SATIONAND IRCAU PSYCHOPATHIC DISEASES UNIVERSITY OF CALIFORNIA AT LOS ANGELES THE CAUSATION AND TREATMENT OF PSYCHOPATHIC DISEASES WORKS BY BORIS SIDIS The Foundations of Normal and Abnormal Psychology Symptomatology, Psychognosis, and Diag- nosis of Psychopathic Diseases The Causation and Treatment of Psycho- pathic Diseases The Psychology of Suggestion Multiple Personality Psychopathological Researches An Experimental Study of Sleep A Study of Galvanometric Deflections The Nature and Causation of the Galvanic Phenomenon Philistine and Genius The Psychology of Laughter The Causation and Treatment of Psychopathic Diseases BY BORIS SIDIS, A.M., Ph.D., M.D. Medical Director of The Sidis Psychotherapeutic Institute BOSTON: RICHARD G. BADGER TORONTO: THE COPP CLARK co., LIMITED Copyright, 1916, by Boris Sidis All Rights Reserved. MADE IN THE UNITED STATES OF AMERICA. THE GORHAM PRESS, BOSTON, U. S. A. WM mt Felix qui potuit rerum cognoscere causas, Atque metus omnes, et inexorabile fatum, Subjecit pedibus, strepitumque Acherontis avari. Fergilius, Georgicce. Hunc igitur terrorem animi tenebrasque necessest Non radii solis neque lucida tela diei Discutiant, sed naturae species ratioque. Lucretius, De Rerum Natura. r (0 p! LU 435044 INTRODUCTION Psychopathic diseases are not hereditary they are acquired characteristics. "Weak nerves," "a run down, exhausted nervous system, " whatever the terms may mean, may overlap psychopathic conditions, but the two are by no means equivalent, much less identical. Psychopathic states are not "weak nerves" or "fatigued nerves." Above all, there is no need to obscure the matter and resort to the much abused, mystical and mystifying factor of heredity. It is easy to shift all blame on former generations, where in most cases the fault is close at hand, namely, a debased environment, a defective training, and a vicious education. Under the rigorous conditions of primitive life in- dividuals who have been unfortunate, and have become affected with mental troubles and emotional afflictions are mercilessly exterminated by the process of tribal and social selection. Each generation weeds out the individuals who have been unfortunate enough to fall under unfavorable circumstances, and have become mentally sick, suffering from acquired psychopathic disturbances. In primitive life the crippled, the maimed, the wounded, the sick fall by the way, and are left to perish a miserable death. In fact, the less for- tunate, the wounded and the stricken in the battle of life, are attacked by their own companions they are destroyed by the ruthless social brute. The gregarious brute has no sympathy with the pains and sufferings of the injured and the wounded. The faint and the ailing are destroyed by the herd. Civilization, on the other hand, tends more and more towards the preservation of psychopathic individuals. We no longer kill our sick and our weak, nor do we (0 ii Introduction abandon them to a miserable, painful death we take care of them, and cure them. Moreover, we prevent pathogenic factors from exercising a harmful, malign social selection of the "fit." We do our best to free ourselves from the blind, merciless, purposeless selec- tion, produced by pathogenic micro-organisms and by other noxious agencies. We learn to improve the ex- ternal environment. We do not condemn people to death, because they are infected with smallpox, typhus, typhoid bacilli, or be- cause of an infected appendix. We no longer regard them as sinful, unclean, accursed and tabooed. We vac- cinate, inoculate, operate, and attempt to cure them. By sanitary and prophylactic measures we attempt to prevent the very occurrence of epidemics. Our valua- tion of individuals is along lines widely different from those of the stone age and the cave man. We value a Pascal, a Galileo, a Newton, a Darwin, a Pasteur, and a Helmholtz far above a Milo of Croton or an African Johnson. Civilization is in need of refined, delicate and sensi- tive organizations, just as it is in need of galvanometers, chronometers, telephones, wireless apparatuses, sensi- tive plates, and various chemical re-agents of a highly delicate character. We are beginning to appreciate delicate mechanismsfand sensitive organizations. We shall also learn to train and guard our sensitive natures until they are strong and resistant to the incident forces of an unfavorable environment. The preservation of psychopathic individuals accounts for the apparent increase of neurotics in civilized communities. It may be well to add that, although the occasions for sudden, intense, overwhelming shocks are not so prevalent in organized societies as they are in primi- tive savage communities, the worries, the anxieties, the Introduction Hi various forms of slow, grinding fears of a vague, mar- ginal, subconscious character, present in commercial and industrial nations, are even more effective in the production of psychopathic states than are the isolated occasions of intense terrors occurring in the life of the primitive man of the paleolithic or neolithic periods. In my works I lay special stress on the fact that the psychopathic individual has a predisposition to dissocia- tive states. Early experiences and training in child- hood enter largely into the formation of such a pre- disposition. Still, there is no doubt that a sensitive nervous system is required, a brain susceptible to special stimuli of the external environment. This, of course, does not mean that the individual must suffer from stigmata of degeneration. On the contrary, it is quite possible, and in many patients we actually find it to be so, that the psychopathic individual may be even of a superior organization. It is the sensitivity and the delicacy of nervous organization that make the system susceptible to injurious stimulations, to which a lower form of organization could be subjected with impunity. An ordinary clock can be handled roughly without disturbance of its internal workings, but the delicate and complicated mechanism of a chronometer requires careful handling and special, favorable con- ditions for its normal functioning. Unfavorable conditions are more apt to affect a highly complex mechanism than a roughly made instrument. It is quite probable that it is the superior minds and more highly complex mental and nervous organizations that are subject to psychopathic states or to states of dis- sociation. Of course, unstable minds are also subject to dissociative states, but we must never forget the fact that highly organized brains, on account of their very complexity, are apt to become unstable under iv Introduction unfavorable conditions. A predisposition to dissocia- tion may occur either in degenerative minds or in minds superior to the average. Functional psychosis requires a long history of dissociated, subconscious shocks, given to a highly or lowly organized nervous system, dating back to early childhood, As Mosso puts it: "The vivid impression of a strong emotion may produce the same effects as a blow on the head or some physical shock." We may, however, say that no functional psychosis, whether somopsychosis or psychoneurosis, can ever be produced simply by physi- cal shocks. In all functional psychoses there must be a mental background, and it is the mental background alone that produces the psychosis and determines the character of the psychopathic state. The basis of functional nervous or psychopathic mal- adies is essentially a pathological process involving the nervous system in as definite a way as the invasion and infection of the organism by various species of bacteria, bacilli, and other micro-organisms which attack the individual during his lifetime. Like infectious diseases, psychopathic deviations, abnormalities, and excesses are acquired by the indi- vidual in the course of his relations with the external environment, and are as real as syphilis, smallpox, diphtheria, cholera, and the bubonic plague. To re- gard them as imaginary, or to relegate them to the action of Providence or to heredity is theoretically a misconception, and practically a great danger to human- ity. There is nowadays a veritable craze for heredity and eugenics. Biology is misconceived, misinterpreted, and misapplied to social problems, and to individual needs and ailments. Everything is ascribed to heredity, from folly and crime to scratches and sneezes. The Introduction v goddess Heredity is invoked at each flea-bite in morsu pulicis Deum invocare. Even war is supposed to be due to the omnipotent deity of Heredity. Superior races by their patriotism and loyalty destroy the weak and the helpless, and relentlessly exterminate all peace- ful tribes. Such warlike stock comes of superior clay. The dominant races have some miraculous germ-plasm (chromatin) with wonderful dominant "units" (chro- mosomes) which, like a precious heritage, these races transmit, unsullied and untarnished, to their descend- ants. Wars, carnage, butcheries make for progress, culture, and evolution. Our boasted civilization with its "scientific" business thoroughness and its ideal of "efficiency" attempts to carry into effect this quasi- evolutionary doctrine this apotheosis of brute force under the aegis of science. The eugenic belief is really a recrudescence of the ancient savage superstition of the magic virtues of noble blood and of divine kingly stock. All nervous, mental, neuropathic, and psychopathic maladies are supposed to be a matter of heredity. If people are poor, ignorant, superstitious, stupid, de- graded, brutal, and sick, the eugenists unhesitatingly put it all up to poor stock. The eugenic remedy is as simple as it is believed to be efficacious: Introduce by legislation "efficient" laws favoring "eugenic" mar- riage, sterilize all the "unfit," and teach the masses control of births. The select and chosen stock alone should multiply the millennium is then bound to come. Such is the doctrine of our medico-biological sages. "Scientific" farmers and breeders of vegetables, fruits, and cattle are regarded as competent judges of human "breeders." Agriculturists and horticulturists set themselves up as advisers in "the business of raising good crops of efficient children. " Bachelors, spinsters, and the childless generally, are specially versed in vi Introduction eugenic wisdom and pedagogics. All social ills and individual complaints are referred to one main source heredity. With the introduction of eugenic legislation, with the extermination of the socially unfit, among whom the greatest men and women may be included, with the philanthropic sterilization of the "defectives," with the breeding of good "orthodox, common stock," and with the eugenic Malthusian control of births, all evil and disease on earth will cease, while the Philistine "superman" will reign supreme for evermore. In the Middle Ages all diseases and epidemics, all wars, all social and private misfortunes were considered as visitations of Divine wrath. In modern times our would-be eugenic science refers all ills of the flesh and woes of the mind to an outraged Heredity. The dark ages had resort to prayers, fasts, and penitence, while our age childishly pins its faith to the miraculous virtues and rejuvenating, regenerative powers of legislative, eugenic measures, sterilization, seclusion, restriction of marriage, and to the eugenic Malthusian control of births. Our scientists in eugenics gather hosts of facts, showing by elaborate statistical figures that the family history of neurotics reveals stigmata of degeneration in the various members of the family. "The Jukes" and their ilk are trumpeted about as great discoveries of eugenic research work. Any group of individuals of various "breeds" and "families," living under the action of the same conditions, social, economical, and educational will have the same impress. Anthropology has found this out in the case of so-called "nations" and "races." The eugenic inquirers do not stop for a moment to think over the fact that the same sort of evidence can be easily brought in the case of most people. In fact, the eugenists themselves, when in- quiring into the pedigree of talent and genius, invari- Introduction vii ably find somewhere in the family some form of disease or degeneration. This sort of "scientific" evidence leads some eugenic speculators, without their noticing the reductio ad absurdum, to the curious conclusion or generalization that degeneration is present in the family history of the best and the worst representatives of the human race. The so-called scientific method of the eugenists is radically faulty, in spite of the rich display of long pedigrees and family histories, of colored plates, stained tables, glittering biological speculations, brilliant math- ematical formulae, and complicated statistical calcu- lations. The eugenists pile Ossa on Pelion of facts by the simple method of enumeration which Bacon and the thinkers coming after him .have long ago con- demned as puerile and futile. From the savage's belief in sympathetic, imitative magic with its consequent superstitions, omens, and taboos down to the articles of faith and dogmas of the eugenists we find the same faulty, primitive thought, guided by the puerile method of simple enumeration, and controlled by the wisdom of the logical post hoc, ergo propter hoc. What should we say of the medical man who should claim that measles, mumps, cholera, typhoid fever, yellow fever, malaria, tetanus, and various other in- fectious diseases are hereditary by quoting learnedly long tables of statistics to the effect that for several generations members of the same family suffered from the same infectious diseases? What should we say of the medical advice, forbidding marriage to individuals whose family history reveals the presence of exanthe- mata? We stamp out epidemics not by eugenic measures, but by the cleansing of infectious filth and by the extermination of pathogenic micro-organisms. Every human being has a predisposition to small- pox, cholera, tetanus, bubonic plague, typhus fever, viii Introduction malaria, and to like infectious diseases, but there is no inherent necessity for everyone to fall a victim to the action of pathogenic organisms, if the preventive and sanitary conditions are good and proper. No one is immune against the action of bullets, cannon balls, shells, and torpedoes, or to the action of various poisons, organic and inorganic, but one is not doomed to be killed by them, if one does not expose oneself to their deadly action. Every living organism is by the very nature of its cellular tissues predisposed to the wound- ing by sharp instruments, or to the burning action of fire, but this does not mean an inherent organic weak- ness to which the organism must necessarily submit and perish. We are all of us predisposed to get in- jured and possibly killed, when we fall down from a high place, or when we are run over by an automobile or by a locomotive, but there is no fatalistic necessity about such accidents, if care is taken that they should not occur. We may be predisposed to neurosis by the very nature of complexity, delicacy, and sensitivity inherent in the structure of a highly organized nervous system, and still we may remain healthy and strong all our life long, provided we know how to keep away from noxious agencies. The creed of the inevitable fatality of neurosis is as much of a superstition as the Oriental belief in the fatalism of infectious diseases, plagues, and accidents of all kinds. Such fatalistic superstitions are dangerous, fatal, because they distract the attention from the actual causes and from the requisite prophy- lactic measures. We go far afield in search for the remote source of our troubles, when the cause is close at hand. We need only open our eyes to see the filth of our towns, the foul, loathsome slums of our cities, the miserable train- ing, the wretched education given to our children, in Introduction ix order to realize at a glance the source of our ills and ailments. We should lay the guilt at the door of our social order. We starve our young. We starve our children physically and mentally. We piously sacrifice our tender children and the flower of our youth to the greedy, industrial Moloch of a military, despotic, rapacious plutocracy. Wit- ness semi-civilized Europe with its lauded culture brutally shedding the blood of its youth and manhood on the altar of commercial patriotism. It is not heredi- ty, it is the vicious conditions of life that stunt the physical, nervous, and mental growth of our young generation. When we are confronted with the miserable, degraded, crippled forms of our life, we fall back cheerfully on some remote grandparent and credulously take refuge in the magic panacea of eugenics. The practical aspect is clear. Psychopathic neurosis in its two varieties, Somatopsychosis (Somopsychosis) and Psychoneurosis, is not hereditary, but acquired. We should not shift the blame on former generations and have resort to eugenics, we must look to the im- provement of mental hygienic conditions of early child- hood, and to the proper education of the individual. It is easy to put the blame on grandparents, they are dead and cannot defend themselves. Could they arise from their graves, they could tell some bitter truths to their 'degenerate' descendants who are ready to shift responsibility to other people's shoulders. It is about time to face the truth fairly and squarely, a truth which is brought out by recent investigations in psychopathology, that the formation of psychopathic neurosis with all its characteristic protean symptoms, is not hereditary, but acquired. Neurosis arises within the life cycle of the individual, it is due to faulty training and harmful experience of early child life. x Introduction Future medicine will be largely prophylactic, pre- ventive, sanitary, hygienic, dietetic. What holds true of medicine in general holds true of that particular branch of it that deals with neurosis. The treatment will become largely prophylactic, preventive, educa- tional, or pedagogic. It is time that the medical and teaching professions should realize that functional neurosis is not congenital, not inborn, not hereditary, but is essen- tially the result of a defective education in early child life. BORIS SIDIS. Sidis Institute, Portsmouth, New Hampshire, TABLE OF CONTENTS CHAPTER PAGE Introduction i I. Psychopathic Reflexes 21 II. Main Clinical Forms of Neuroses and Psychopathies 26 III. The Source of Psychopathies 33 IV. Embryonic Personality and Psycho- pathic Affections 38 V. The Fear Instinct and Psychopathic States 43 VI. Manifestations of Fear Instinct and Symptoms of Psychopathic Diseases. . 