Causation and Treatment of Psychopathic Diseases

THE CAUSATION AND TREATMENT OF PSYCHOPATHIC DISEASES

Boris Sidis, Ph.D., M.D.
Boston: R. Badger, 1916

AS we have pointed out the fear instinct is the arousal of the impulse of self-preservation. Psychopathic conditions are at bottom fear states which in turn are based on the abnormal, pathological conditions of self-preservation. This is manifested in the fundamental trait of extreme selfishness characteristic of all psychopathic patients. The patient is entirely absorbed in himself and is ready to sacrifice every one to his demands and cravings.

For many years, day after day and night after night, I lived with patients who were under my care, observation, and treatment. One trait always revealed to me the predominant characteristic under the constantly changing psychopathic symptom-complex and that is the extreme selfishness of the patients. There is no greater egotism to be found than in the typical cases of psychopathic affections. This egotism runs parallel to the condition of the psychopathic state. This does not mean then that every egotist is necessarily psychopathic, but every psychopathic case is essentially egotistic. The psychopathic patient does not hesitate a moment to sacrifice to his “affection” father, mother, brother, sister, husband, wife, lover, friend, and children. In severe cases the patient stops at nothing, and only fear of suffering, sickness, evil consequences, and punishments can alone restrain the patient. In some extreme cases the patient is occasionally almost diabolical in his selfishness.

The constant sympathy which the patients crave from others and which they demand, if it is not given to them immediately, is but an expression of their extreme obsession by the impulse of self-preservation. In their struggle for self-preservation they forget everything else, nothing is remembered but themselves. This condition becomes the ground character which is often expressed in a frank, brutal way. Even in the best of patients one can find glimpses into the depths of the psychopathic soul which is nothing but the immense egotism of the beast, worsted in the struggle for existence, tortured by the agonizing pangs of the fear instinct.

In the vanity, conceit, arrogance, and overbearing attitude towards others, friend or stranger, as well as in the total indifference to the suffering of his intimate friends and acquaintances we once more find the expression of that infinite selfishness which obsesses the psychopathic patient. In order to get rid of some slight inconvenience, or to obtain some slight pleasure the patient will put others as well as his “near and dear ones” not only to inconvenience, but to permanent pain, and even torture. The patient lacks confidence, at least that is what he complains of, but he does not hesitate to demand of his best friends and even of total strangers all the services possible, if they are given to him, thinking that he is fully entitled to them. The patient has the conceit and vanity of his great worth in comparison with other people. The world and especially his family, friends and lovers, should offer their happiness and life for his comfort.

Even when the psychopathic patient does some altruistic act, it is only in so far as he himself can benefit by that deed. He is ready to drop it as soon as the work does not answer his selfish purposes. Himself first and last, that is the essence of psychopathic life.

The patient is convinced of his goodness and kindness and of his human affections which are far superior to those of the common run. He adores himself, and he is always ready to dwell in the glory of his delicacy and extraordinary sensitivity. This trait he is specially anxious to impress on his friends, on his family, and even on those whom he apparently loves. “I am the delicate being of whom you all, unappreciative, gross, insensible people, should take care.” That is the principle on which the psychopathic patient lives. The patient will do anything to attract attention to this side of his personality. He will emphasize his sickness, exaggerate his symptoms and even manufacture them for the benefit of those who dare to ignore him or who pay little attention to his condition, to his wants, needs, caprices, and passing whims. There is nothing so tyrannical and merciless as the autocratic “weak” will of a psychopathic patient once he gains ascendancy.

The patient’s whole attention is concentrated on himself, or more specially on the symptoms of his psychopathic malady, symptoms which obsess him for the time being. Whatever the symptoms be, permanent or changing, the patient's demand is to have others sympathize with his illness from which he suffers, to have them realize the fearful agonies which he undergoes. The selfishness of the patient is exacting and knows no bounds. The whole world is to serve him, and be at his command. The psychopathic patient is driven by the impulse of self-preservation and by the furies of the fear instinct.

Many of my psychopathic patients tell me that they feel sensitive as long as they witness the sufferings of other people, otherwise they do not care to know anything about them. They are anxious to have such things away from them as a nuisance. They insist on being surrounded only with pleasant things or with persons and objects that contribute to their health. Everything is absorbed by the worship of the Moloch Health to whom the patients sacrifice everything. Pain, suffering, and distress of other people are looked at only from the standpoint of the possible effect they may have on the patient’s precious health. Like Nero, who was probably of a psychopathic character, the psychopathic patient is ready to burn others for his health; if necessary, to torture health out of others.

One of my patients, who is very intelligent, tells me frankly that he uses others to squeeze out of them strength for himself. As soon as he can no longer get it, or has obtained all he could, he is anxious to part with them, gets tired of them, and even begins to be resentful, because they are in the way of his health. Another of my patients was ready to burn parks, stables, and destroy everything, if he knew that it was good for his health. Other patients of mine do not hesitate to wake up the whole house of people to help themselves in insomnia or indigestion. Many of my patients take pleasure in forming acquaintance and even friendship with people, ask for their sympathy, require their help and assistance, come to them early in the morning and late at night, disturb their sleep in the small hours of the morning, display all the symptoms of indigestion, nausea, eructation, and vomiting. Then the patients turn round, abuse the person who helps them, telling him disagreeable things, because he is no longer useful. A few hours later the patients may turn again for help to the same person, because they find that they could still make use of him.

Psychopathic patients do not hesitate, for the alleviation of their pains, of depression, of insomnia, to take a bath in the early morning and wake up all the other patients. The others will not hesitate to do the same. They are entirely absorbed in themselves. Self is the only object of their regard. A patient, a clever lawyer, aptly characterised one of my most severe and most typical psychopathic cases as “egomaniac.” “When you talk of gravity, ‘I am gravity’ she claims. Talk of the Trinity: ‘I am the Trinity.’” As a matter of fact, every psychopathic patient is an egomaniac.

“And certainly it is the nature of extreme self-lovers, as they will set an house on fire, and it were but to roast their eggs. . . . . . . .

“That which is specially to be noted is, that those which are sui amantes sine rivali, are many times unfortunate.”

Driven by the impulse of self-preservation and by the anguish of extreme fear, the psychopathic patient may be pitied as a most unfortunate, miserable wretch.

In the psychognosis of the particular condition, mental or nervous, be it object, idea, or action from which the patients suffer, the instinct of self-preservation with its instinctive emotion of fear can always be found in the background of consciousness or in the subconsciousness. An insight into a series of cases will help best to understand the fundamental, psychopathological processes that give rise to the different forms of psychoneuroses and somatopsychoses.

