not susceptible of proof, and do not admit of argument. Insane persons usually reason right; but the conclusions are wrong, because the premises are false.

There may be perversion not only in regard to fundamental principles of belief, but there may also be error, in a degree amounting to disease in the faculties exercised in reasoning from these principles. Inferences, which every sound mind would discover to be false, are sometimes made by lunatics from premises, which are true.

2. That there is often a diminution of intellectual power, in a degree amounting to disease, comes within the experience of some, and the observation of all. The memory may be imperfect, the agreement or disagreement between ideas may not be discerned, or the mental operations may be slow and unequal.

3. An augmentation of one or more of the intellectual powers is another deviation from a state of sound mind. That it is a disease, may perhaps be denied; and if it be a disease, many might wish to be sick. The disease consists, not in a proportional and permanent augmentation of each faculty, but in the temporary excess of vigor and activity of one or more of the faculties above their just proportion. In some, the quickness and extent of the memory is increased; in some, the imagination is too active; in some, there is increased talent of ridicule and sarcasm; in some, there is a hurry and quickness in all the intellectual operations.

The augmentation of intellectual power is sometimes sudden and wonderful. A gentleman of moderate mental endowments, who played an indifferent game at chess, became deranged in 1819. There was at first some doubt as to the reality of his insanity. On a certain evening he came from his room with a blanket over his shoulders, in the character of an Indian chief; his head elevated, his body very erect, his step long and firm. His whole manner had an air of dignity, and conscious superiority. He took his seat at a table, upon which was a chessboard, and played several games with several persons, by whom he had often, if not usually, been beaten. But he was now conqueror in almost every game. He played with a skill and quickness, never approached by him before or afterwards. All doubt of his insanity was now removed in the judgment of his physician. That judgment was afterward fully confirmed, by a complete developement of the disease.

As there is disease, of intellect, without disease of the passions, so there may be disease of the passions, without apparent disease of intellect. In diseases of the pathetical states or functions, there may be exaltation or depression of one or more of the passions. These diseases are more to be dreaded than any others, to which man is liable. The passions, being the source of all his actions, and continually demanding of the intellectual powers the means of their gratification, if they be in excess, they urge to action beyond the bounds of reason, and the subject of them is driven and hurried on to the perpetration of the most atrocious deeds. Here the law sees no delusion, and holds the miserable offender accountable for his acts. This, perhaps, is the only practicable rule, consistent with the safety of society.

The physician, however, must take a different view of these deplorable cases. He must discard the policy of the law, and attend to the voice of humanity and of truth. It is true, the passions are under the control of every man in a state of sound mind. Whoever possesses this power of control, and neglects to exercise it, is responsible for deeds arising from his negligence. But the man, who has lost this power by the exaltation of one or more of the passions, who does not possess that self-control, which belongs to every man of sound mind, labors under a mental defect,—a deviation, which as truly constitutes a disease, as does any deviation from a state of health in the intellectual or vital functions. If the passions are all in due proportion, they are productive of the good, for which our Creator designed them. But when one or more of them is exalted, they will be followed by mental disturbance. Such may be their influence upon the intellectual powers, that what is right, or what is wrong may not be discerned; or the feeling of obligation to avoid the latter and pursue the former may be overpowered, or lost in the diseased desire of gratification. There may be an extravagance of feeling, as there was in the days of chivalry, or the crusades, or has been in periods of religious or political excitement, which may obscure the intellectual vision, and lead the blinded enthusiast into the greatest absurdities.

But there is another state of mind, in which one or more of the passions are depressed, and evince a defect of vigor and activity. There are persons, who are almost destitute of friendship, love, or hope, and nearly all the kind and benevolent affections. Others are scarcely susceptible of hatred, envy, or revenge, &c. And again, there are some, in whom there is a kind of general apathy, who feel no interest in the affairs of life, or in the happiness of themselves or of others. These are deviations from a sound state, and fall within the conditions of mental disease. They are not the natural and original states of the individual, but temporary changes induced by particular causes.