54 VII. The Main Principles of Psychopathic Diseases 64 VIII. The Law of Recession 73 IX. The Law of Reversion 76 X. The Process of Degeneration 81 XI. The Impulse of Self-Preservation in Psychopathic Diseases 86 XII. Neuron Energy and Neurosis 129 XIII. Clinical Cases 163 XIV. Psychognosis of Psychopathic Cases. .. 185 XV. Psychognosis of the Psychopathic Sub- stratum 247 XVI. Psychopathic Fears 280 XVII. General Psychotherapeutic Methods. . . 332 XVIII. The Method of Hypnoidization 363 XIX. Clinical Cases of Hypnoidal Treatment . . 376 XX. The Hypnoidal State and Reserve En- ergy 396 Index 409 The Causation and Treatment of Psychopathic Diseases CHAPTER I PSYCHOPATHIC REFLEXES THE profound influence of the central nervous system, more especially of the cortex with its mental processes, on bodily activities, on glandular, circulatory, and visceral functions, is now firmly established by psychophysiological and psychopathological research work. As Darwin puts it: "The manner in which the secretions of the alimen- tary canal and of certain glands, as the liver, kidneys, or mammae are affected by strong emotions, is an excellent instance of the direct action of the sensorium on these organs." The heart is extremely sensitive to sensory and ideosensory stimulations. Claude Bernard has shown how the least excitement of sensory nerves reacts through the pneumogastric nerve on the heart. The vasomotor system is directly acted on by the sensorium. Early investigators (Bidder, Schmidt, Richet) ob- served the fact that the sight of food causes the secre- tion of gastric juice. Pavloff in his experiments has shown that the central nervous system acts on the secretions of the stomach through the vagi nerves that innervate its glandular activity. Pavloff made a gastric fistula in the dog, then exposed the esophagus, opened it, and sewed the cut end to the edges of the wound. Food taken by the mouth fell out through the opening, but an abundant secretion of gastric juice 21 22 Causation and Treatment, Psychopathic Diseases was observed. There are two moments in the process of secretion: (i) The psychic moment, the perception of food and, (2) the chemical moment. According to Pavloff, the psychic moment is the more important. By the term "unconditional reflex" Pavloff means to indicate the response which the animal with a fistula in the secretory glands reacts by secretion to a normal stimulus, such as bread, meat, and other food. By "conditional reflex" Pavloff indicates the reaction made by the operated animal to a stimulus artificially associated with the unconditional reflex. Thus during the time the animal is fed, a light is flashed or a whistle is sounded or various figures are shown to the animal, as Doctor Orbeli has done. After a series of repetition, twenty, thirty, or a hundred, the animal reacts with secretion to that artificially associated stimulus. When another stimulus is in its turn associated with that of the conditional reflex, the result is not an increase, but a total inhibition of the conditional reflex. Savadsky modified the conclusions of the previous investigators, but he affirms the fact that an intense stimulus completely annihilates the secretion of the conditional reflex, such as is due to scratch stimulus, for instance, while a weak stimulus produces a lesser effect. He finds that the external stimulus inhibits the condition of the nerve centres. In summarizing the work of previous investigators in Pavloff's labora- tory, Orbeli says: "Vasiliev and Mishtovt have shown that any phenomenon indifferent in itself may not only become a source of a new conditional reflex, but may become a special inhibitory agent in relation to the existing conditional reflexes. This quality of the nervous system to work out special cases of inhibition makes the conditional reflexes a delicate index of reactions of the organism to its external environment. " On the strength of experiments performed on the Psychopathic Reflexes 23 visual reactions of the dog, Orbeli comes to the same conclusion with Vasiliev, Mishtovt, Babkin, and Sav- adsky. Similarly in the experiments carried on in my lab- oratory on the galvanic reflex, I find that the results coincide with Pavloff's experiments on inhibition. In a letter to me Pavloff writes that he is at work on the higher activities of the brain of the dog, studying mental reactions by the methods of conditional reflexes. According to Pavloff, mental life, however complex, can be studied successfully by the reactions of glandular secretions. An intimate relation exists between the functions of the central nervous system on the one hand and the sensory, motor, glandular, and visceral functions on the other. This vital relation, though unobtrusive to the casual observer, stands out clear and distinct in the domain of certain nervous and mental disturb- ances, such as hysteria, hystero-epilepsy, larval epilep- sy, neurasthenia, psychasthenia. All such conditions are mental disturbances, conscious or subconscious, and are termed by me psychopathies^ recurrent mental states. Recurrence of the symptom complex is path- ognomonic of psychopathies, or briefly, of neurosis. This essential trait of recurrence, found in neurosis, is a reversion to a low type of mental life. I refer all those who are interested in the subject to my work on the moment consciousness, studied from a psychobio- logical standpoint in my recent volume, The Founda- tions of Normal and Abnormal Psychology. In psychopathic affections the disturbance consists in the formation of non-adaptive associations of central neuron-systems with receptors which normally do not have as their terminal response the particular motor and glandular reactions. 24 Causation and Treatment, Psychopathic Diseases In Pavloff's experiments the flow of saliva or of gastric juice in the dog with the fistula could be brought about by association with blue light, with the sound of a whistle, by a tickle, a scratch, or by various diagrams, squares, circles, as in the experiments of Orbeli. What holds true in the case of conditional reflexes in regard to saliva and gastric juice, also holds true of other conditional reflexes formed by psychopathies. The mechanism in psychopathies is the same which Pavloff and bis disciples employ in the formation of various conditional reflexes in the case of the dogs. All kinds of abnormal reactions of a morbid character may thus be formed in response to ordinary stimuli of life. Emotions are specially subject to associations of a morbid or psychopathological character. The physi- ological effects of emotions may be linked by associa- tive processes with ideas, percepts, and sensations which are ordinarily either indifferent or give rise to reactions and physiological effects of a type opposite to that of the normal. Milk may excite nausea, a rose induce disgust, red paint produce fainting, while the croak of a crow, Limburger cheese, overripened game, the smell of garlic and asafcetida may be enjoyed with delight. The reactions of muscle and gland are like so many electric bells which by various connections and com- binations may be made to ring from any sensory button or receptor, as Sherrington would put it. An object, however harmless, may become associated with re- actions of anguish and distress. This holds true, not only of man, but also of the life of the lower animals. Associations and reactions, motor, circulatory, gland- ular, however abnormal, formed by young animals, persist through life. This holds specially true in the case of the higher and more sensitive animal organisms, such as the mammals. All training and formation of peculiar reactions, such as various tricks, habits, Psychopathic Reflexes 25 scare-habits, scare-pain reflexes depend entirely on this plasticity of the nervous system to form new associa- tions, or as Pavloff and his school put it, to form condi- tional reflexes and inhibitions in regard to glandular secretions as well as to other psychophysiological reactions. Psychopathies are essentially pathological affections of associative life. Psychopathic maladies are the formation of abnormal, morbid "conditional reflexes" and of inhibitions of reactions of associative normal life activity. CHAPTER II MAIN CLINICAL FORMS OF NEUROSES AND PSYCHO- PATHIES A brief outline of the classification of nervous and mental diseases, made by me in my various works, is of importance to a clear understanding of the etiology and differen- tial diagnosis of the neurotic affections under discussion. The different forms of nervous and mental diseases may be classified into organic and functional. By organic affections we mean to indicate all patho- logical modifications of the neuron and its processes taking place in the very structure, probably in the cytoreticulum, of the nerve cell. Under this category come such maladies as general paralysis, dementia praecox, and mental and nervous affections of an in- volutionary and degenerative nature. Such diseases are termed by me Organopathies or Necropathies. By functional affections we mean to indicate all neuron changes in which the neuron functions and their reactions to external and internal stimulations are involved in the pathological process without, how- ever, affecting the anatomical structure of the nerve cell. The pathological changes are not permanent, recovery of normal function is possible. Functional nervous and mental diseases may in their turn be subdivided into Neuropathies and Psycho- pathies. Functional neuropathic diseases are disturbances of functioning activity of the neuron, due to defective metabolism in cellular nutrition, brought about by external, and especially by internal stimuli-secretions, 26 Clinical Forms of Neuroses and Psychopathies 27 hormones, and other agencies. The pathological pro- cess in functional nervous and mental diseases produces few, if any, anatomical, structural changes in the neuron. The pathology of functional neuropathic diseases (probably of the cytoplasm) is essentially chemico-physi- ological in character. Neuropathic diseases include maladies in which the neuron undergoes degenerative changes which at first may bring about an apparent increase, then an inhibi- tion, and finally a complete suspension of neuron function, not terminating in the destruction of the neuron. This follows the general physiological law that all causes which tend to destroy the vital functions of cell activity begin at first to work as stimulants and after- wards become depressants, finally ending in the total destruction of the cell or of the neuron in the case of the nervous system. Thus in many cases small doses of opium or of morphine, chloral or other toxic and autotoxic products bring about an excitement. In such cases we should increase the dose or repeat it, if we wish to obtain depressant effects. In ether and chloroform anesthesia before the deep state of anes- thesia sets in there is a stage of excitement. This law holds true in the case of the process of degeneration of the nervous system in the various forms of nervous and mental diseases as in the process of the downward course of cellular disintegration. In neuropathic disturbances neuron restitution is possible. Neuropathic affections are produced by poisons, organic or inorganic, by autotoxic products, by hyposecretion or hypersecretion, or total absence of glandular secretion or hormones in the economy of the organism. Here belong all the temporary, or recurrent maniacal, melancholic, and delusional states, puerperal mania, epileptic insanity, the mental aberrations of 28 Causation and Treatment, Psychopathic Diseases adolescent and climacteric periods, periodic insanity, alternating insanities, and in general all the mental affections at present known under the description of manic-depressive insanity. Where the disease depends not so much on the neuron itself, but on the interrelation of neurons in a complex system, on association of systems of neurons, the con- dition is psychopathic in nature. In psychopathic troubles the neuron itself may remain unaffected, may be perfectly normal and healthy. The disorder is due to associations with systems of neurons which are usually not called into action by the function of that particular neuron or neuron system. Briefly stated: Organopathies or Necropathies include a group of psychophysiological symptoms accompanied by struc- tural, necrotic changes of the neuron, terminating in the ultimate death of the neuron systems involved in the pathological process. Neuropathies include a group of psychophysiologi- cal manifestations due to pathological functional neu- ron modifications, capable of restitution through a more perfect, more normal metabolism. Psychopathies are pathological phenomena of psy- cho-physiological dissociation and disaggregation of neuron systems and the resultant disturbances of ag- gregate functions, the neuron itself, remaining undam- aged and untouched. The Psychopathies may be classified into: Somato- psychoses or Somopsychoses and Psychoneuroses. This classification may be represented by the follow- ing diagram (Fig. i): The psychopathies may present chiefly somatic symptoms, such as paralysis, contractures, convulsions, or anesthesia, hypoesthesia, hyperaesthesia of the vari- ous organs, glands, and tissues. Such mental diseases Clinical Forms of Neuroses and Psychopathies 29 Nervous and Mental Diseases Organic Organopathies Neuropathies Somatopsyohoaes or Somopsychoses Functional Psychoneuroses or neuropsychoses Fig. i may be termed somatic psychoses, somatopsychoses. The somatic psychoses or neuroses would comprise the various manifestations of what is at present described as hysteria and neurasthenia as well as the milder forms of hypochondriasis. In all such diseases the psychical symptoms form the prominent elements of the mental malady. The patient remains unaware of the underlying mental grounds. So much is this the case that the patient is offended, if his trouble is regarded as purely mental in character. The mental side of the diseases is then said to be submerged subconsciously. In the psychoneuroses or neuropsychoses the physical symptoms are, on the contrary, few or none at all, while the predominating symptoms are entirely of a mental character. The patient ignores his physical condition, even if any exists, .and his whole mind is occupied with mental troubles. Such conditions are to be found in all obsessions, fixed ideas, imperative impulses, and other allied morbid mental states. Thus 3O Causation and Treatment, Psychopathic Diseases one patient is in agony over the unrighteousness of his conduct, another is obsessed by a terror of some myste- rious agency, or by religious and moral scruples. The two clinical forms of psychopathies are in strong contrast. In the somatic psychopathies or somatopsy- choses, the patient brings before the physician physi- cal symptoms stomach derangements, intestinal pains, contractures of limbs, menstrual disturbances, affec- tions of the sexual organs and their functions, paresis, paralysis, anesthesia, headaches, and similar bodily troubles. It is for the physician to discover the under- lying mental states. In the mental forms, .the psycho- neuroses, the patient omits reference to his physical condition. He usually states that he has always been physically well, and some patients assert that they are sure that they will always be physically well, that the whole trouble is purely mental. "I have no physical trouble," he tells the physician, "all my troubles are mental. If you could cure me of my mental suffering, I should be perfectly happy." The psychosomatic patient lays stress on his physical symptoms and is offended when they are declared to be mental; the psychoneurotic, on the contrary, insists on his mental symptoms, and becomes impatient when the physician pays attention to physical symptoms or to bodily functions. The psychosomatic patient be- lieves he is afflicted with some awful, incurable, physical malady, such as cardiac trouble, tuberculosis, or some other fatal bodily, disease. The psychoneurotic, on the contrary, ignores all physical troubles, but he thinks he is on the verge of insanity. The psychosomatic seeks to be assured that he is not an incurable invalid. The psychoneurotic wants to be certain that he is not crazy. The psychosomatic wishes to know whether or no he is really and truly free from some malignant disease, some horrible infection, or some fatal physical Clinical Forms of Neuroses and Psychopathies 31 malady. The psychoneurotic is anxious to be con- vinced that he is not insane, and that he is not to end the rest of the days of his life in some retreat or asylum for the insane. The clinical difference between the soma- topsychoses and neuropsychoses is a fundamental one, and is of the utmost consequence in prognosis and treat- ment. The somatopsychoses simulate physical and organic nervous troubles. Thus, many "hysterical" forms simulate tabes, or paralysis agitans, hemiplegia, para- plegia, or epilepsy, while many of the neurasthenic, hypochondriacal, and their allied states simulate tumor or cancer of the stomach, intestinal obstructions and glandular derangements; cardiac, laryngeal, pneumonic, hepatic, splanchnic, ovarian, tubal, uterine, renal, and hundreds of other bodily afflictions. The neuropsychoses or psychoneuroses simulate all forms of mental disease, beginning with melancholia and mania and ending with general paresis and de- mentia. Psychopathic affections can be differentiated from the various forms of insanity by the following important symptom: Readiness of the patient to get an insight into his trouble. The psychosomatic and the psycho- neurotic are characterized by the fact that they are anxious to learn the nature and causation of their trouble. They are eager to learn the psychogenesis of their affection, and will do everything in their power to help the physician in his examination and study of their case. Even in the cases where the idea is fixed, the obsession intense, and the impulse uncontrollable, they are anxious to listen to views different from their own, and, in fact, are always on the lookout for some help to get rid of the insistent mental states. No matter how fixed the mental state may be, it will temporarily give way to suggestion and persuasion. 