The inhibition of the patient’s activities, with the exception of the most primitive impulses of self-preservation with its instinct of fear, limits the patient’s life to such an extent that the interests and the activities are reduced to automatic repetition of reactions to stimuli of a stereotyped character. The stimuli must be the same otherwise the patient does not care to respond. He loses interest in his business, in reading, in his work, and games. The attention keeps on wandering. Games, pleasures, and hobbies in which he formerly used to take an interest lose all their attraction for him. The life he is disposed to lead is of a vegetative existence. He is afraid of anything new. The things are done in an automatic way. Routine and automatisms are characteristic of his activities. At first the patient tries to shake the slumber of his life, but afterwards he gives in and submits to the monotony which still further emphasizes the pathological process.

This routine life is a reaction by his organic, biological processes against the onset of the pathological processes. Meanwhile the family, or friends, and even physicians, noticing this tendency in the patient, advise him to occupy himself, to forget his troubles, to get pleasures, to see some interesting things, and thus become distracted. This is often effected by taking the patient away from his environment and making him travel in foreign countries. While distraction of attention may be of use in some cases where there is brooding, due to some misfortune, it is certainly of little use and even harmful in many psychopathic cases.

Before proceeding with the other factors bring a few cases, showing the factor of self-preservation with the fear instinct as its manifestation.

As a little girl Mrs. R’s health seemed well. She was active in out-of-door games which she enjoyed. She was only a middling student.

R. received little training of any sort from her mother, and was regarded by the neighbors as a “pert” child. She was never given household tasks to do and she always disliked housework. As a child, if she was refused anything she wanted, she would cry and scream and kick till it was given her, and even up to 18 years of age would throw herself about on the floor, screaming when she thought herself misused.

For the last twenty years she has regarded herself as an invalid. She complains of headaches, backaches, pains in the chest and abdomen, “indigestion,” lack of appetite, and many other ailments. Not all of these complaints all the time, but never free from some of them.

She is fond of company, likes to gossip, to play bridge, and to dance,—provided always that her husband or mother is present. Her comments on her neighbors are usually very harsh, and, while much interested in them, she has little sympathy. The summer vacations are spent at a camp; she enjoys fishing and motoring there, but is never free from her aches or her fears.

She is always eager to talk about her ailments. She will cry and moan and say she wants to get well, and fears she will “do something rash.” She says she thinks she might “do away with herself,” if she should find herself alone in the house. She fears she may go insane.

She has no real interests in life. When she wakes in the morning, she wonders how she is going to get through the day—how kill the time.

Besides these various complaints and fears she is full of other phobias, the result of child fears. She fears to be left alone in the house or to go out alone on the street. For fifteen years she has not gone alone from her home to the business street of the village,—always her husband or her mother must be with her. Either her husband or her mother is with her every hour of the twenty-four, not in the same room necessarily, but in the house. She will not walk on the street with a group of people whom she has known all her life unless her husband or mother be of the party. She will drive her husband’s automobile, a big touring car, and enjoy doing so, but her husband or mother must be in the car. She also has great fear of crowds; even with her husband she insists on sitting in the rear pew at church. If the rear pew is occupied she will go home, though there may be plenty of vacant seats further front. She is terribly afraid of disease, germs, and contagion,—she is always very anxious and in a panic on this matter of disease.

A couple of years ago, after death of grandfather, had fear of death, lasted for five months. Two years later, relations with girl, abortion, fear of being prosecuted, of being accused of the crime. Has also other fears and anxieties, such as of money, also of signing his name wrongly, or other illegal acts, fear that he may be come insane, inefficient, incapable. Suspects people of knowing him or of knowing the girl, and possibly reporting to the police. Cries, intense fear and anxiety. Knows that the object of fear is unreal; the emotion is too strong for him, it has become associated with everything he does or reads. Fears come over him, over reminiscences from childhood, lest he has done something bad or evil. Psychoanalytic physicians have especially helped in cultivating those harmless memories of childhood, and have associated them with the central instinct of fear and anxiety. The patient is extremely self-centred, thinks only of himself, inordinately selfish. Obsessed with self and fear.

Mr. F., age 32, graduate of Cornell. Masturbated when young; read literature on the subject and began to worry and fear about the consequences, began to dream, had sexual dreams which frightened him more; worried more, read more, and dreamt more. Entered college (Cornell), and felt miserable, obsessed with fear of mental ruin. Laid up with sprained knee for a few weeks (age 21); became constipated; physician spoke about auto-intoxication. Feels bad; physician ascribed to bowels, then began the fear consequences. (Psychosomatic.) Feels depression and headache (thinks due to auto-intoxication.) Had some headaches in school (probably thinks he had.) When a child he was very timid, sensitive, and shrinking, diffident, “painful to talk to him.” Had a dread and terror of his parents, who were severe with him, used to beat him mercilessly. Had strict religious training, was very conscientious about religion. Always worried about his health; is extremely selfish.

Obsessed by the impulse of self-preservation and fear-instinct, and with utter disregard of others, the patients are convinced of their extraordinary kindness, gentleness, sympathy, martyrdom, and even saintliness. It is from this class that all the neurotic philanthropists are recruited. Psychopathic patients are always ready to sacrifice themselves for the good of humanity, they talk endlessly about goodness, and may even devote themselves to charity work and instruction for the “poor and degraded.” A patient of mine worked for three years for the good of the poor, had “high ideals and a sensitive conscience,” according to his accounts, but abandoned readily his wife and children. Another patient, a young woman, a typical psychopathic, full of high ideals, ran away with a married man, had a child that died by exposure. This patient was interested in modern education and improvement of humanity. She never cared to do anything for anybody, and without any hesitation took advantage of others in order to satisfy the least whim that might have crossed her mind, especially those whims that relate to health. She had all kinds of directions, prescriptions, exercises, requisite for the strength and health of the body and the nerves.

One of my patients was afraid when I happened to go away; he used to be anxious about my going and my coming. Was it love or devotion? I found out that he was afraid that I might be killed. This fear was developed in him by an actual accident in which his brother had died, but the same fear associated with me was due to the fact that the patient was sure that my treatment was requisite for his health and welfare. He was in fear lest I might be killed, he would be unable to get his treatments, and thus lose time in getting back his health.