Exaltation, and depression of passion, are sometimes manifested alternately in the same individual. Has been for several years subject to alternations of these states, without disease of the intellectual powers. During the state of depression he talks little—scarcely answers questions—goes to bed early—sleeps well—rises late—takes food regularly—is indifferent about his dress—refuses to walk, or ride, or to attend church—writes no letters—reads no newspapers—discovers no interest in any person or kind of business. He is not anxious, or distressed on any subject—is perfectly quiet and inoffensive. After being depressed from two to five weeks, he gradually becomes more active, gay, and full of business. As a first change, he begins to smile, and answer questions; then to sit up later, sleep less and rise earlier—walks, and rides when requested. In a few days, he begins to converse freely, read newspapers, and play at chess. Next he calls for his best clothes—is anxious to attend church, visit every where, and see every body—plans voyages—is full of business—writes letters to all parts of the United States, to England, France, Holland, &c.—becomes gay—dances, sings—is irrascible—offended when opposed—passionate, and violent—tears his clothes—breaks windows, swears, strikes, kicks, bites, dashes drinks in the faces of attendants, and sometimes says, I would send you to hell, if I could; ‘but instantly, sensible of the inhumanity of his wishes, and becoming calm, adds, with good feeling, ‘But I would remove you to heaven in one minute.’ The paroxysms of passion, in various degrees, are repeated many times in a day, from the most trifling causes, and without malice. In this case, the changes from depression to exaltation of passion are usually gradual—often sudden, and sometimes instantaneous. The paroxysms are, almost universally, free from any apparent disease of the intellectual powers. His letters are well written, his plans of voyages are judicious, and the whole discovers an intimate knowledge of business. When the transitions are gradual, he appears, during the intervals, quite well for several weeks, and is a kind hearted, intelligent, agreeable man.

To exhibit clear and exact views of an insane mind, it seemed necessary to consider separately diseases of the intellect, and diseases of the passions; yet they are seldom so observed in fact. During health the intellect may discover some supposed good, real or imaginary, and then will arise the desire to obtain it; or it may detect some supposed evil, real or imaginary, and then will arise the desire to avoid it, and, perhaps, to punish its author. Or one or more of the passions may become excited, and seek to be gratified, and then the intellect is to devise the means to accomplish the end. These relations continue in a state of disease, the disordered intellect suggesting opportunities for the indulgence of the passions, or the excited passions, in their turn, prompting the intellect to provide for their gratification. Hence the most common form of insanity is a combination of disordered passions, and disordered intellect, in variety and gradations almost infinite.

Such, too, is the connexion between the mental operations and various organic functions, that diseases of the one frequently induce diseases of the other. Hence insanity arising from moral causes, as jealousy, anger, remorse, unexpected adversity or prosperity, soon produces disease in some of the abdominal viscera. Hence, too, diseases of the alimentary tube, the liver, and the uterus, often produce mental diseases.

It has been my object to notice some of the connexions between sound mind and mental disease, that I might suggest for your future consideration the importance of mental philosophy, as a necessary part of a medical education. It is the number and extent of the mental powers of man, that constitutes the vast difference between him and every other terrestrial being. It is mind, that traverses the ocean, and converts a wilderness into fruitful fields. It was the mind of Newton, which explored the heavens, weighed the planets, and measured their distances. It was the mind of La Place, which again journeyed through the celestial regions, and returned with new proofs of the power and wisdom of the creator. But in the most exalted views of the mind of man, there appears enough of frailty to teach him humility. It is subject to disease. Its powers may be prostrated in a few uneasy days. In a single moment, the noblest intellect may be reduced to the humble condition of the most ordinary mind. Such changes are obvious to all, and leave no one in doubt of their nature. It it not usual, however, that the subversion of the mind is the work of an hour, or a day. The attacks of insanity are commonly gradual, and in passing from a state of sound mind to a state of derangement, the changes are almost imperceptible.

‘Such thin partitions do the bounds divide,’ that it may be difficult to form a satisfactory opinion, whether an individual be, or be not deranged. In determining a question so important to him, the first inquiry should certainly be to ascertain the actual states of mind, as manifested by the countenance, conversation, and conduct. But this knowledge will be of little use, unless it be compared with some standard—the standard of sound mind.

The medical student is required to learn of chemistry and natural philosophy the laws of inanimate matter—to toil, at the risk of life, in learning the structure of the body, and the functions of its organs; yet it is only incidentally, that the functions of the mind become an object of his attention. That, which acquires all knowledge, may itself remain unknown. A knowledge of the faculties of the human mind, and the laws of its operations, can be acquired by no man except by deep attention to the mental changes, of which he is conscious. He must find within himself the facts and experiments, from which alone he can deduce the principles of mental science. In making these deductions, he will discover a new world, beautiful and wonderful, ‘the image of God.’

Mental philosophy is interesting to physicians, as men of science. It will repay their labors, as curious men, seeking amusement; as students of nature, of good morals, and of sound religion. It is also interesting to them as a profession. No where does it cast a clearer or a stronger light, than it throws upon the darkness of a disordered mind. In cases of alleged or pretended insanity, physicians are frequently called to give opinions, upon which the verdict of a jury or the judgment of a court may mainly depend. Here rests upon the medical witness a most solemn responsibility. The decision may involve consequences, more important to individuals and the community, than the treatment of the disease. It may extend to the disposition of property, validity of contracts, responsibility for crimes, even to the jeopardy of life. Before another anniversary of this society, some of its fellows may be involved in a calamity, by which property, or character, or life, may turn upon the question of sanity or insanity. It may be that this question will be decided upon testimony, which some of you may be required to give—and the correctness of this testimony may depend upon a correct knowledge of sound mind.

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