32 Causation and Treatment, Psychopathic Diseases No matter how deep and intense the emotional state of the psychoneurotic and psychosomatic, it can be distracted and dissipated by the personal touch of some firm and trusted friend, or by the influence of the con- fidential physician who has an insight into the nature of the malady. Neither the emotions nor the ideas are immovably fixed, they are always ready to give way to other associations. Moreover, the psychoneurotic is always ready to receive such different associations and welcomes them with all his might and main. There is a great amount of optimism in the psychosomatic and psychoneurotic. This is clearly revealed in the various religious and mental cults which often delight the heart of the psychopathic patient. There is a large amount of cheerful hope in the very make-up of functional psychosis. CHAPTER III THE SOURCE OF PSYCHOPATHIES THE main source of psychopathic diseases is the fundamental instinct of fear 1 with its manifesta- tions, the feeling of anxiety, anguish, and worry. Fear is one of the most primitive instincts of animal life. Our life is so well guarded by the pro- tective agencies of civilization that we hardly realize the extent, depth, and overwhelming effect of the fear instinct. Fear is rooted deep down in the very organi- zation of animal existence; it takes its root in the very essence of life, the instinct of self-preservation. Pri- mus in orbe deos fecit timor. "The progress from brute to man," says James, "is characterized by nothing so much as the decrease in frequency of the proper occasion for fear. In civil- ized life in particular it has at last become possible for large numbers of people to pass from the cradle to the grave without ever having had a pang of genuine fear. Many of us need an attack of mental disease to teach us the meaning of the word. Hence the possibility of so much blindly optimistic philosophy and religion. Fear is a genuine instinct, and one of the earliest shown by the human child." lUnder "fear instinct" are included all afferent and efferent processes, sensory, glandular, and motor reactions that accompany this fundamental in- stinct. The sensory, glandular, and motor processes, the latter processes in the form of afferent kinaesthetic sensations, all enter in a synthetized state of what is re warded as the affective, emotional experience of fear. The sen- sory, glandular, and motor elements, the afferent and efferent processes, are not separate and distinct from central elements, as some psychologists and psychopathologists are apt to suppose, but these peripheral processes are intimately related to and even enter into the very constitution of the so called central elements or central affective processes of the instinct. 33 34 Causation and Treatment, Psychopathic Diseases Similarly, Sully says: "Fear appears early in the life of the child as it seems to appear low down in the zoological scale. Fear probably appears in the vague form (i.e., without any distinct representation of a particular kind of evil) in connection with presentation, e.g., of strange animals, which have contracted no associations from individual experiences and which derive their emotive force from special inherited associations. Experience is, however, the chief de- termining factor in the evocation of fear." "Fear," says Darwin, "is the most depressing of all the emotions; and it soon induces utter, helpless prostration, as if in consequence of or in association with the most violent and prolonged attempts to escape from the danger, though no such attempts have actually been made." The fear of coming evil, especially if it is unknown and mysterious, gives rise to the feeling of anxiety. "If we expect to suffer," says Darwin, "we are anx- ious." James regards anxiety, especially the pre- cordial anxiety, as morbid fear. "The anxious con- dition of mind, " says Bain, " is a sort of diffused terror. " Fear often expresses itself through cardiac and circula- tory affections, giving rise to the feeling of anxiety. Anxiety is nothing else but the working oj the instinct of fear. James makes an attempt to enumerate the various objects of fear in men, and especially in children. Among these he regards "strange animals, strange men, strange places, such as the fear of the sea in chil- dren who have not seen the sea before. The great source of terror to infancy is solitude. Black things, and especially dark places, holes, caverns, etc., arouse a peculiarly gruesome fear. This fear, as well as that of solitude, of being 'lost,' are explained after a fashion by ancestral experience. High places cause a fear of The Source of Psychopathies 35 a peculiarly sickening sort. Fear of the supernatural is one variety of fear. This horror is probably explica- ble as the result of a combination of simple horrors. To bring the ghostly terror to its maximum many usual elements of the dreadful must combine, such as loneli- ness, darkness, moving figures, inexplicable sounds, especially of a dismal character, moving figures half discerned, or if discerned, of dreadful aspect, and a vertiginous baffling of expectation. This last element, which is intellectual, is very important. It produces a strange emotional curdle in our blood to see a process with which we are familiar deliberately taking an un- wonted course. Any one's heart would stop beating, if he perceived his chair sliding unassisted across the floor. The lower animals appear to be sensitive to the mysteriously exceptional, as well as ourselves. My friend, W. K. Brooks, of the Johns Hopkins University, told me of his large and noble dog being frightened into a sort of epileptic fit by a thread which the dog did not see. Darwin and Romanes have given similar experi- ences. The idea of the supernatural involves that the usual should be set at naught. In the witch and hob- goblin, other supernatural elements, still of fear, are brought in caverns, slime and ooze, vermin, corpses, and the like. A human corpse seems normally to produce an instinctive dread which is no doubt some- what due to its mysteriousness, and which familiarity rapidly dispels." The fear of the unknown, of the unfamiliar, of the mysterious is quite common with children, with savages, and barbaric tribes. The fear of coming unknown, unfamiliar evil is specially a source of anxiety to the young or untrained, uncultivated minds. All taboos of primitive societies, of savages, of bar- barians, and also of civilized people take their origin, according to recent anthropological researches, in the 36 Causation and Treatment, Psychopathic Diseases "perils of the soul," or in the fear of impending evil. As the great anthropologist Frazer puts it: "Men are undoubtedly more influenced by what they fear than by what they love." We know how in the case of the ancient nations omens, whether religious or meteorological, such as storms, thunders, lightnings, comets, and eclipses, were regarded with great terror. Armies used to throw away their arms and run panic-stricken on the occasion of the appearance of a comet or of an eclipse. Even in the civilized times of the Athenian republic there was a terror of eclipses and of other unfamiliar natural phenomena. Thucydides, in his history of the Pel- oponnesian wars, puts the appearance of comets among national disasters. The fear of coming unknown, unfamiliar evil is especially a source of anxiety to the young or untrained, uncultivated minds. This fear of some unknown evil befalling a person may become a source of great fear and anxiety when developed in early childhood. This fear of strangeness, of un- familiarity, a feeling of being lost, developed in early childhood, may remain unassociated and thus give rise to a state of vague fear. Different forms of epilepsy are often associated with the fear instinct. In most men the instinct of fear is controlled, regulat- ed, and inhibited from very childhood by education and by the whole organization of civilized, social life. There are cases, however, when the instinct of fear is not moderated by education and civilization, when the instinct of fear is aroused by some particular incidents or by particular objects and states. In such cases, fear becomes associated with definite situations, giving rise to morbid fear and anxiety, resulting in the mental diseases known as psychopathies or recurrent mental states, psychoneuroses and somatopsychoses. In all such cases we can find the cultivation of the The Source of Psychopathies 37 instinct of fear in early childhood. Superstitions, and especially the early cultivation of religion, with its "fear of the Lord" and of unknown mysterious agencies, are especially potent in the development of the instinct of fear. Even the early cultivation of morality and conscientiousness, with their fears of right and wrong, often causes psychoneurotic states in later life. Relig- ious, social, and moral taboos and superstitions, associ- ated with apprehension of threatening impending evil, based on the fear instinct, form the germs of psycho- pathic affections. What we find on examination of the psychogenesis of psychopathic cases is the presence of the fear instinct which becomes associated with some interest of life. The interest may be physical in regard to bodily func- tions, or the interest may be sexual, social; it may be one of ambition in life, or it may be of a general charac- ter, referring to the loss of personality, or even to the loss of mind. The fear instinct may become by culti- vation highly specialized and associated with normally indifferent objects, giving rise to the various phobias, such as astrophobia, agoraphobia, claustrophobia, ery- throphobia, aichmophobia, and other phobias, according to the objects with which the fear instinct becomes as- sociated. Objects, otherwise indifferent and even pleas- ant, may by association arouse the fear instinct and give rise to morbid states, like the "conditional reflexes" in Pavloff's animals. 435044 CHAPTER1V EMBRYONIC PERSONALITY AND PSYCHOPATHIC AFFECTIONS THERE is another factor which helps to arouse the fear instinct, and thus plays an important role in the causation of psychopathic maladies. This factor is a narrow, suggestible personal life. In my work " The Psychology of Suggestion," I proved by a series of experiments that the conditions of suggestibility are: Fixation of attention, monotony, limitation of voluntary movements, limitation of the field of consciousness, inhibition. I have shown that these conditions are favorable to disaggregation of consciousness. I have pointed out that a disaggrega- tion of consciousness with an inhibition of the con- trolling, waking consciousness is one of the important conditions in the causation of subconscious states with their accompanying abnormal suggestibility. In other words, the inhibition of the personal self, or even the limitation of the personal self, helps the formation of dissociations which constitute the soil of all psycho- pathic diseases. When the person, therefore, is limited in his interests, is narrow in his range of knowledge, is ignorant and superstitious, and his critical personal self is embryonic and undeveloped, the predisposition to mental disaggregation is pronounced. The fear instinct has full sway in the production of psychopathic states. With the limitation and inhibition of the critical per- sonal self, with the limitation and narrowness of per- sonal life interests, there goes an increase of the sense of the unknown and the mysterious, cultivated by religion and superstition, with the baneful consequence of the 38 Embryonic Personality and Psychopathic Affections 39 development of the fear instinct, the cause of psycho- pathic affections. In the embryonic personality of the child as well as in the undeveloped or narrowed individuality of the adult the sense of the strange, of the unknown and the mysterious, is especially apt to arouse the fear instinct. In fact, the unfamiliar arouses the fear instinct even in the more highly organized mind. "Any new uncer- tainty," says Bain, "is especially the cause of terror. We become habituated to a frequent danger, and realize the full force of apprehension only when the evil is previously unknown. Such are the terrors caused by epidemics, the apprehensions from an unexperienced illness, the feeling of a recruit under fire. . . . The mental system in infancy is highly susceptible, not merely to pain, but to shocks and surprises. Any great excitement has a perturbing effect allied to fear. After the child has contracted a familiarity with the persons and things around it, it manifests unequivocal fear on the occurrence of anything very strange. The grasp of an unknown person often gives a fright. This early experience very much resembles the manifesta- tions habitual to the inferior animals." In another place Bain rightly says, "Our position in the world contains the sources of fear. The vast powers of nature dispose of our lives and happiness with irresistible might and awful aspect. Ages had elapsed ere the knowledge of law and uniformity prevailing among those powers was arrived at by the human intellect. The profound ignorance of the primitive man (and, we may add, of the undeveloped, limited, and superstitious adult) was the soil wherein his early conceptions and theories sprang up; and the fear inseparable from ignorance gave them their character. The essence of superstition is expressed by the definition of fear. An altogether exaggerated estimate of things, the ascription 40 Causation and Treatment, Psychopathic Diseases of evil agency to the most harmless objects, and false apprehensions everywhere, are among the attributes of the superstitious man." Compayre, in speaking of the fear of the child, says, "In his limited experience of evil, by a natural generali- zation, he suspects danger everywhere, like a sick person whose aching body dreads in advance every motion and every contact. He feels that there is a danger everywhere, behind the things that he cannot under- stand, because they do not fit in with his experience. The observations collected by Romanes in his interest- ing studies on the intelligence of animals throw much light on this question; they prove that dogs, for instance, do not fear this or that, except as they are ignorant of the cause. A dog was very much terrified one day when he heard a rumbling like thunder produced by throwing apples on the floor of the garret; he seemed to under- stand the cause of the noise as soon as he was taken to the garret, and became as quiet and happy as ever. Another dog had a habit of playing with dry bones. One day Romanes attached a fine thread which could hardly be seen, to one of the bones, and while the dog was playing with it, drew it slowly toward him; the dog recoiled in terror from the bone, which seemed to be moving of its own accord. So skittish horses show fright as long as the cause of the noise that frightens them remains unknown and invisible to them. It is the same with the child. When in the presence of all these things around him, of which he has no idea, these sounding objects, these forms, these movements, whose cause he does not divine, he is naturally a prey to vague fears. He is just what we should be if chance should