For the sake of his “health” the patient will not stop at anything short of murder, and even that will only be on account of the evil consequences to his health. There is no wonder that the “Christian Science” neurotic has well named her trouble “Health and Science.” This is essentially psychopathic. The psychopathic makes of health his science and religion.

The psychopathic patient may be regarded as a case of parasitism. The parasite, living on his host, gradually loses all active functions, a condition followed by atrophy of organs no longer necessary to the life existence of the organism. According to Demoor, “Atrophy begins with function when an organ has become useless. This uselessness may arise from two causes; the function may be no longer useful to the individual or to the species, or it may be assumed by another organ.” When an organism turns parasite, it is an economy of nutrition and energy to save as much as possible. The tendency of parasitism is to dispense with unnecessary functions in the struggle for existence. The loss of function and atrophy is from the less useful, to the more useful, to the functions absolutely indispensable to survival; from the less essential, to the more essential, to functions absolutely essential to the life existence of the individual. The life activity of the parasite becomes more and more narrowed, circumscribed, and dwindles down to a few functions requisite to its life existence, namely self-preservation, nutrition, and reproduction. With the further increase of parasitism even the digestive and reproductive functions become simplified, the parasitic individual becomes reduced to the most fundamental of all impulses, the impulse of self-preservation.

The penalty of parasitic life is the simplification of organic activities, the atrophy of all higher and complex life processes. This is what takes place in the case of the psychopathic individual. All higher activities, all higher interests cease; in many cases even the sexual instinct becomes gradually atrophied, the patient’s life is being narrowed down to the impulse which is absolutely requisite for life existence, namely the impulse of self-preservation with its concomitant fear instinct.

The growth of the impulse of self-preservation with its fear instinct brings about their hypertrophy which in turn hastens the degenerative process of atrophy of all higher and more complex activities. The psychopathic patient in the process of degeneration and atrophy falls so low that not only moral, social, and intellectual, as well as other psychomotor processes become gradually diminished and atrophied, but in many cases even the instinct of reproduction, requisite for the preservation of the species, is made subservient to the impulse of self-preservation and the fear instinct. In psychopathic life all activities are narrowed down to the pettiness of individual existence. All psychopathic interests are reduced to the sorry life of self and fear.

Lacking interest in anything but himself, terrorized by the fear of existence, the psychopathic patient lives a dreary, monotonous life out o€ which he seeks to escape. Monotony, ennui, indifference form the curse of his life. The patient is in a frantic condition, constantly in quest of interests which he cannot enjoy. Nothing can interest him, because he has no other interest but himself, and that is so narrow, that it can hardly fill existence. As a matter of fact he is afraid to meet his fears, he is afraid of himself. He is bored with himself, bored with everything and with everybody. He is constantly eager to find new pastures and new excitements, so as to fill with some living interest his poor, narrow, mean, short existence full of fear, misery, wretchedness, and brutish selfishness.

The patient is afraid of work, because it may “fatigue and exhaust” him, and may bring about a state of disease, while he looks for health. He has no interest, because he thinks only of his little self, reduced to digestion, evacuation, and sleeping. The psychopathic patient leads an inactive existence of a sluggard, a lazy, idle existence of a parasite, and still he is driven to life and activity which, from the very nature of his narrow, parasitic individuality, he can no longer enjoy. He has the ideals of a hero and lives the life of a coward. Obsessed with the anxious fears of the self-impulse he avoids the terrors of life, and drags the grey, monotonous existence of a worm. Hence there is a tendency in the psychopathic patient to be on the lookout for ever new energetic personalities, lean on them, suck out all the energies he possibly can, then reject his new friends unhesitatingly and brutally, and be again in search for new personalities who can disperse, for ever so brief a time, the fearful monotony and dread of his miserable, psychopathic existence. That is why the patient may be characterized as a psychopathic leech, or truer still psychopathic vampire. For it is on the life and blood of other people that the psychopathic ogre is enabled to carry on his bewitched, accursed, narrow, selfish existence, full of terror and anguish of life.

The following account by Schopenhauer describes well the psychopathic individual:

“The aim of his life is to procure what will contribute to his bodily welfare, and he is indeed in a happy way, if this causes him no trouble. If however the luxuries of life are heaped upon him, he will inevitably be bored, and against it he has a great many fancied remedies,—balls, theatres, parties, cards, gambling, horses, women, drinking, travelling, and so on (had Schopenhauer lived in contemporary America he might have added New Thought, Christian Science, and other cheerful religious metaphysics and psychoanalytic, Freudian twaddle); all of which cannot protect one from being bored”. . . . “Nothing really interests them but themselves. They always think of their own case as soon as ever any remark is made, and their whole attention is engrossed and absorbed by the merest chance reference to anything which affects them personally, be it never so remote; with the result that they have no power left for forming an objective view of things should the conversation take that turn; neither can they admit any validity in arguments which tell against their interests or their vanity. . . . They are so readily offended, insulted, or annoyed that in discussing any impersonal matter with them, no care is too great to avoid letting your remarks bear the slightest possible reference to the very worthy and sensitive individuals whom you have before you, for anything you may say will perhaps hurt their feelings. True and striking observations, fine, subtle, and witty things are lost upon them; they cannot understand them. But anything that disturbs their petty vanity in the most remote and indirect way, or reflects prejudicially upon their exceedingly precious selves,—to that they are most tenderly sensitive. In this respect they are like the little dog whose toes you are so apt to tread upon inadvertently—you know it by the shrill bark it sets up; or again they resemble a sick man covered with sores and boils, with whom the greatest care must be taken to avoid unnecessary handling. And in some this feeling reaches such a pass that, if they are talking with any one, and he exhibits, or does not sufficiently conceal his intelligence and discernment, they look upon it as a downright insult; although for the moment they may hide their ill will, their malice, and hatred.”