cast us suddenly into an unexplored country before strange objects and strange beings suspicious, always on the qui vive, disposed to see imaginary enemies be- Embryonic Personality and Psychopathic Affections 41 hind every bush, fearing a new danger at every turn in the road." Similarly, Sully says, "The timidity of childhood is seen in the readiness with which experience invests objects and places with a fear-exciting aspect, in its tendency to look at all that is unknown as terrifying and in the difficulty of the educator in controlling these tendencies. " Sully is right in thinking that intellectual culture tends greatly to reduce the early intensity of fear. "This it does by substituting knowledge for ignorance, and so undermining that vague terror before the unknown to which the child and the superstitious savage are a prey, an effect aided by the growth of will power and the attitude of self-confidence which this brings with it." An uncultivated personality with a limited mental horizon, with a narrow range of interests, a personality sensitive to the moral categorical impera- tive, a personality trained in the fear of the Lord and mysterious agencies, is a fit subject for obsessions by the fear instinct. In certain types of functional psychosis and neurosis the patient has an inkling of the fear instinct in his dread of objects, or of states of mind, moral scruples, lack of confidence, blushing, religious or social expecta- tions of some coming misfortune and some mysterious evil, but he is not aware of the fear instinct as developed in him by the events and training of early childhood. The fears of early childhood are subconscious. At any rate, the patient does not connect them with his present mental affection. In other types of psychopathic affections the patient is entirely unaware of the whole situation, he is engrossed by the symptoms which he regards as the sum and substance of his trouble; the fear is entirely subconscious. The fear instinct fostered by frights, scares, dread of sickness, by religious instruction with its fear of the 42 Causation and Treatment, Psychopathic Diseases Lord, by moral and religious injunctions and duties with fear of punishment or failure in the moral stand- ard and duties, the enforcement of social injunctions with the consequent dread of failure and degradation, all go to the cultivation of the fear instinct which in later life becomes manifested as functional psychosis with all its baneful effects. Thus a psychoneurotic in his account writes: "I dwell on my childish acts because of my religious training, because of the superstitions charged with religious and pseudo-moral emotions." The fear of the Lord, especially when cultivated in early childhood, is not only as the Bible has it, "the beginning of (religious) wisdom," but is also the be- ginning of morbid mental states, the source of psycho- pathic affections. As Bacon puts it: "Natura enim rerum omnibus viventibus indidit metum ac formidinem, vitce atque essentitz sues conservatricem, ac mala ingruentia vitantem et depellentem. Ferumtamen eadem natura modum tenere nescia est, sed timoribus salutaribus semper vanos et inanes admiscet; adeo ut omnia (si intus conspici darentur) Panicis terroribus plenissima sint, prae- sertim humana." CHAPTER V THE FEAR INSTINCT AND PSYCHOPATHIC STATES THE fear instinct is the soil on which grow luxuriantly the infinite varieties of psycho- pathic affections. The body, sense, intellect, and will are all profoundly affected by the irresistible sweep of the fear instinct as manifested in the overwhelming feeling of anxiety. The fear instinct and its offspring anxiety weaken, dissociate, and paralyze the functions of the body and mind, giving rise to the various symptoms of psychopathic diseases. The fear instinct keeps on gnawing at the very vitals of the psychopathic patient. Even at his best the psychopathic patient is not free from the workings of the fear instinct, from the feeling of anxiety which, as the patients themselves put it, "hangs like a cloud on the margin or fringe of consciousness. " From time to time he can hear the distant, threatening rumbling of the fear instinct. Even when the latter is apparently stilled the pangs of anxiety torment the patient like a dull toothache. Montaigne, the great anatomist of human passions, in writing of fear, says, "I am not so good a naturalist (as they call it) as to discern by what secret springs fear has its motion in us; but be this as it may, it is a strange passion, and such a one as the physicians say there is no other whatever that sooner dethrones our judgment from its proper seat; which is so true, that I myself have seen very many become frantic through fear; and even in those of the best settled temper, it is most certain that it begets a terrible astonishment and confusion during the fit. I omit the vulgar sort, to 43 44 Causation and Treatment, Psychopathic Diseases whom it one while represents their great-grandsires risen out of their graves in their shrouds, another while hobgoblins, specters, and chimeras; but even among soldiers, a sort of men over whom, of all others, it ought to have the least power, how often has it converted flocks of sheep into armed squadrons, reeds and bull- rushes into pikes and lances, and friends into enemies . . adeo pavor etiam auxilia formidat. . . The thing in the world I am most afraid of is fear, that passion alone, in the trouble of it, exceeding all other accidents Turn pavor sapientiam omnem mihi ex animo expectorat. Such as have been well banged in some skirmish, may yet, all wounded and bloody as they are, be brought on again the next day to the charge; but such as have once conceived a good sound fear of the enemy will never be made so much as to look the enemy in the face. Such as are in im- mediate fear of losing their estates, of banishment or of slavery, live in perpetual anguish, and lose all appe- tite and repose; whereas such as are actually poor, slaves or exiles, ofttimes live as merrily as other folks. And the many people who, impatient of perpetual alarms of fear, have hanged or drowned themselves, or dashed themselves to pieces, give us sufficiently to understand that fear is more importunate and insup- portable than death itself." In the present fearful war of European nations against the pressure of invasion by Teutons .and their allies, a war unparalleled in the history of humanity for its extensive, brutal destructiveness, a war in which all the inventions of ages are made subservient to the passions of greed, hatred, and ferocity, having one purpose, the extermination of man, a war surpassing all battles ever waged by man or beast, in such a calami- tous clash and slaughter of nations, the fear instinct comes to the foreground, claiming its victims, working The Fear Instinct and Psychopathic States 45 havoc among the frenzied, struggling armed masses and terrified, stricken populations. That fear is a fundamentally important element in neuroses and psychoses has been fully acknowledged by many a neurologist and psychiatrist. Thus, Oppen- heim says, "Fear is a common symptom in the neuroses. It may be an indefinite feeling of anxiety not awakened by any particular cause, or it may be definite concepts and external influences which call the fear into action. The sensation is variously described. It has its seat, as a rule, in the cardiac region, at other times in the head. The patient feels as if his heart were standing still; he thinks that he must fall or that he will get a stroke. Some explain the condition thus: 'It seems to me that I have done something wrong, as if some- thing terrible is going to happen.' The expression of the face reveals a condition of anxiety, the fear often producing vasomotor, secretory, and motor disturb- ances; the face reddens or becomes pallid, perspiration breaks out, the saliva ceases to flow, the lips and tongue become dry, the pulse and respiration become acceler- ated." "A materially different picture," says Kirchoff, " is presented when the feeling of fear enters the symp- tom group (of melancholia). This feeling is referred to the cardiac region (precordial fear), and is one oj the most important and frequent accompaniments of severe melancholia. The external quiet of severe simple melancholia becomes converted into anxious restless- ness. From the start sleep is almost always disturbed because the patient is tormented by the pressure in the cardiac region. Other disagreeable sensations soon follow, such as constriction of the neck or a dull feeling in the head; bad dreams and anxious thoughts become more numerous. The daily work may make the con- dition endurable during the day for a time, but in the 46 Causation and Treatment, Psychopathic Diseases stillness of the night it is rapidly intensified, and if sleep does not refresh the excited brain, the days likewise are filled more and more with disheartening fears. The implication of the organs of the body is much more distinct in anxious than in simple melancholia. The appetite is lost, the nutrition is rapidly impaired. Respiration is superficial, the heart's action is accelerat- ed and often irregular, the pulse is small, the skin is cool. When the terror shows variations or occurs in paroxysms, its increase is shown by suppression of the urine and perspiration, its subsidence by increase in these secretions. The more chronic the precordial fear the more indistinct do these symptoms become. . . . . Religious notions are often awakened and are then explained as the dread of being possessed by evil spirits. ... In more severe cases the internal life becomes a real dreamy condition in which external expressions are received in a confused, shadowy and inimical manner. A terrible, baseless, but paralyzing fear takes possession of consciousness." The anxiety states of neurosis and psychosis are essentially due to the awakening of the fear instinct normally present in every living being. The fear instinct is a fundamental one; it is only inhibited by the whole course of civiliza- tion and by the training and education of social life. Like the jinn of the "Arabian Nights," it slumbers in the breast of every normal individual, and comes fully to life in the various neuroses and psychoses. Kraepelin and his school lay, with right, special stress on the fact that "Fear is by far the most important persistent emotion in morbid conditions Fear is manifested by anxious excitement and by anx- ious tension." "Experience," says Kraepelin, "shows an intimate relationship between insistent psychosis and the so-called 'phobias,' the anxiety states which in such patients become associated with definite impres- The Fear Instinct and Psychopathic States 47 sions, actions, and views." They are associated with the thought of some great unknown danger, although the patient may be aware that in reality nothing of the kind will befall him. Violent heart action, pallor, a feeling of anxiety, tremor, cold sweat, meteorismus, diarrhea, polyuria, weakness in the legs, attacks of fainting, so that the patient loses control of his limbs and occasionally simply collapses. "These states," says Kraepelin, with his usual insight into abnormal mental life, "remind one of the feeling of anxiety which in the case of healthy people may in view of a painful situation or of a serious danger deprive one of the calm- ness of judgment and confidence in his movements." Thus, we find from different standpoints that the feel- ing of anxiety with all its accompanying phenomena is one of the manifestations of the most fundamental, the most potent, of animal instincts, the fear instinct which is at the basis of all psychopathic maladies. The fear instinct, as the most subtle and most funda- mental of all instincts, is well described by Kipling: " Very softly down the glade runs a waiting, watching shade, And the whisper spreads and widens far and near; And the sweat is on thy brow, for he passes even now He is Fear, O Little Hunter, he is Fear! " Ere the moon has climbed the mountain, ere the rocks are ribbed with light, When the downward dipping trails are dank and drear, Comes a breathing hard behind thee snuffle snuffle through the night; It is Fear, O Little Hunter, it is Fear! "On thy knees and draw the bow; bid the shrilling arrow go: In the empty, mocking thicket plunge the spear; But thy hands are loosed and weak, and the blood has left thy cheek It is Fear, O Little Hunter, it is Fear! 48 Causation and Treatment, Psychopathic Diseases "When the heat-cloud sucks the tempest, when the slivered pine trees fall, When the blinding, blaring rain-squalls lash and veer; Through the war gongs of the thunder rings a voice more loud than all It is Fear, O Little Hunter, it is Fear! "Now the spates are banked and deep; now the footless boulders leap Now the lightning shows each littlest leaf-rib clear. But thy throat is shut and dried, and thy heart against thy side Hammers: Fear, O Little Hunter, This is Fear!" A well known author, a psychopathic sufferer, writes : "Carlyle laid his finger upon the truth, when he said that the reason why the pictures of the past were always so golden in tone, so delicate in outline, was be- cause the quality of fear was taken from them. It is the fear of what may be and what must be that over- shadows present happiness; and if fear is taken from us we are happy. The strange thing is that we cannot learn not to be afraid, even though all the darkest and saddest of our experiences have left us unscathed; and if we could but find a reason for the mingling of fear with our lives, we should have gone far towards solving the riddle of the world. " Dr. Crile lays special stress on the pathological aspect of the fear instinct: "That the brain is definitely influenced damaged even by fear has been proved by the following ex- periments : Rabbits were frightened by a dog but were neither injured nor chased. After various periods of time the animals were killed and their brain-cells com- pared with the brain-cells of normal animals wide- spread changes were seen. The principal clinical phenomena expressed by the rabbit were rapid heart, accelerated respiration, prostration, tremors, and a The Fear Instinct and Psychopathic States 49 rise in temperature. The dog showed similar phenom- ena, excepting that, instead of such muscular relaxa- tion as was shown by the rabbit, it exhibited aggressive muscular action. Both the dog and the rabbit were exhausted but, although the dog exerted himself active- ly and the rabbit remained physically passive, the rabbit was much more exhausted. "Further observations were made upon the brain of a fox which had been chased for two hours by members of a hunt club, and had been finally overtaken by the hounds and killed. Most of the brain-cells of the fox, as compared with those of a normal fox, showed exten- sive physical changes. "The next line of evidence is offered with some reservation, but it has seemed to me to be more than mere idle speculation. It relates to the phenomena of one of the most interesting diseases in the entire category of human ailments I refer to exophthalmic goiter, or Graves' disease, a disease primarily involving the emotions. This disease is frequently the direct sequence of severe mental shock or of a long and in- tensely worrying strain. The following case is typical: A broker was in his usual health up to the panic of 1907; during this panic his fortune and that of others were for almost a year in jeopardy, failure finally occurring. During this heavy strain he became increas- ingly nervous and by imperceptible degrees there developed a pulsating enlargement of the thyroid gland, an increased prominence of the eyes, marked increase in perspiration profuse sweating even palpitation of the heart, increased respiration with frequent sighing, increase in blood-pressure; there were tremor of many muscles, rapid loss of weight and strength, frequent gastro-intestinal disturbances, loss of normal control of his emotions, and marked impair- ment of his mental faculties. He was as completely 50 Causation and Treatment, Psychopathic Diseases broken in health as in fortune. These phenomena resembled closely those of fear and followed in the wake of a strain which was due to fear. " Animals in which the fear instinct can be aroused to a high degree become paralyzed and perish. Under such conditions the fear instinct not only ceases to be of protective value, but is the very one that brings about the destruction of the animal obsessed by it. "One of the most terrible effects of fear," says Mosso, "is the paralysis which allows neither of escape nor of defense." The fear instinct is no doubt one of the most vital of animal instincts, but when it rises to a high degree of intensity, or when it is associated with familiar " and useful objects instead of strange and harmless objects, then we may agree with the great physiologist, Haller, that the phenomena of fear are not aimed at the preservation, but at the destruction of the animal, or as Darwin puts it, are of "disservice to the animal." This is just the condition found in psychopathic diseases. The fear instinct becomes aroused in early life and cultivated by training, educa- tion, and environment, becoming associated in later life with particular events, objects, and special states. When the instinct of fear is aroused in connection with some future impending misfortune, the feeling of expectation and all its psychological changes, mus- cular, respiratory, cardiac, epigastric, and intes- tinal, go to form that complex state of anxiety and anguish, so highly characteristic of acute varieties of psychopathic disease. When fear reaches its acme, the heart is specially affected, the circulatory and respira- tory changes become prominent, and give rise to oppression and depression which weigh like an incubus on the patient the feeling known as "precordial anxiety. " The Fear Instinct and Psychopathic States 51 The fear instinct is the ultimate cause of the infinite varieties of psychopathic diseases. Stanley Hall seems to accept this view of the subject. In his recent paper on Fear, he writes: "If there be a vital principle, fear must be one of its close allies as one of the chief springs of the mind. . . In spite of his former "psychoanalytic" inclinations, Professor Hall now asserts that "Freud is wrong in interpreting this most generic form of fear as rooted in sex. . . Sex anxieties are themselves rooted in the larger fundamental impulse of preservation of life with its concomitant instinct of fear. " This is the etiology on which I laid stress in my papers and works on the subject of psychopathic diseases. So deeply convinced is Professor Stanley Hall of the primitive and funda- mental character of the fear instinct, that he refers to the facts that "if the cerebrum is removed, animals, as Goltz and Bechterev have proved, manifest very intense symptoms of fear, and so do human monsters born without brains, or hemicephalic children, as Sternberg and Lotzko have demonstrated. " Oppenheim, Kirchoff, Kraepelin, and recently other psychologists and neurologists of note all concur that fear is a fundamental factor in the pathology of neurosis. As physicians, we must remember the importance of fear in cases of surgical shock. So potent, all embracing, and all pervading is the fear instinct, that the physician must reckon with it in his private office, in the hospital, and in the surgical operating room. "The acute fear of a surgical operation" Crile writes, "may be banished by the use of certain drugs that depress the associational power of the brain and so minimise the effect of the preparations that usually inspire fear. If, in addition, the entire field of opera- tion is blocked by local anesthesia so that the associa- 52 Causation and Treatment, Psychopathic Diseases tional centers are not awakened, the patient will pass through the operation unscathed." In a number of my cases psychognosis clearly reveals the fact that even where the neurosis has not originated in a surgical trauma, surgical operations reinforced, developed, and fixed psychopathic conditions. The fear instinct arises from the impulse of self- preservation without which animal life cannot exist. The fear instinct is one of the most primitive and most fundamental of all instincts. Neither hunger, nor sex, nor maternal instinct, nor social instinct can com- pare with the potency of the fear instinct, rooted as it is in self preservation, the condition of life primodial. When the instinct of fear is at its height, it sweeps before it all other instincts. Nothing can withstand a panic. Functional psychosis in its full development is essentially a panic. A psychogenetic examination of every case of functional psychosis brings one in- variably to the fundamental fear instinct. Fear is the guardian instinct of life. The intensity of the struggle for existence, the preservation of life of the animal, is expressed in the instinct of fear. The fear instinct in its mild form, when connected with what is strange and unfamiliar, or with what is really dangerous to the animal, is of the utmost consequence to life. What is strange and unfamiliar may be a menace to life, and it is a protection, if under such conditions the fear instinct is aroused. It is again of the utmost importance in weak animals, to have the fear instinct easily aroused by the slightest strange stimulus; the animal is defenseless, and its refuge, its safety, is in running. The unfamiliar stimulus may be a signal of danger, and it is safer to get away from it; the animal cannot take chances. On the other hand, animals that are too timid, so that even the familiar becomes too suspicious, cannot get their food and cannot leave The Fear Instinct and Psychopathic States 53 progeny, they become eliminated by the process of natural selection. Even in weak animals an intensified state of the fear instinct becomes biologically abnormal, pathological. The fear instinct is abnormally developed in psy- chopathic disturbances. Harmful stimuli or expecta- tion of danger to themselves, to their family, or to friends may arouse the feelings of anguish, anxiety, worry, manifestations of the fear instinct. Objects, thoughts, stimuli, situations, and events of expected danger may keep on changing, persisting for a longer or shorter time, but the underlying pathological state of the fear instinct remains, easily fusing with exper- iences of possible danger to all included within the circle of the patient's self-regard. Events or situations with fixed sensory stimuli, when repeated, fix the neurosis, very much in the same way as are the "conditional reflexes" in PavlofFs experi- ments. Other sets of stimuli of an ideational character are transient in duration, while the general, apprehen- sive, subconscious condition persists unchanging to seize again and again on ever new objects and thoughts, forming psychic compounds of various degrees of stability. CHAPTER VI MANIFESTATIONS OF FEAR INSTINCT AND SYMPTOMS OF PSYCHOPATHIC DISEASES IF we examine closely the symptoms of fear, we invariably find the symptoms of functional psychosis. Fear affects the muscular and sensory systems, the vasomotor system, the respiratory system, the sudorific glands, the viscera, the heart, the intestines, etc. Bain, in describing the emotions of fear or terror, says "The appearances may be dis- tributed. Terror on the physical side shows both a loss and a transfer of nervous energy. The appearances may be distributed between the effects of relaxation and effects of tension. The relaxation is seen, as regards the muscles, in the dropping of the jaw, in the collapse overtaking all organs not specially excited, in trembling of the lips and other parts, and in the loosen- ing of the sphincters. Next, as regards the organic processes and viscera. The digestion is everywhere weakened; the flow of saliva is checked, the gastric secretion arrested (appetite failing), the bowels de- ranged; the expiration is enfeebled. The heart and cir- culation are disturbed; there is either a flushing of the face or a deadly pallor. The skin shows symptoms the cold sweat, the altered odor of the perspiration, the creeping action that lifts the hair. The kidneys are directly or indirectly affected. The sexual organs feel the depressing influence. The secretion of milk in the mother's breast is vitiated. " Darwin gives the following description of fear: "The frightened man at first stands like a statue motionless and breathless, or crouches down as if to escape observation. The heart beats quickly and violently; but it is very doubtful if it then works more 54 Fear Instinct, Symptoms of Psychopathic Diseases 55 efficiently than usual so as to send a greater supply of blood to the body; for the skin instantly becomes pale, as during incipient faintness. The paleness of the surface, however, is probably in large part or is ex- clusively due to the vasomotor center being affected in such a manner as to cause the contraction of the small arteries of the skin. That the skin is much affected under the sense of great fear we see in the marvelous manner in which the perspiration immediately exudes from it. This exudation is all the more remarkable as the surface is then cold, and hence the term, a cold sweat; whereas the sudorific glands are properly excited into action when the surface is heated. The hairs also on the skin stand erect, and the superficial muscles shiver. In connection with the disturbed action of the heart the breathing is hurried. The salivary glands act imperfectly; the mouth becomes dry and is often opened and shut. I have also noticed that under slight fear there is a slight tendency to yawn. One of the best symptoms is the trembling of all the muscles of the body. From this cause and from the dryness of the mouth, the voice becomes husky or indistinct, or may altogether fail." If we turn now to the manifestations of psychopathic maladies, we meet with the same symptoms: (a) The attacks may be muscular, involving symp- toms such as trembling, shaking, paresis, paralysis, or rigidity; there may be affection of locomotion or of muscular co-ordination. (b) There may be sensory disturbances, anaesthesia, paraesthesia, analgesia, or hyperalgesia, as well as affec- tion of muscular sense and kinaesthesis. (c) There may be skin disturbances, such as arrest of perspiration or profuse perspiration, especially under the influence of emotions, worry, and fatigue; such perspiration may also occur at night, and in some cases the fear of tuberculosis may be associated with such conditions. 56 Causation and Treatment, Psychopathic Diseases (d) The lungs may become affected functionally, and there may occur respiratory disturbances; coughing, hawking, apnea, dyspnea, and asthmatic troubles may result. (e) The heart becomes affected, bringing about precordial pain; palpitation of the heart, bradycardia, tachycardia, and cardiac arrhythmia may result. (/) The stomach and intestines become affected; indigestion, vague fugitive soreness and pain may be experienced all over or in special regions of the ab- domen; constipation or diarrhea may ensue. (g) The renal apparatus may become affected and its activity arrested, or, as is more often the case in the milder forms of psychopathic troubles, there may be present an alteration in the amount or frequency of micturition, such as is found in the conditions of anuria and polyuria. (A) Menstruation becomes disturbed, and we may meet with conditions of dysmenorrhea, amenorrhea, menorrhagia, and other disturbances of the tubes, ovaries, and uterus. (i) There are disturbances of the nervous system, such as headache, and a general dull sensation of fatigue and paresis of all mental functions, with dizziness and vertigo. On the mental side we find in the psychopathies the following disturbances: (a) Affections of perceptual activity, illusions and hallucinations. (b) Affections of intellectual activity, argumenta- tiveness in regard to insignificant things, metaphysical and theological disputations. (<:) Affections of the moral sense, scrupulousness, overconscientiousness, not living up to ideal states. (d) Affections of religious life, commission of sins and fear of punishment. ( lev* '*' 5! M I { M i 4 I K | d s? ^ 5 ** >*< I al 4< ^ S S * ^ y ifil = is If Static energy is indicated by the diagram N W F I. By organic energy is meant that energy contained in the very structure of the tissues of the neuron, not as yet decomposed into their inorganic constituents. This is indicated by diagram I F G H. These phases of neuron energy are not different kinds of energy, in the sense of being distinct entities; they merely represent progressive phases or stages of the same process of neuron activity. Liberation of neuron energy is correlative with active psychic and physical manifestations. Hence states of the nervous system corresponding to liberations of Neuron Energy and Neurosis 131 energy are designated as waking states. Restitution of expended energy or arrest of liberation of neuron energy goes hand in hand with passive conditions of the nervous system; hence states of restitution or arrest of energy are termed collectively sleeping states. The ascending arrow, indicating the process of restitution of energy, corresponds to the ascending arrow on the right, indicating the parallel psychomotor sleeping states. The descending arrows indicate physiological and pathological processes of liberation of energy, and also their concomitant psychomotor waking states. "Ascending" and "descending" mean the rise and fall of the amount of neuron energy, taking the upper level of dynamic energy as the starting point. Briefly stated, descent means liberation of energy with its concomitant psychomotor, waking states. Ascent means restitution of energy with its parallel sleeping states. The cycles in dynamic energy correspond to the physiological manifestations of the nervous system in the activity and rest of the individual in normal daily life. Concomitant with the expenditure of dynamic energy of the neurons, the individual passes through the active normal waking state, and, hand in hand with the restitution of this expended dynamic energy, he passes through the sleeping state of normal daily life. When, however, in the expenditure of energy, the border line or margin, A K or N W, is crossed, dynamic and reserve energies are used up, and reserve and static energy are drawn upon. In crossing A K or N W the border line that separates the normal physio- logical from the abnormal or pathological psychomotor manifestations is stepped over. "The thresholds of our psychological systems are usually raised, mental activity working in the course of 132 Causation and Treatment, Psychopathic Diseases its development and growth of associative processes under ever-increasing inhibitions with ever-higher thresholds. . . . On account of the high thresholds and inhibitions, not the whole amount of the psycho- physiological energy, possessed by the system, is manifested; in fact, but a very small portion is displayed in response to stimuli coming from the habitual environment. What becomes of the rest of the unused energy ? It is stored, reserve energy. "Biologically regarded, we can well see the importance of such stored or reserve energy. In the struggle for existence the organism whose energies are economically used and well guarded against waste will meet with success in the process of survival of the fittest or will have good chances in the process of natural selection. The high thresholds and inhibitions will prevent hasty and harmful reactions, useless waste of energy, unnecessary fatigue, and states of helpless exhaustion. Moreover, natural selection will favor organisms with ever greater stores of reserve energy, which could be put forth under critical conditions of life. In fact, the higher the organization of the individual, the more varied and complex the external environment, the more valuable and even indispensable will such a store of reserve energy prove to be." Static energy may be divided into two phases, according to the nature of the process of liberation of neuron energy. As long as the process of liberation of energy effects only a dissociation of systems of neurons the correlative psychomotor manifestations fall under the category of psychopathies. If, however, the process of liberation affects the neuron itself, bringing about a disintegration of its constituent parts compatible with restitution, the correlative psychomotor manifestations fall under the category of neuropathies. This process of disintegration, equivalent to cell degeneration may Neuron Energy and Neurosis 133 end in death, in the dissolution of the neuron itself. When the dynamic energy is used up in the course of life adaptations and the reserve energy is drawn upon, there may be the danger that the energy may be used until the static energy is reached and the neuropathic conditions are manifested. These conditions, however, are preceded by psychopathic disturbances which involve the associations of neurons. Associative life becomes disturbed, unbalanced, and emotional reactions become more violent and more frequent. On the one hand there is a reversion to lower forms of mental activity and lower instincts, especially to the impulse of self-preservation with the instinct of fear, and on the other hand the reactions of the emotions become more intense and pathological, since the governing action of intelligent self-control is absent. In such cases, as I have pointed out in this and in my other works, the lower instincts, especially that of self- preservation and fear will prevail. The patient will be tortured by his selfish fears of protection of his individu- ality against the supposedly terrible dangers that threat- en his life existence. The patient will then be obsessed by his fears and by his wishes flowing out of his fear and deranged, intensified, uncontrollable impulse of self-preservation. The fear instinct when reaching a certain intensity may give rise to functional patho- logical changes in glandular secretions, also in the metabolism of cytoplasm and nucleus of the neuron, and may finally bring about actual degenerative changes in the body of the neuron. One cannot help quoting Dr. Crile: "Fear is born of the innumerable injuries which have been inflicted in the course of evolution. Fear, like trauma, may cause physiologic exhaustion of and morphologic changes in the brain-cells. The repre- 134 Causation and Treatment, Psychopathic Diseases sentation of injury, which is fear, being elicited by phylogenetic association, may be prevented by the exclusion of the noci-association or by the adminstration of drugs like morphine and scopolamin, which so impair the associational functions of the brain-cells that immunity