The love of the psychopathic patient is at bottom self-love, it is like the love of the wolf for the lamb. Lover, husband, child, friend, father, mother, brother, sister are all for the patient’s self. “When the attack is on” exclaimed a psychopathic patient, affected with cardiac palpitation and intense fear, “I am too d——d scared about myself to think about her!” The psychopathic patient is a parasitic ogre with an hypertrophied ego. Patients who claim to love children when the latter are well and healthy, avoid them, like a pest, when the children happen to fall sick, for fear of disease and for fear of the sick children, producing an evil influence on the patient’s “sensitive” nerves. The patient is afraid to come near sickness, or even afraid to hear of evil things, such as descriptions of misfortunes, ailments, accidents, and sufferings, because they may upset him and arouse his fears about himself. All the patient wants is to be surrounded with cheer, joy, merriment, excitement, and happiness which he is unable to enjoy. The psychopathic patient is in constant search after happiness. Not that he is interested in the problem of happiness from a moral, philosophical or even purely religious standpoint. His interest is of the crudest, the meanest, the most selfish kind. It is happiness for self, a low, mean, short, and brutish self. Psychopathic happiness is not human, it is the anguish of the beast, cornered by terror. The patient is tortured by happiness, tantalized by fear. Egotism, fear, and ennui are the harpies of psychopathic life. I take almost at random a few quotations from the writings of a psychopathic patient, writings which may be regarded as typical of all other patients: “What truths must I realize to become happy? How shall I get an absorbing interest and be happy? How am I to feel happy about the right things? What is this vague discontent, because I do not desire people’s welfare? Is it wise for people to get all kinds of healthy happiness they can? (Patient claims to be scrupulously religious, extremely conscientious, and highly moral). My happiness is affected by the happiness of others. That is as it should be, is it not so? . . . Knowing my abilityes and circumstances to what extent is it possible for me to obtain happiness? . . What are the means by which my happiness may be brought about? . . . How far should I pursue the happiness of others? . . . What interest shall I have or cultivate so as to make my life happy? . . . I want to do the high and the great. Must I not grow from the small to the high? . . . When I get well and free from my fears will I feel that if I thought things out they would be all wrong while I will feel strong and happy? . . . Should I be contented to do humdrum things? . . . What is the secret of greatness and of happiness?” . . .

Psychopathic patients subscribe to the “cheerful” effusions of “New Thought,” and plaster the walls of their rooms with elevating “Rules for Health and Happiness.”

The writings and accounts of the patients are full of introspection about health and about the minutiae of their feelings in the various parts of their body. Some of the patients with a literary turn keep on writing volumes about the most minute symptoms of their trouble to which they happen at any moment to be subject. I have numbers of manuscripts, biographies, autobiographies all telling the same old story of “blighted lives” due to ill health, drugs, and treatments, all describing with the over-scrupulous exactness of microscopic anatomy the different symptoms that plague them by night and day. The patients tell of their talents and remarkable abilities superior to the average run, of their ill luck and failures, due to their unfortunate state of ill health.

In quoting from some of the accounts given to me by the patients themselves I wish to attract attention to this side of the patient's mental condition, the expression of the impulse of self-preservation, manifested in the general panic of health, or fear of disease, whether mental, nervous or physical, phrenophobia, or pathophobia.

I give a couple of illustrations of accounts given to me by patients. These accounts of symptoms are put by the patients in the form of precise bookkeepers’ inventories. The symptoms are described with the most exacting minuteness. Such summaries are often accompanied with long winded annotations and appendices:

“S. P. S. Age forty. Average weight 160 lbs. Married. Profession, lawyer and author.

“No bad family history. No syphilis, scrofula, or insanity. No organic disease, except enlarged prostate.

“Neurasthenia, perhaps congenital. Objects like fishes floating before the eyes. Incessant tinnitus aurium. Occasional subjective odors and tastes. Eczematous eruptions.

“These symptoms have appeared years ago, some of them as results of the grippe.

“Hay-fever with asthma for years, a very bad case. Produced great prostration. Some symptoms of this disease present the year round. Occasional insomnia. Occasional nocturnal and diurnal horrors. Inability to remain quiet or composed.

“Uric acid diathesis inherited from both sides, producing muscular and arthritic rheumatism.

“Occasional aphasia, inability to pronounce such words as “prelate;” rarely, slight stammering.

“Almost absolute lack of concentration. Great impairment of memory. Occasional great depression of spirits. Occasional inclination to cultivate obsessions, controllable by will-power. Sometimes experiences of auditory hallucinations.

“My trouble is inability to work even moderately without having as after effects physical agitation and heightened irritability, shown in bodily sensations, in restless and jerky movements of hands and feet and—on occasions of suspense or conflict—in violence both of manual and vocal expression; the motor discharges passing, it would seem, through the lower centers without giving higher centers a chance at them; for will power and higher control generally is certainly not weakened, where there is time for its exercise. (I say ‘time,’ but of course the true differentia may be something else). These effects increase with continued work till it is manifestly time to stop and wait for some weeks or months till they wear off.

“My occupation is that of editorial writer. In it I both earn a living and keep myself in touch with the material for an investigation which is of dominant interest to me, viz., the social functioning of the social man, which involves on one side the social statement of the theory of knowledge, and on the other the interpretation of society in terms of the knowing man. Forget this detail, and remember only that my main interest and activity is one which—regardless of the detail as to whether my ultimate product is good or bad—involves high pressure brain work while I am at it.

“My recent history is as follows: Three years ago I stopped work and began to cry (conventional style). One year ago after a return to the office had been followed by return to investigation I developed ‘emotional exaggeration,’ as described in following memoranda, and also tendency to motor violence, as mentioned above. After a summer on a farm, followed by three months of investigation (without office work) three to five hours a day, the motor phenomena are at the front, and I have had to stop work again.

“Three years ago Dr. R. of this city pronounced me physically sound all over, after all the usual tests. He has repeated the verdict this week, and my reflexes, etc., have been tested and pronounced normal by a nerve specialist of this city (rather, by his assistant), whose name I omit because of the nature of my description of his report on me attached hereto.

“Extract from a personal letter of my own, describing the examination I have already received.

“Other grandparents, one, cancer in old age; one, cholera young; one young, cause of death unknown to me now.

Effects lasted three or four years. Think took mercury (?) pills for even longer time.

Returned home in N. in spring. Feeble through the summer. Note sharp and complete cessation of self-abuse two or three months before this breakdown.

“Remember nothing to report during college period, nor reportorial, save that one time, perhaps ‘03, I combined unwonted executive duties with a rushing piece of magazine work in midsummer, and was highly wrought up before finishing it.

“Winter, ‘07-‘08. Doing regular editorial work, correcting proof sheets of a book on government that appeared in the spring of '08, my father was seriously sick for a time, and certain business matters, not my own, had to be watched by me. Result, February, ‘08, cursed everybody in the office one day, wanted to run away, instead walked home, had conventional hysterics, and temperature. A fool doctor, first comer, talked about inflammation of the later showed blood pressure and everything else normal.

“I did not begin investigations on the lines of my dominant interest until July ‘09.

“September-December, ‘10. Took up personal investigations, three to five hours a day, five days, perhaps, a week. Gradually improved for six or eight weeks, then grew rapidly worse. Did not return to newspaper.

Digestion good. A slight constipation will greatly increase feeling of agitation and irritableness. Sometimes bodily agitation seems localized along oesophagus.

Usually very good. When I can work I sleep nearer nine hours than eight. After a motor explosion will be exhausted and sleep well. Of late apt to be wakeful in early morning hours, but rarely is the wakefulness combined with agitation. Agitated wakefulness was common for a short period in spring of 1910.

“Thighs. Numbness and stinging sensations in left thigh in fall of ‘08. Did not recur till fall of ‘10. Then noticed in middle front of left thigh, and above right knee. Pains superficial. Numbness, burning, stinging, sometimes violent stabbing pains, pressure sensations. Noticeable in general only when walking, but at their worst also when standing and even when lying down. Sometimes caused me to halt, but have taken long cross-country walks despite them. Pains have ceased entirely within last month, since general condition became worse.

“Liquor. Use very little, even at meals. Purely a social matter. Since days when I was a reporter the only time of fairly steady drinking was in Paris in ‘08.

“Smoking. Became distasteful in winter months of ‘09 (Nov.-Dec). Later produced marked stimulation of pulse, also seemed to increase irritableness. Stopped entirely January, 10, except for half a dozen smokes last of which preceded a slight nausea.

“Mental condition. My private opinion is that I never could work so effectively as now, either as regards fertility or balance. Under the conditions however, I do not pretend to be a judge of that. By ‘effectively’ I refer to tests entirely within the work being done, not to any value the work may or may not have by social tests.

“Self-control. It seems stronger, if anything, within a certain range, that is, I come nearer being decent towards people I meet. Unfortunately too much happens, as described below, that does not get within range of will control.

“Depression and Exaltation. Neither appears. Can enjoy living thoroughly, when I am not working.

“Fear. In ‘08 was afraid of my razor. Had to stop shaving. Nothing of the kind since then.

“Suspiciousness. Imagine I had it in strong form in ‘08 but think not now, at least no more than normal for me.

“Emotional exaggeration, and reverberation of emotions. This was characteristic in the spring of ‘10, when I quit work and for some time afterwards. If I would think somebody, as my landlord, or some condition, was wrong, I would begin to fume inwardly; I could not shake off the preoccupation. I would have the sense of agitation in the body as well as the exaggerated emotion, and the reverberation might continue for hours. Have had a few beginnings of such experiences this fall, but nothing marked. Looking back at them they appear as the beginnings of what might have become fixed ideas. My specialized exaggerations never ‘stick’ this way. I easily free myself of them.

“Violence in word and movement. The worst symptom now. Restless or jerky movements of hands and feet. Spluttering talk and sounds that I haven’t the slightest intention of producing. If I am crossed on trivial matters, but especially in arguments or reasoning, or kept in suspense, I become explosively irritable. As for instance smashing a chair on the floor, tearing up papers which I had to wait to have signed, hitting a waiter in the face with a bill of fare when he brought me the wrong dish. All of these things being done, as far as I can tell, without my being aware I was going to do them; but, of course, with sufficient habitual control to prevent very destructive acts yet.

“Tendency to get things finished, so as not to be bothered with thinking I still have them to do. Plain feverish haste and insistence on being busy. This is normal with me, but exaggerated now. Have not yet found the key to a low-toned life.

“Work. When in library work I become feverish at the start, but can settle down and retain good concentration for five or six hours unless definite physical conditions or some varieties of noises disturb me.

“Talkativeness. A recent phenomenon is nervous talkativeness under any and all conditions where normally I would be silent.

“Mischief. When I stop work it has been very difficult thus far to keep out of any variety of mischief that comes along. Such interference must therefore be assumed at each period described above when I have been supposed to be resting completely.

Many of the phenomena above described are closely comparable with what takes place on a smaller scale after physical fatigue; as, for instance, if I take an all day cross-country walk, have to entertain visitors in the evening and get insufficient sleep, I would feel and act next day much as I feel now all, or almost all, of the time.

Usual recreation is long walks in the country. Of late years, however, rarely above twenty miles. Probably overdo in this under some weather conditions. Winters '08-'09 and ‘09-‘10 have done regular gymnasium work.”

Some of the patients modestly ask of me to accomplish for them a few things in one treatment: The following is a good type of many others:

“I realize a few of my greatest faults which I wish you to correct. You corrected my whiskey habit. Now I wish you to help me along the following lines:

(3) To be enthusiastic in taking exercise in the open air and otherwise, and in playing golf, tennis and the like.

(4) To have even greater energy and application in my business, to be tireless and very exact in reading newspapers and other journals.

(5) To be quicker and more prolific in discovering hidden aspects of the news and the developments, and in producing feature articles and pictures having the elements of what is known as ‘heart’, or ‘human interest’—that is, popular interest.

(6) To be to a greater degree capable of attracting the respect and confidence of superiors and inferiors.

(7) To be fluent―to a proper degree—in speech, and convincing, always retaining the command of my higher faculties.

Could you give these suggestions at one time? I can ill spare any time. . . .I am an easy subject.” Patient is a newspaper man.

The psychopathic patient talks about his humanitarian ideals, about his great abilities superior to the common run of humanity, and how with his talents he is willing and has been willing to confer benefits on poor suffering humanity in spite of the fact that he has to struggle with his poor health, physical, nervous and mental. In spite of the overwhelming fatigue due to ill health, and in spite of the fearful ideas and impulses that have beset him day and night he still has succeeded to fight his way through. The patient hankers for notoriety, for praise, for appreciation by other people, and is apt to complain that the family, neighbors, acquaintances and even friends cannot appreciate his good points, his good will, and his high ideals to which he conforms his life, tortured as it is with pains and suffering of poor health. The egocentric character of the psychopathic patient is bound up in his abnormally developed impulse of self-preservation and in his pathological state of the fear instinct.

Thus one patient opens his account with the phrase: “From boyhood I had a sensitive conscience.”

Another patient writes: “As a child I had a keener instinct as to the real unexpressed attitude of those about me toward each other than the average child.”

One of my patients, an extremely puny being of mediocre intelligence, writes: “I have always, from the earliest childhood, felt that I was different from those about me; and I must acknowledge that it was not alone a feeling of inferiority on account of poor control, but a feeling that I understood more than they. I was, however, of a delicate constitution and suffered from ill health.”