to fear is established. Animals whose natural defence is in muscular exertion, among which is man, may have their dischargeable nervous energy exhausted by fear alone, or by trauma alone, but most effectively by the combination of both. "Under the dominance of fear or injury, however, the integration is most nearly absolute and probably every expenditure of nervous energy which is not required for efforts toward self-preservation is arrested; hence fear and injury drain the cup of energy to the dregs. "Fear influences every organ and tissue; each organ or tissue is stimulated or inhibited according to its use or hindrance in the physical struggle for existence. The exhaustion following fear will be increased as the powerful stimulus of fear drains the cup of nervous energy, even though no visible action may result." As the static energy is reached and with the lack of functional energy especially of the dynamic character, that kind which is habitually utilized in the ordinary relations of life, the patient will experience a mon- otony and a void in his life activity. He will have a feeling that something is wanting for his happiness; he will feel a craving for ever new stimulations, and will tear around for ever new impressions and excite- ments; he will be restless and ask for ever new amuse- ments and distractions. He will do anything and everything to fill up this gap of his life, because life appears to him empty and devoid of all interest; he will talk of ennui and even of suicide, and will be of a pessimistic turn of mind, and as such will approach Neuron Energy and Neurosis 135 closely to melancholic condition. He will crave for new pleasures and enjoyments, but will soon tire of them and ask for others. He will be in the condition of a leaking barrel, the more one pours into it the more is required to fill it. The restlessness, this misery of craving for new pleas- ures and excitements to still the pangs of the fear in- stinct with its gnawing, agonizing anxiety, brings the patient to a state in which he is ready to drink and to use narcotics of all kinds of description. What the patient needs is some way of reaching his re- serve energies and bring about an absorbing interest so as to take him out of the misery of monotony and ennui of life, save him from the listlessness and in- difference into which he is apt to fall. Such a state of misery is to him unbearable. Something must be done to free himself from the depression of spirits and from the low level of energies and the self-fear instincts from which he suffers such agonies. The constant craving for stimulation, this reaction to the anxiety of the morbid fear instinct, is the expression of the state of exhaustion of available dynamic energy for the purposes of life activity. The patient attempts to draw on his latent reserve energy; since this form of energy is not accessible to the stimula- tions of common life, he tries to release the energy by means of artificial stimuli, be it morphine, alcohol or by other stimuli of an excitatory character. The very craving for affection, sympathy, attraction of attention, love, and more especially love of a sexual character are all expressions of the same tendency of endeavoring to stimulate to activity some sources oj dynamic energy. The low ebb of dynamic energy drives the individual to resorting to means by which he can whip himself into new forms of liberation of neuron energy. The impulse of self-preservation 136 Causation and Treatment, Psychopathic Diseases drives the organism to the finding of new ways by which it can keep itself in existence. The psychopathic patient is driven by fears, by fears of life and death. The very wishes of the psychopathic individual flow from the fears of self-preservation. What the psychopathic individual is unable to accomplish the physician has to do for him. The psychopathologist must make a close psychognosis of the case, he must learn all the factors that have brought about the present state, change accordingly the condi- tions of living, if this be possible; moderate the intensity of the impulse of self-preservation with its fear instinct; stimulate the patient to activity, and above all in various ways to liberate in the patient the locked-up sources of reserve energy. Once the sluices are opened the amount of energy coming is sufficient to drive away the psychopathic state. In studying, by a close psychognosis, the various cases of psychopathic affections I wish especially to attract the student's attention to the fact that fatigue, whether physical, nervous, or mental, plays an important role in the condition of the patient. Again and again in giving account of his condition the patient will tell of the fact that in the case of fatigue, whether he thinks he experiences it or whether there is an actual state of it, that is, whether hallucinatory or real, the psychopathic symptoms come to the fore-ground in an ever more uncontrollable condition. "Extreme fatigue" says Mosso "whether intellectual or muscular, produces a change in our temper, causing us to become more irritable; it seems to consume our noblest qualities those which distinguish the brain of civilized from that of savage man. When we are fatigued we can no longer govern ourselves, and our passions attain to such violence that we can no longer master them by Neuron Energy and Neurosis 137 reason. " Mosso gives an account of his own condition during states of fatigue. "Education, which is wont to curb our reflex move- ments, slackens the reins and we seem to sink several degrees in social hierarchy. We lose the ability to bear intellectual work, the curiosity and the power of attention, which are the most important distinguishing characteristics of the superior races of man. Persons who suffer from affections of the nervous system are usually irascible. We see that hysteria is a condition of the nervous system comparable to that produced by fatigue." Mosso works with the ergograph in his study on the various states of fatigue muscular, nervous and mental. "One of my colleagues who sometimes forgets the time, as he says, feels great weakness of vision after having given too long a lecture. This phenomenon appears especially at the beginning of summer, when the excessive heat affects his digestion. Any slight brain fatigue, particularly a lecture of an hour and a half, is then sufficient to obscure his sight so much that he cannot read. This asthenopia arises from exhaustion of the nervous system, and disappears a few hours after he has finished lecturing." Fatigue or being easily fatigued is a trait of psycho- pathic affection. Almost without exception psycho- pathic patients complain that they cannot keep long their attention on anything, especially on subjects that require concentration and close intellectual activity. In such cases they complain that they get easily fatigued. In fact some patients as a matter of defence may suffer from asthenopia. They complain that on reading, if continued long, about an hour or more, specks begin to appear before the eyes; the field of vision becomes darkened, as if a cloud or mist hangs over them, the page begins to rock, the words move, everything begins to swim before the eyes, so that the 138 Causation and Treatment, Psychopathic Diseases patients must quit their reading, or their work, such as knitting or crocheting. The same holds true in the case of concentration of attention on a difficult subject that requires persistent effort of thought, or persistent muscular activity, even if the latter is not otherwise exhausting, as far as the physical side is concerned. Some patients when the dis- ease is at its height cannot concentrate their attention even as much as five minutes. Their attention keeps roaming, and cannot remain on the same subject for any appreciable length of time. The same holds true with motor activities, the pa- tients are restless, they cannot sit for a couple of min- utes in the same place, they cannot keep still in the same position; their limbs keep on wiggling all the time, their fingers keep on moving, beating tattoos, the muscles of the face keep on twitching or moving slightly. The energy is not banked up, it is not steady in its discharge, the reactions are not synthesized, they are not integrated. There is a sort of a constant leak of neuron and muscular energy in response to slight external and internal stimuli. This condition is manifested by the consciousness of extreme fatigue at the least exertion, physical or mental, and also by the symptoms of fatigue on awaken- ing. The patients sleep restlessly; sleep does not give them recuperation, they feel even more fatigued on awakening than on going to sleep. The patients can- not find any rest for themselves. "However little attention" Mosso writes in another place "we may have given to the subject, we are all aware that after too long a walk, or after any violent exercise, such as gymnastics, fencing, or rowing, we are less fit for study. It is true that sometimes after moderate exercise intellectual work seems to become easier; this arises from the stimulating effect of muscular Neuron Energy and Neurosis 139 work, which we shall have occasion later to consider at length. The best example of the incapacity for attention produced by muscular fatigue is given by Alpine ascents. Only with great difficulty could Saussure do a little intellectual work on Mont Blanc. 'When I wished to fix my attention for a few consecutive moments, I had to stop and take breath for two or three minutes.' " In my own case I have observed that great muscular fatigue takes away all power of attention, and weakens the memory. I have made several ascents. I have once been on the summit of Monte Viso and twice on that of Monte Rosa, yet I do not remember anything of what I saw from those summits. My recollection of the incidents of the ascents becomes more and more dim in proportion to the height attained. It seems that the physical conditions of thought and memory become less favorable as the blood is poisoned by the products of fatigue, and the energy of the nervous system con- sumed. This is the more singular in my case, because I have a good memory for places. "Several Alpinists whom I consulted agreed with me that the last part of an ascent was least distinctly remembered. Varracone, the barrister, well known for his daring ascents, one of the most distinguished writers belonging to the Italian Alpine Club, told me that he was obliged to take notes during an ascent, because on his return in the evening he remembered almost nothing. The following day, when the fatigue had passed off, many particulars recurred to his memory which he believed he had entirely forgotten. "Pinel, the founder of modern psychiatry, who towards the end of the eighteenth century was Professor of Mental Diseases in Paris, showed that political revolutions profoundly affect the nervous system of a nation, and bring about an increase in the number of 140 Causation and Treatment, Psychopathic Diseases the insane. The last civil war in America was a sad confirmation on a large scale of this statement, and important papers were published bearing on this point. Among others that of Professor Stokes deserves mention as containing very curious psychological documents. "Sclerosis of the brain often results from prolonged emotion and cerebral overstrain. Just as a paralysis of the spinal cord may be produced by forced marches, so likewise may a paralysis of the nervous system be produced by cerebral exhaustion. I shall return to this later when I bring together for closer comparison the phenomena of muscular and those of nervous fatigue. "Political men, with few exceptions, wear themselves out by overwork and age very rapidly. The corre- spondence of Cavour is full of allusions to the sleepless nights and the profound exhaustion both of body and of mind which his political campaigns cost him. Scarcely had the law abolishing religious corporations been passed (to quote a single example) when we find him writing to M. De la Rive: 'After a keen struggle, a struggle carried on in Parliament, in the salons, at Court and in the street, and rendered the more painful by a crowd of distressing circumstances, I find my in- tellectual powers exhausted, and have been forced to seek recuperation by several days' rest. Thanks to my natural elasticity, I shall soon be able to take up the burden of office once more, and before the end of the week I expect to have returned to my post.' "In Cavour's letters a happy expression has struck me, which he uses several times to indicate a physiologi- cal conception, the necessity, namely, of rest after excessive mental work. He says that one must let the brain lie fallow, like a field which is allowed to rest, so that it may be sown again the next year. "Another of our greatest politicians, whose life was Neuron Energy and Neurosis 141 worn out by excessive work, was Quintino Sella. I was one of his friends, being bound to him no less by gratitude than by the great admiration which I had for him. In the last year of his life I was often with him, and was among the first summoned to his death-bed. I informed myself of the details of his last illness, and was convinced that he died from the effects of cerebral overstrain. He suffered from a prolonged and excessive fatigue which slowly destroyed his forces. "Originally robust and endowed with great energy, he would fight to the very last, and in the effort over- stepped the limit of possible recovery. "I recollect that he made an appointment with me for seven o'clock in the morning, and for me who sleep well this was an unwonted hour in winter. But in the evening after dinner even he was fatigued, and being overcome with sleep could not maintain the conversa- tion. How different he was in those last years from the time I first knew him on the Alps or in the dis- cussions at the Lincei. His will, his energy, his political skill, were exhausted, and we regarded him anxiously feeling great uneasiness about him. "I have questioned several of my friends who have held office in the Government upon the subject of overstrain. One of them writes to me that he experienced the greatest fatigue when he had to give audience. When he had to receive numerous visitors in the evening, tired as he was with the day's work, and to cudgel his memory for forgotten details, the effort became insupportable. For the sake of exactitude I quote a portion of his own letter: 'In a few months my hair turned from black to white. I have often experienced a regular pain in my brain, quite different from the neuralgia from which I sometimes suffer. This was a dull, aching pain, an uncomfortable sense of weight, which I attributed to actual cerebral 142 Causation and Treatment, Psychopathic Diseases exhaustion. The culminating symptom was insomnia, or a restless sleep in which I uttered such groans that my wife frequently awakened me believing that I was ill. My stomach was atonic, all trace of appetite gone, and sexual desire suppressed.' " I begged another of my friends, who was a Minister for several years, to give me some notes on the state of his health during a protracted and very lively contest which he had to carry on in Parliament in the defence of one of his bills. Here is his reply: 'My character was much altered. I suffered from an extraordinary degree of nervous excitability. Usually good-natured and affectionate in my family life, I became taciturn and extremely irritable; and perhaps things would have gone from bad to worse had not my friends, urged thereto by my family, constrained me to leave my work and go off to the country. I was get- ting no good from my food, though my muscular ener- gy had not decreased, save that in the evening I felt as if I could not move from my seat. My sight was much affected, and I suffered from sudden nervous twitches.' "These notes are of the more importance in our study of the effects of great and continuous work, in that their writer is a man of great capacity and energy who attained to power in the prime of life, when he was already inured to Parliamentary contests. "For other evidence regarding overpressure among politicians, I have been indebted to the kindness of some of my colleagues, who have tried to attend patients of this class. "Affections of the heart and neurasthenia become very common among those members who take part in the Parliamentary debates. I shall record some facts regarding them which have been made known to me by their physicians. Neuron Energy and Neurosis 143 "There is one very energetic member who succumbs from time to time to cerebral fatigue, and is forced to call in medical aid. In his case the first symptoms are insomnia and headache, but these are not sufficient to arrest him in the rush of his political engagements. He perceives that he is exhausted only when at the end of a sitting of the House he cannot recall what has been said at the beginning. He is then terrified and dejected, because he finds himself out of the fight. Sleep is of little use to him, for he dreams continually of the debates and of political affairs. This is one of the most serious symptoms of cerebral overstrain. When our day's occupations pursue us in our dreams and we feel insufficiently rested in the morning, there is no need to consult a doctor; we must take a holiday or greater evils will follow. "Another member, after having