The following is a characteristic report made by me about the condition of a psychopathic patient:

“He is not interested in anything but himself and in his business or money making for self-enrichment. Daily, when he is left to himself, I have to get a hold of him, and lead his mind away from his supposed troubles and financial affairs over which he worries. His central state, almost delusional in character, is fear of impoverishment. He is afraid he has only a hundred thousand dollars which will hardly suffice for his expenses. (The patient is sixty-five and has no children). His worry is based on fear of disapprobation and possible disparaging opinion of his friends and his acquaintances in regard to his failures in life. Being a lawyer, he was never appointed to any prominent position. He made little money in his investments. To this should be added the much lamented loss of his wife’s health which might have given him room in the social swim. Conceit, vanity, vain-glory, greed, ambition, grounded in a hyperaesthetic self-consciousness, associated with the fear of utter ruin, all go, as so many constituents, to form the patient’s pathological, mental aggregate. I have tried to interest him in various other things than his petty self and its fears. I am sorry to say that thus far all my attempts have not been successful. The patient is too old, his life is too firmly rooted in the impulse of self-preservation with its accompanying fear instinct.”

“Age 38. Apparently in good health except for a nasal and throat catarrh. Nose has been operated upon several times and a considerable part of the middle bone removed which before had obstructed the air passages. Less catarrhal trouble since operations. Perforation size of pea left between nostrils. Always had trouble with eyes until about four years ago when properly fitted with glasses for reading. Eye trouble caused by semi-paralysis of accommodation muscles. No eye trouble now. Suffer during the whole winter with cold hands and feet. Height 5-9½, weight 165. Now practicing law and have been engaged in like occupations last ten years, except one spent in mining. Mentally inclined toward philosophical studies. Fond of outdoor sports, trees, flowers, etc. No excesses at present. Worked too hard in early life on farm. Nervous temperament and extremely sensitive of others’ opinions and words. Make too much of an attempt to satisfy the expectations of others. Have had several difficulties at various times with other men which resulted in considerable physical and mental compliments and honors paid to me. The parties were always much larger and used foul methods and as I am inclined to use kindly methods and much consideration for those weaker or inferior to myself these difficulties have caused much mental worry and disturbance. Have attended a number of prize fights and always suffer extremely from increased heart action when I see them, or a personal encounter of any kind. Sleep lightly and often wake with a shudder though I have little recollection of any dreams. Find heavy drowsiness during waking hours. Unmarried. Would probably have been married years ago, if financially able.

“Always have an indefinable dread of something fearful going to happen. This is my greatest difficulty. I am too sensitive about taking issue with others. I have tried the real estate business, but this fear or dread has prevented me from approaching others for fear that they might take it as a personal affront, and in trying to be just I have been unjust to myself.

“There is no apparent reason why I should not accomplish much for myself and also do others good except this abnormal modesty and reluctance to oppose contrary wishes of others. I know I possess much latent force, if I can only bring it forth. In trying a case I have little difficulty. It is when matters must be taken up personally outside a formal court that I suffer. I feel a natural antagonism to some people and it is almost impossible for me to prevent myself opposing them on every occasion.

“I have felt for a long time that something not apparent on the surface was wrong. I feel that my strength will come only through some psychic cure which the ordinary physician passes over as superstition. I always believed that my eye trouble would be found to be out of the ordinary and, though some of the best specialists prescribed for me, it was a serious handicap until an experiment was made at my own suggestion, and I now have stronger eyes than the average man of my age, though several specialists advised me to quit any work which required reading. My nose and throat are the causes of much trouble yet.

“I understand the theory of suggestion. I will purchase any books you direct and read them.

“The burden of my plaint is that I should be positive whereas I am negative.”

A patient of mine, a clerk of average intelligence, with hardly any ability, but with plenty of selfishness, introspection, and immeasurable conceit, writes about his ideals in life:

“I would ask that this manuscript be considered in connection with my other two writings. I have already partially covered this ground in my autobiography. I should be glad to have my general outlook on life considered, and to receive suggestions relative to vocations and avocations, since my anxieties regarding these are inseparably intermingled with my thoughts of physical and mental health.

“Of course, since childhood my ideals have undergone a gradual modification. First, there was the religious motive of life: I wanted to be a soldier of the Cross and assist in the regeneration of souls and their preparation for the life beyond. . . . I began to meditate upon ethical theories. . . . It appears that in doing the world's work the tendency is to specialize. . . . In the matter of choosing my employment my own interest is identical with the interest of society. At different times of my life I have fancied I had a liking for one calling or another. . . . My lines of thought have gradually drifted into the philosophical (patient means the various occult scribblings about ‘health metaphysics’). I now ask myself why I should be a lawyer, a physician, a minister, a philanthropist or any other special thing? I conceive that a man’s life is largely what circumstances make it, and it may be, therefore, that I shall always be a clerk in an office, trying to be useful in a small way; but now we are talking of influencing such matters as far as we can by choice. I imagine that perhaps my field is in the line of ethics, philosophy, or whatever words may be used to signify the general principles governing human affairs. My reasons for thinking so are as follows: First, I feel a strong interest in those principles comparing to no other interest in my life. Second, I find very few people who seem to feel any such interest in such matters. Third, I believe such principles to be of supreme importance. The question is,—Is my position in regard to general truths so peculiar that I should regard it my mission to give those subjects more attention in study and expression than do other men?

“The question I want to settle is,—Do other men feel this same philosophical interest, realize the broad field of human obligation, and come down to special occupations, not because they are more interesting to them than the general field, but because they realize they must specialize in order to properly assist in carrying on the world’s work? If this be so then I am mistaken in thinking I should give particular attention to general principles. But my observations have gone to show that the average physician, lawyer, merchant, or politician is not interested in the broad questions of life, but only in medicine, law, business, or politics caring little for the relation of his vocation to other vocations except as he makes his bread by it. Why then if the various departments of human activity must be correlated, and if the individuals making up those respective departments have no disposition to do the correlating,—should it not be done by those who are interested in the general field?”

It means that such work could be and should be done by the patient, by the philosophical clerk, interested in the general metaphysics of health.

Such confessions can be easily elicited from psychopathic patients even in their best moral states of apparent diffidence and humility. This paranoidal aspect of self-aggrandizment is present in all psychopathic cases. In some this trait stands out more clearly and distinctly than in others. It is, however, present in all psychopathic patients, if one observes them closely and attentively. It is the expression of an intensified state of the impulse of self-preservation and fear instinct. In other words, it is a state of an exaggerated, hypertrophied egotism.

“We must appeal to a law higher than the material law” a patient writes in his account. “I worried much over it. Since that time the relation of mind and matter greatly interested me. . . . My health at this time failed; I lost appetite and strength, had hysterical symptoms. I was treated for general neurasthenia. . . ." Psychopathic, philosophical and ethical speculations and interests have their sole source in fear of sickness and self-preservation.

“One of my anxieties,” another patient writes, “of my present life is connected with my business and my relationship to my partners. I am naturally conscientious and inclined to be not only earnest and sincere, but serious. My nature, instincts, and desires are not superficial. Yet my relation to the business is a superficial one. I am neither fitted by natural tastes nor by training for the indoor, rather mechanical, conventional, and routine processes upon which business and commercial success depends. . . . “Without the common motives of an ordinary merchant (greed) I am placed in the position of the one who lives not by the usual and conventional standards of right and wrong, but rather by a more exalted and a more rigid one of his own making which, unsupported by habit, and institutions, requires a greater loyalty, a higher resolve, and a firmer will than is required of the conventional and conforming citizen. Emerson says it demands something Godlike in one who would essay such a task, not placing the same values on money, trade, commerce, and profit as the natural money maker and money lover, and not the opportunity to substitute and supplement the usual motives by and with the larger, and to me more compelling, of community betterment and employee welfare. . . .”

Another patient writes of himself, “The hypersensitive nervous systems, with the initial shock has inhibited the development of my highest potentialities and my highest endeavors.” He summarises his symptoms: “Dread and anxiety about being away from home and friends, self-consciousness, mental sluggishness, quick fatigue, inability for deep thought, general state of irritability.”

One patient tells me that he suffers from fatigue, insomnia, dullness, inability of concentration of attention, failure in studies, slowness of comprehension, and so on; and yet he gives his opinion on every conceivable subject with papal infallibility, and hints at being an undeveloped, unappreciated genius.

Perhaps a few more of my cases will help one to realize the character and nature of the psychopathic diathesis:

M. A. Age 43, female, married. Sister and brother died of tuberculosis. When young, she herself had an attack of tuberculosis from which, however, she entirely recovered. This made her, from her very childhood, think of herself and of the fear of death. She is suffering from menstrual irregularities with scanty discharges. She also suffers from headaches, backaches, indigestion, intestinal pains, borborygmus, and eructations. Her mind is entirely engrossed with herself, she is totally unable to think of anybody but herself. The whole world is for her sake, and she does not scruple to utilize anyone who is willing to serve her. She will take advantage of everybody and would not care what the feelings of others might be about her extreme selfishness. If she were sure that no fine or punishment would follow, she would not hesitate to take anything that belongs to others, no matter whether it be friend or enemy, provided it does her good, drives away any of her discomforts or fears of disease, or gives pleasure to her, even if the others were in agony on account of it. If there were a prize on selfishness, she would be sure to fetch it. She is sure to take advantage of people who do not know her and who practice the ordinary civilities and amenities of life in regard to her When the people refuse her demands she does not mind it, and goes to look for other victims who have as yet no knowledge of her temperament, character, and sickness. Everything is legitimate in order to get well and healthy.

The patient talks of high ideals and of service to humanity, and yet she has not hesitated to lure away a man who had a wife and three children. She made him divorce his wife, who was her bosom friend, had him marry herself. She spends all his money on her “artistic dresses,” while his former wife, the mother of three children, and his little family are allowed enough to keep them from starvation. The patient goes around travelling, visits physicians, cures herself, keeps on being sick in various health resorts, learns all kinds of fads and their modes of healthy living, keeping away from diseases, wasting carelessly her husband’s money.

The patient is in terror of disease and of old age. She is in fear even to think of such things. She carries around with her all kinds of prescriptions and directions as to how to avoid disease and old age. Everything must be subservient to her impulse of self-preservation and instinct of fear. She has dwindled to a parasitic existence, obsessed with the lowest instincts of life. She avoids all responsibilities; all she wants is to use others as much as she can in order to obtain for herself the highest possible benefit. When she meets people who do not know her she is quick in taking advantage of them. Life to her has no duties, but rights. Patient is a typical parasite. She would cheerfully sacrifice a nation to get out a mite of pleasure, comfort, and health.

V. S. Age 49, female. Married; no children. She has three sisters and two brothers who are all well. As a child she lived in great poverty, she was neglected and met with accidents and scares; suffered from sickness until her little body was emaciated from privation. She managed, however, to go through school and became a clerk in a small store; she was very careful of her appearance which meant to her a good marriage, a comfortable life. She also took good care of her health which was rather precarious, on account of the many colds and painful menstrual periods, accompanied by severe headaches. At the same time on account of the poor life led, she also suffered from some obscure intestinal troubles, more specially from severe constipation, relieved by frequent and large enemas. After years of precarious health and quests for happiness, for marriage, she finally somehow succeeded in marrying a well-to-do merchant in whose store she had worked as clerk. Immediately after marriage she rigged up a “beautiful home with rich mahogany furniture” which even the husband regarded with a gasp, settled down to a life of leisure and complete idleness, and began to attend to her health.

The patient gradually began to find more and more troubles with her organs, from pelvis and intestines to the top of the head. Nothing was quite right. Things could be improved. As she went on the impulse of self-preservation gained more and more control over her. Along with this impulse the fear instinct gained in strength, became more and more extensive, she became a psychopathic sufferer.

The patient became full of fear which, by the principle of proliferation and diffusion, kept on growing and diffusing in ever new directions and spreading to ever new associations and systems. The central fear was poverty. Patient was afraid she might become poor. This is naturally a fear from her early childhood,—the fear of suffering in poverty, a fear which persisted throughout her life. The fear became accentuated and developed with time, it became intensified with the onset of menopause. She was afraid to spend money, especially sums above a five dollar bill. No matter how much she tried to reason with herself this fear persisted. She was afraid to buy new things which she regarded more or less expensive. She was afraid to put on new dresses, to buy new furniture, to spend money in any way. In fact, quite often the fear was so uncontrollable that even when she had no thought of threatening poverty, she was in a panic at being con-fronted with expensive purchases.

The fears then began to spread to other things, such as giving away small articles or loaning books, or presenting any things or objects that might be regarded as expensive and valuable. The fears spread to other activities of life that might prove of some importance and value.