undergone great fatigue at the House, was attacked by palpitation at an official banquet where he had to propose a toast, and was forced to limit his speech to a few words. From that day he had frequent attacks of palpitation, and suffered from nausea when he was obliged to work at his desk. He was troubled with insomnia, and had remarkable fits of trembling in his legs and hands, more especially when he appeared in public. Some- times when he was making a speech this trembling became so noticeable that he had to sit down. The smallest indiscretion in diet was followed by diarrhea lasting for two or three days. "All these phenomena are the more characteristic of overpressure in that the man in question possessed a good constitution with no unfavorable hereditary predispositions, and always enjoyed good health before entering political life. He complained to his medical adviser that he had become irritable; and being naturally of a good-natured and pacific disposition, 144 Causation and Treatment, Psychopathic Diseases he felt every outburst of anger as a profound humilia- tion." An important feature in the symptom-complex of psychopathic diseases is the fact that the patients, after fatigue, feel worse, as far as their general symptoms are concerned, more depressed, the fears come to the surface with great intensity, and often become uncontrollable. In cases where the patient gets control over his fears, the onset of fatigue brings about the recurrent states of the fear instinct in their full emotional vigor. A patient, a physician, writes to me: "The prevailing symptoms are dread, fear and anxiety about travel and being away from home, mental sluggishness, quick fatigue and inability for concentrated thought." Another patient, a physician of a good deal of experi- ence, in consulting me about his psychopathic state of fears which he has been trying to control for a couple of years, finds that the fears become uncontrollable and overwhelming with the onset of fatigue. When- ever he gets very tired, especially when working in the laboratory and the clinic for many hours on a work that has to be completed, he finds that he begins to suffer from insomnia; along with it the fears rise to the surface of consciousness with an intensity that is almost horrifying. Later on this state of fears, this arousal of the fear instinct begins to recur more and more easily, the fatigue state keeps on recurring with greater ease and at shorter intervals. The patient finds that fatigue, especially emotional and intellectual, requiring con- centration of attention, and worry over the outcome of the work invariably bring about the onset or recurrence of the fears in their full intensity. The result in the physician's case was the usual one, the patient formed an intense fear of fatigue, a. fatigue-fear. Neuron Energy and Neurosis 145 Fatigue-fear is quite common with psychopathic patients. A vicious circle is formed. The fear instinct by its continuous action and arousal of the wearisome and exciting emotion of fear produces fatigue, and conversely fatigue helps to produce a more intense condition of the fear instinct and the impulse of self- preservation. The patient is afraid that overfatigue might injure him and might give rise to a worse state of health or disease. Finally there is formed the fear of doing any thing, the fear of fatigue, the searching after composure and euphoria, the restless hunting after rest. In the treatment of psychopathic diseases the physician must take this condition into account. A few cases will best bring out this point of "fear fatigue. " "My early fears were such as are common to children. I feared the dark and was very fearful when sleeping in a room by myself. As a boy I was very timid and bashful. "At the age of eight to twelve I remember thinking that my mother might die. My mother was in poor health at the time, having suffered a nervous breakdown at the death of my father. "At the age of ten or twelve there came into my life something to be noted perhaps as a neurasthenic symptom. At this time I gradually became possessed of a fear; I was afraid to leave home, that is, to get away from my own home and home people. This grew upon me to such an extent as to make life very miserable, for, to leave home and home people even for a day, I thought I was going to die. I would become faint and turn pale. "This fear kept me at home a great deal during this period, for I would not leave home unless accompanied by some of my people. Finally I decided to conquer this thing or die in the attempt. So one day I left Causation and Treatment, Psychopathic Diseases home alone to attend a carnival in a neighboring town. This fearful dread was constantly with me and as I would think about it I would become weak and faint. Nervous waves of apprehension and fear would pass over me, and I would feel as if I were sinking. At one time during the day I became very faint, turned pale and was sick. I tried to drink something cold, but this made me more sick. I found a place to sit down and this spell passed off. "Having conquered this, I began to outgrow this fear, so that from that day on it gradually wore away until I had no fear whatsoever of leaving home. "As I grew out of the boyhood stage into my 'teens I was quite ambitious and entered rather vigorously into work at an early age. I worked hard on the farm during the summer and attended school during the winter. "As I grew out of the 'teens I came to have periods of great mental depression and that often without any cause. These depressions, beginning at about the age of eighteen, grew upon me as I became older. At length they would affect me so as to incapacitate me for work, and while under this mental depression would be able to work only through great effort of will. "At various times during my life, some matter of minor importance, such as some trouble or difficulty, would become fixed upon my mind and I would seeming- ly be unable to throw it off. This would throw me in a depression and I would feel tired out and without ambition until things gradually wore off. "One night I awoke out of troubled sleep with a fearful start and thought I was going crazy. The tortures I suffered for the next half hour are well nigh indescribable. The next day I was in a highly nervous state and had great fears that I would go insane. This Neuron Energy and Neurosis 147 shock finally wore off somewhat, and I did not 'consult a physician as I think I should have done. "I continued with my college work as I was attending college at this time, but I continued to suffer the tor- ments of the damned and had constant fears, was very much depressed and always tired out. "This was about Easter time, 1911 and during my Easter vacation I took a trip away from home, hoping that the change would relieve my mind of the fearful state in which it was in. I came back none the better for my trip. "I now went back to my college work and finished the year in this wretched state. Now, with vacation on and the cause of my trouble entirely removed, I thought I should improve, but instead continued to remain in this miserable state of mind, extreme lassitude, and a morbid mental depression almost all the time. Occasionally my spirits would rise for a time and I would think I was improving, but this was only temporary or spasmodic and would last for a few hours or a day or two, when I would again sink into the usual state of depression. "I now consulted a physician who said I had had a nervous breakdown and that with proper rest I would regain my strength and be well again as usual. "Upon this advice I remained at home during the summer, doing only what I wanted to about the house. I did not gain, however, during the summer. "During the summer I was out camping for a week, where, under the influence of congenial young people, I lost sight of my troubles and gained wonderfully both in strength of mind and body. This improvement took place within one week and at the end of that time I went home a new man. " In September, 1911,! went to southwestern Virginia where I had the promise of work and where I thought 148 Causation and Treatment, Psychopathic Diseases the change would improve my condition. In October, 1911, I began work with the C. C. Co., Bristol, Va., but soon found myself so incompetent to do the work, and the work caused such a strain and suffering on my part that I dropped it for a time, and, after consulting a local physician, went up into the mountains of East Tennessee. Here I spent ten days or two weeks tramp- ing around the mountains and eating heartily. The change of environment and climate seemed to work no improvement in my condition. "I came back to Bristol and took up my work again, but had to give it up soon, because of the fearful strain under which I worked. However, as I did not gain at all during the period of idleness I resolved to go to work again if it killed me. So I went to work on December n, and continued until August, 1912. " In December I began treatment with an osteopathic physician and continued for four months. He did nothing for me whatsoever, but take my money. "During the eight months I was working, I observed every possible chance for my improvement, took physical culture exercises, cold plunge every morning, studied my diet till I was relieved of constipation, but in spite of all this I gradually lost flesh until by Aug- ust I, I had lost twenty pounds and was so weak at times that I could hardly move. "I was returning to my home in Vermont in August, to recuperate, and I stopped in Washington, D. C., to consult Dr. W. He advised me to return home and spend six weeks in recuperating, and if at the end of that time I was not improved I could return to him for treatment, or he would refer me to some one in New England, or Boston. "Following Dr. W.'s advice I returned home and availed myself of every possible opportunity to have a good time. But at no time did I have a rise of spirits Neuron Energy and Neurosis 149 or any feeling of well-being whatsoever. I began to eat well and sleep well, but there was no change in the condition of mental depression or extreme lassitude. My strength and weight increased somewhat, but not enough to make any perceptible difference. "On October 4, I began treatment with Dr. Sidis. For the first four days I did not improve at all; in fact, I was more despondent than usual and very nervous at times, which was the result of the change in conditions and certain anxieties and fears which the new under- taking caused me. "On the 1 8th, there was a marked improvement in my condition. I rose with the usual depression, took a cold plunge, went outdoors, and, as I was walking about the house, began to feel better. This good feeling came on quite rapidly and continued throughout the day. This improvement seemed to be principally in the mental condition, an uplifting of the great de- pression, freedom from cares and anxieties, and also a general return of strength and powers. This im- provement was general throughout the week. During this week I felt very much improved and would talk freely with the boys, and the world began to look dif- ferent to me. However, I was not confident that this condition was permanent, I feared that I might go back at any time. I would be very tired when night came, but without the usual depression. At times as I was thinking about myself it would seem as if I would relapse at once into the former condition, and only by great will-power could I throw this off and stop thinking about it until this feeling would pass away. As the week passed I outgrew these fears of a sudden relapse, and it seemed as if the improvement had come to be permanent. "The cure began to go down slowly and gradually; and without any cause that I can ascribe to, I lost hold 150 Causation and Treatment, Psychopathic Diseases of the improvement I had gained. That is, by degrees I returned to the lowered condition in which I was pre- vious to October 18. I had fully relapsed to the condi- tion in which I could not seem to go lower." After six months' of hypnoidal treatment, disintegra- tion of fear system, well balanced and careful control of work and rest and nutrition, the patient gained forty- five pounds, and returned home well; has stayed well for three years and is doing work. "My earliest recollection," one of my patients writes in a final account, "of having any mental or nervous trouble begins at fourteen. Primary cause of disease (if cause be mental) became operative at twelve, for then I learned of the habit of masturbation but was deterred from indulging at first except very infrequently, by a terrifying idea that it was not right, and a few months later by reading a booklet about electric belts telling of the terrible effects of the habit on the mind and the nervous system. I began to do a man's work at twelve, was large for my age, so the thirteen or fourteen hours of work a day might have done me harm. Was practically full-grown at sixteen. At fourteen the habit of self-abuse got firm hold on me. Practiced vice almost every other day. Fear of harmful results undiminished,but a foolish idea that through preventing loss of semen (i.e., I thought it was prevented) by pressure on the urethra would make habit almost harmless. This idea let the habit get strongly fixed. Ignorance of physiology self-evident. Practiced habit till sixteen, at same time, almost daily, read advertise- ments in newspapers by quack specialists for 'Diseases of Men ' which gave various symptoms of lost manhood resulting from masturbation and other causes. "Among the symptoms which impressed themselves strongly on my mind and which I thought I had and were being caused by my habit were: lack of energy, Neuron Energy and Neurosis 151 loss of memory, lack of self-confidence, fatigue, inability to concentrate mind, weakness and lassitude, and a long train of similar ones. At the end of fifteenth year during a hot and strenuous harvest at driving a binder, and immediately afterwards, distinctly remember being very cross, irritable, tired, and easily depressed, and then occurred on one occasion what seemed a strange loss of memory : I could not remember the names of three of our hired men after an absence of a month. Shortly after I became sixteen, I became so convinced of and frightened by the harm I thought masturbation was doing me that I broke it off abruptly, and practiced it only at long intervals of several months. I thought I had done myself great harm. My mind seemed to be in particularly bad condition and I felt a lack of energy physically. My mental weakness and physical condition caused me so much alarm that I wrote to a quack specialist for diseases of men. He answered that I had nervousness, sexual weakness, lack of erectile power (I thought this symptom partic- ularly indicative of great harm), weak kidneys, etc. Had no money so could not take his treatment. His letter gave me the first impression that I was nervous. Prior to that I had no definite idea of the nature of my disease and even then didn't know what nervousness meant and didn't associate it with exhaustion, although I really was easily fatigued. In my first letter to the quack I wrote that I had syphilis, thinking that because my hair was falling out badly I had that disease, so great was my ignorance. "About this time I bought an old family doctor book which told of the terrible effects of self-abuse, and that nervousness was almost incurable. At about the middle of the sixteenth year I thought I had been seen in the act of masturbating (I probably was seen) by one of our hired men. Believing he would tell the whole 152 Causation and Treatment, Psychopathic Diseases neighborhood about it, I was seized with a profound spell of mental depression. I overpowered the fellow one night (he was not big and I, even at sixteen, was over six feet tall and quite muscular) threatened his life, but he denied telling or knowing about my habit. Swore him to secrecy. Some of his acquaintances would look at me with a queer smile and I was quite certain that he told. "For several months afterwards I was troubled with profound mental depression and weakness. After I became seventeen, I decided to go to a normal school in a neighboring town. I graduated from common school at fifteen, but had to work the next winter. Father took me to the normal school, arranged every- thing, and then left me there alone. The idea of going to school gave me much pleasure, but this with the unusual sights and sounds I had seen and heard during the day (the town was a much larger one than I had ever been in before) had the effect of so exciting me that I could not sleep that night. I went to school the next day not worried about this loss of sleep and was enrolled in all my classes. Tried to study in the evening, but found my mind confused, my memory bad, and my old depression was still there. "I was unable to sleep the next two nights so I went home and consulted a physician. Told him I had insomnia. The physician said my trouble was mental, but I could not understand or believe it. I went to school for a week, but complete insomnia drove me home. The physician, on my first visit, said I had been reading a whole lot of quack literature on sexual matters and that that had done me harm. Partial insomnia followed for two months and then restful sleep came with the use of a new compound of drugs. With the use of an electric belt and the hard spring work the insomnia disappeared the next month. Neuron Energy and Neurosis 153 "In the fall when hard work was over the fear that the insomnia would return took hold of me. The insomnia did return, and the strongest sedatives that two different physicians could give me failed to make me sleep for three weeks. Both physicians said the trouble was mental, and I was now told that drugs would do me no good. I resigned myself to death or insanity. I took to religion, stopped worrying, and sleep came in a week. My physician told me again and again that the trouble was mental, but I thought it was from a shattered nervous system caused by self-abuse. The insomnia was much less severe during the late fall and winter of my eighteenth year. During most of my nineteenth year could only sleep six and a half or seven hours in spite of hard work. This worried me and I felt exhausted and feared that my health was being ruined. "All these years, whether I had slept well or not, I still had the same old physical fatigue, melancholia, and mental weakness. At eighteen began to read New Thought literature and to get vague ideas of the sub- conscious mind, suggestion, psychotherapeutics; with them came more of a belief in mental methods, but still the idea haunted me that self-abuse had caused my condition. When nearly twenty, decided to take mental treatment from a pretended authority in psycho- therapeutics at Chicago. He wanted to give me 'absent treatment.' The local physician advised me against it and told me to go to school and to mix with the young people as much as possible. I went to school, only took two or three subjects, and though I slept six or seven hours (often more), thought I had insomnia, worried about it, felt terribly weak, mentally and physically, went home at end of term thoroughly exhausted, so I thought and felt. During these last two years read a great deal of drugless healing and 154 Causation and Treatment, Psychopathic Diseases physical culture literature, thus formed a strong prejudice against drugs and a firm belief in the so-called natural methods of healing. The last-mentioned physician had also said my disease was mental. How- ever, I didn't think he knew anything about psycho- therapy. I now wrote to the (to me eminent) psycho- therapist of Chicago. He answered that I was a neurasthenic of the truest type. "I began to sleep better immediately, thought him a great authority, and tried to follow his advice to the letter. Followed his advice very closely in spite of many ups and downs, much more faithfully than I ever followed yours, shameful as it is to admit it. I still had all my old symptoms, except that of insomnia. I got discouraged with him and quit him. I ought to mention here that since I was thirteen I never had a friend and never went visiting, except to a few dances which I did by the advice of my quack doctor who tried to get me to cultivate my social faculties. I was discouraged for about a month, then got new faith in the regime I had been following, added some nature cure and New Thought ideas to it and still hoped for success. "I went to school the following winter with the resolution to succeed or die. Slept little the first week, but for the four following months slept well in spite of considerable study. Study, I used to think, would cure insomnia. In the fourth month of my stay at school, I took two extra subjects and cut my sleep to seven hours. I was obliged to study unusually hard to get my work done. I had always had spells of depression without apparent cause, but during this fourth month a sense of exhaustion gradually developed in me, and I seemed to be losing ground in my studies. After a month and a half of this new regime insomnia came on, from fatigue and seemingly not at all from Neuron Energy and Neurosis 155 anxiety about sleep. I was soon completely prostrated by fatigue and insomnia (the insomnia now becoming formidable again: five or six hours of sleep) so that I couldn't study, managed to stay till end of term, a period of a month and a half in this condition. I consulted Dr. A., who said that my trouble was prob- ably physical, and that I needed a great deal of sleep. "I had put my whole heart and soul into psycho- therapeutic methods of cure for nearly two years and it had apparently ended in complete failure. Dr. A's opinion that my disease was physical settled the matter in my mind. I was convinced I needed rest, sleep, and proper nourishment. Dr. Mitchell's 'rest cure' was what appealed to me, but Dr. A., would have me go to Boston and consult nerve specialists. I went to Boston, consulted Dr. P., who questioned me, tried my reflexes, and said I had a strong physique and a 'great heart.' He said my disease was caused by subconscious ideas, and that I had to work, because people in my condition always get worse with rest. He sent me to you. I feared that Dr. P. and you had told me my disease was mental just for suggestive effect, and that my disease might be physical to a considerable extent. "Came to Boston and went to work. The work was not hard, but the fatigue was terrible and by the end of the sixth month seemed to have grown un- bearable. In the evenings after work it was so great I couldn't talk. "The idea that 'rest cure' might have been better for me was in my mind at your Institute and also during the first six months in Boston. "Sleep came a week later. Highly enthusiastic about this achievement. Resolved to go to school. Fatigue disappeared for several weeks during period of elation. Should say that the above work was first I had done 156 Causation and Treatment, Psychopathic Diseases away from home, and was naturally worried under a very cross employer. I consulted you again, you advised me to go to school. I went to school about a month without dropping my other work (I took only two subjects), but at the end of that period I had to drop manual labor from overpowering sense of mental weakness and physical fatigue. I got through first term with much difficulty. By this time I began to make friends. I got through second term with less difficulty and more social experience. At beginning of third term I got insomnia from a fatigue which had been gradually growing to a terrifying degree. "Two visits to you at Portsmouth made me feel highly elated for about two months. My fears and worries may be reduced to one, and that is 'Fatigue.' I am not worried about sleep at present, but there is still the haunting idea that hard study with little physical exercise would cause it. I am mentally and physically fatigued most of the time and yet the amount of work I do is ridiculously small. I don't accomplish anything and don't see how I can ever make a living, if I don't get rid of the fatigue. Depression accompanies the fatigue, if the latter is at all severe, and makes everything look black. Your statement at my last visit that my fatigue was caused by my fear of it and constantly thinking of it, struck me with great force. It seems so very reasonable, and appeals to me so strongly that it bids fair to do me great good. After re-reading this whole account my disease seems to be a ridiculous matter made up of stupidity and foolish fears." F. E. C., Female, unmarried, forty-three years old. "I have practiced in P. for a few years. Previously a teacher. "I have had no illnesses, except several attacks of intestinal impaction. There is no organic trouble. Neuron Energy and Neurosis 157 "Life has been active and full of interests, with more duties and pleasure than I had time for. The only discomfort I have had was a weariness. I enjoy work and have taken a keen interest in life until lately, when I developed a distaste for everything. "The physical symptoms began in the summer of 1912. I was very tired, but took no vacation except week-end trips at the beach from Friday to Monday. I noticed it was difficult to carry a light suit-case; no grip in hands or strength in arms. One day I hurried to catch a street-car and started to step on. My legs seemed to give away and I fell, striking my head on the pavement. Since then, at times, I have had a fear of getting on cars, and for many months before I stopped work, only a resolute determination not to give way to fear kept me using the public vehicles. I could not lift my foot to the first step, or, having accomplished that, I could not pull myself up without help. The moment I tried to step up I became a dead-weight. "You will understand that I can give you no adequate description of the distress and humiliation I suffered. I lived in dread of the hour coming when I had to get on a car, or into an auto to go home from the office. I thought it was a mental state that I should not yield to, and so I kept up the fight till May, 1914. "During the winter of 1913-14 I realized that my work was deteriorating; my fingers and wrist lacked power to do the mechanical part of my work, but, worse than that, my mind was acting mechanically; I lacked enthusiasm and I was tired all the time, but as great fatigue was a condition that had been present most of my adult life, I paid no attention to it. This seemed a condition of deadness; there was nothing I wanted to do, nowhere I wanted to go, and no one I wanted to see. "If I had had a desire for anything but work I think 158 Causation and Treatment, Psychopathic Diseases I should have taken a vacation sooner. In May I decided to leave the office for the summer. Just then I took a severe cold "grippy" which prostrated me. My left eyelid drooped, and I lost control of it and of my throat and tongue. My voice sounded, as if my mouth were full, and I had great difficulty in swallowing. These symptoms disappear for a time, but return with the least over-exertion or strain. The last six weeks they have been acute. "As soon as I was able to travel I went to the beach for six weeks alone among strangers. I had trouble in dressing myself, cutting meat, and in all the little finger and wrist movements, but I improved in health and prided myself on my ability to get on a car without help when I came home. I returned, because my sister was very ill. It was weeks before she felt sure she would live, and the strain of that time was too great for me. "I felt unnerved and unequal to business or social life. The only thing I seemed to want was cold weather. I felt so utterly tired of the monotony of life in C. "In November, mother and I came to a farm in N. to spend the winter with my sister and her family. The trip was wearing, and I stayed in bed for a month after reaching here. I was benefited by the rest, and enjoyed the crisp, cold air that poured down across the bed from two open windows. "The winter has been severe fifty-seven inches of snow and it has kept me in. I like cold and I wanted to get out, but when I tried to walk on the shovelled paths in the snow, I found myself unexpectedly sitting in a snowbank with no ability to get up, and no knowl- edge of why I should have fallen. I seemed paralyzed by the cold. February, March, and April have been raw, gloomy, depressing months, and I have failed steadily in flesh, strength, and control. Neuron Energy and Neurosis 159 "My legs act like wooden pegs, and I am not always sure of crossing a room without giving way. My jaw won't work well enough to masticate solid food. Some times my neck feels as if it would break like a brittle stick, if I tried to make it hold my head longer. Throat won't swallow, eyes won't focus alike, eyelid droops, arm can't lift a spoon to my mouth at times. All these symptoms disappear, if I take a spoonful of brandy. "My temperature is subnormal, about 95 in morning, and my pulse can hardly be felt. Reflexes normal, perhaps slightly exaggerated. Muscles atonic. I sleep well, sometimes without waking for nine hours. "I feel full of ambition and plans while I am lying down, but I 'wobble,' and terror fills my soul when I have to stand, or walk, or meet new people, and particularly take a step up or down. "Menstruation has always been regular, normal, and free, until and including February 20, 1915. I have not menstruated since. I am told that the pelvic organs are normal, no enlargement, and no atrophy. "My lung capacity is great, my digestion fairly good, constipation is habitual. No pain, except neuralgic twinges. "If I take strychnia in i-ioo gr. doses three times a day and brandy before meals, I manage to eat and walk, but depending on stimulants does not seem to me to be good practice. I have had that treatment this last week only. "While at the beach for a month I recorded my dreams as carefully and accurately as I could. With that as a basis I submitted to an exhaustive quizzing over all my past life. No experience, no emotion of any kind, no conscious desire was concealed, but the cause of this condition was not revealed as far as the physician could determine. "For the last five years I have lived under great 160 Causation and Treatment, Psychopathic Diseases strain. Added to the pressure of financial difficulties, was the strain of much sickness in the family. My mother twice had slight cerebral hemorrhages, an invalid sister with a slow-growing cancer of abdomen caused me much anxiety and distress. There was also a case of tuberculosis, and it seemed that I was never free from care of the sick, never any relaxation at home. "I have given you as complete a history as I know myself. I am weary of carrying the responsibility of the care of myself, I should be glad to be told what to do, and made to do it. " The cases and accounts cited bring out clearly the relation of fatigue, fear, and psychopathic states. Mosso studied the state of professors and lecturers shortly before and after the delivery of lectures. He found that there was excitement which was betrayed in the curves of the ergograph, the sphygmograph, and the curve of blood pressure. "The bladder and the intestine betrayed the internal agitation;" Mosso might have added glandular secretions as shown by Pavlow and his school. More hormones from thyroid, parathoroid, from suprarenal and other glands and organs, associated with emotions, especially with that of fear are, with various chemical modifications of functions, discharged into the blood, and brought to various organs thus effecting serious changes of function. "Dr. Salvioli" Mosso goes on to say "told me that his appetite before lecturing was not as good as usual. I have seen very able orators, famous professors, find themselves upset at the prospect of reading a printed discourse. I remember an electoral banquet at which one of the best known deputies in the Italian Chamber neither ate nor drank till he had run through the speech which he was to read to his electors, and of which he Neuron Energy and Neurosis 161 had the proof in his pocket; and I was told that such was always his custom. With all the admiration I feel for the courage with which he beards his opponents in the Chamber, I cannot help smiling when I read the reports of his fiery interruptions and recall the fear which he experiences in presence of the electors." Here too it is the intensity of the impulse of self- preservation with fear of failure that has brought about the temporary state of psychopathic affection. The overwhelming power of the herd, of the community, the overpowering sense of social force, and the loss of individuality in the mob are especially conducive to the awakening of the fear instinct and to the arousal of the impulse of self-pn nervation. Social disapprobation terrorizes gregarious '-'aan. There is no fear greater than social panic. I pointed this out in my work on social psychology in studying the action of the mob on the consciousness of gregarious man. A good number of the fears presented in psychopathic cases are often of a social, gregarious character. No instinct works with such fatal effects as does the fear instinct among social animals. In a herd, in a crowd, in a mob the fear instinct produces the most dangerous results. In my " Psychology of Suggestion" I established the important law that it is the uncritical, subconscious self or subconsciousness that is subject to suggestions with consequent fatal impulsive actions. The law, as supplementary to and corollary of the first law, is that impulsive, reflex actions are controlled by the critical, personal self. Another important law es- tablished by me in the same work is that the emotional excitement of a social aggregate grows in a geometrical progression. Professor Giddings in discussing the laws of social action adopts these laws. "There are three of these laws" he says "that may be regarded as demonstrated: Impulsive social action is commenced 1 62 Causation and Treatment, Psychopathic Diseases by those elements of the population that are least self-controlled. . . . The law of the extent and intensity of impulsive social action is as follow: Impulsive social action tends to extend and to in- tensify in geometrical progression. . . . The law of restraint of impulsive social action is: Impulsive social action varies with the habit of attaining ends by indirect or complex means," or, truer to say, by rational means, free from emotional excitement. No emotion, however, plays such havoc as the emotion of fear instinct, which is specially subject to the second law of geometrical progression. The awakening of the fear instinct in a social aggregate is overwhelming, irresistible in its effects. At c