Along with it she had fears of digestion and nutrition, nausea, vomiting, intestinal pains, rectal, tubal, and ovarian discomforts, and especially an inordinate amount of eructation which she had when in a state of nervous excitement over things that did not run the way she planned.

The patient was as obstinate as a mule, though claiming that she was doing her best and trying everything in her power to cooperate. She was doing everything in her power to frustrate the physician’s directions, claiming at the same time that she was doing her best, scrupulously following the doctor's directions. She claimed she was nice to people when she was nasty and offensive to everybody who in any way happened not to fall in with her whims and caprices. In fact, even those who went out of their way to please her and did everything in attending on her, and helping her in every way day and night, even those she treated with lack of consideration, even positive disdain and contempt. She was the incarnation of demoniacal obsession, the very type of psychopathic meanness and egotism.

Patient abused and dominated her husband by her sickness, troubles, fainting and crying spells, headaches, moans, and weeping. She made him do everything she pleased. In fact, she tyrannized over her husband, and still she kept on claiming she loved him, could not for a moment be without him, and that on account of her extreme devotion to him, her will was broken.

She was a regular termagant, a demon incarnate. She knew how to make a scene and put the blame on somebody else. It was enough for her to suspect what her friends wanted her to do, she was sure, out of sheer malice, to act the contrary. She was distrustful, spying on others, sneaky, and lying right and left without any scruples; and yet “no one was so mild, so ideal, so kind, so affectionate, so considerate, so calm as she was.” She went around reciting poetry about ideals, health, and happiness. She even persuaded herself that she was very educated, that she was the best business woman, the best critic, appreciative of poetry and of art in general. A veritable Nero, an “egomaniac,” devoid of all love and human sympathy, “she suffered so much, because she was so unusually altruistic.” A coyote in her fear, a tigress in her rage, she claimed the gentleness of the dove and the innocence of the babe.

Patient’s talk was but of self. Not for a moment could she fix her attention on anything else but herself, eating, drinking, sleeping, stools, and feelings. Nothing interested her but herself; she ran from any work, from any occupation, however brief the time might have been. She could, however, talk of herself, of her former achievements, of her moral, intellectual qualities by the hour and by the day. Even games did not interest her, nothing but self, self, and self. This was so evident that one of my patients noticed this characteristic trait and described her as “egomaniac.”

Whenever one spoke of any great man she was sure to have her opinion of him, might have known him; she was at any rate superior to him. She could give her opinion on any conceivable subject in literature, economics, and politics. She was cunning as a savage, and treacherous as a wild brute, and yet she was to all appearances a veritable saint, full of suffering for the sins of humanity and for the faults of her husband who was “boyish and foolish, whom she had to manage,” and whom she did control and handle with an iron rod.

There is no doubt, however, that she herself was driven by her intense, uncontrollable impulse of self-preservation and by the instinct of fear. What specially terrorized her was the slow but sure extension of the fear instinct to more and more objects and acts. The fear instinct kept on creeping on her, slowly choking the life sources of her being. To call the patient “egomaniac” is a mild descriptive term, “tigress,” “satan,” “fiend,” would be more appropriate appellations. In her terror of self-preservation she made hell for herself and for others; she is a fire-brand from hell, fanned by the furies of fear.

F. W. age 47; female; married; has no children. Patient claims to have been an invalid from childhood, at any rate she was of extremely delicate health; she always had to take care of her health, and had to go through all kinds of troubles and diseases, especially digestive and gastro-intestinal. At the age of eighteen she got married and then her family felicity began. She began to complain of all kinds of uterine troubles, more so after a miscarriage. The gynecologist hu-mored her with all kinds of operations and treatments. The fear of disease became strengthened, and finally she cultivated a typical pathophobia; she was in terror of some fearful malady that might possibly take pos-session of her.

Patient wanted to have somebody near her, otherwise she could not stand it. This fear of remaining alone dated from childhood, when at the least discomfort, she asked and screamed in terror for help. A companion or nurse had to be with her day and night, so as to protect her from any impending evil.

Occasionally, to relieve her feelings, in the middle of a conversation, whether for the sake of impressing her family, her husband and her physicians with the gravity of her disease or as a vent for the rising instinct of fear, she emitted a scream, wild and weird in character, reminding one of the howling of a timber wolf, or of the wild whoop of an Indian. This was a habit she kept up from childhood. It was a reaction of her fears and a protection, inasmuch as it was a call for help which was sure to attract attention. The family could not refuse help at hearing such an unearthly call. Later on it was consciously and unconsciously utilized by the patient as a rod to rule the family and especially her husband when the latter happened to become refractory. The fear reaction was thus used as a protection and as a weapon of offence.

Things had to run according to her pleasure or else she was put in a state of nervous excitement and fear with its awful yell of which the family and the husband were in perfect terror; they yielded unconditionally. The patient literally subjugated her husband by her spells of fear, especially by the fearful acoustic performance, the aura, the harbinger of a psychopathic attack.

The patient was always discontented and grumpy. Nothing could satisfy her, nothing was good enough for her. Everything and everybody were criticized. No matter how one tried for her she always found fault with the person. In fact the fault-finding was in proportion to the eagerness one tried to serve and oblige her. The nurses are not good, the servants intolerable, and people in general are bad, mean, stupid, and vulgar. She herself comes from an “old New England family, good blood,”—her grandfather was a fisherman and her father a petty tradesman in a small town. Patient makes great pretensions to education, poetry, art, and drawing. In reality patient is quite dull and ignorant, but unduly opinionated and infinitely conceited.

G. A. Female, age 63. Patient has been obsessed with pathophobia for over thirty-five years. She has been to a number of physicians and to many sanitariums, looking for health everywhere, not finding it anywhere. The fears date to her early childhood. She was regarded as a delicate child, the fear of disease was strongly impressed on her. She went through a number of children's diseases. Although she had a number of sisters and brothers, the child’s supposed delicate constitution was the fear and the worry of the parents. This fear was communicated to the child who for the rest of her life became a psychopathic patient with the characteristic developed impulse of self-preservation and intense fear of disease. She could not think of anybody but herself, everything had to be arranged for her, for her food, for her sleep, and for her rest. She kept on complaining at the slightest change either in herself, in others, or in the arrangements of the house, or in the weather. Everything had to be arranged just as she demanded, otherwise she was sick, or was going to become dangerously ill.

When about the age of thirty, she married a widower with two children. She trained the children to obey her commands implicitly, otherwise she resorted to the rod of sickness. The pathophobia, consciously or unconsciously, became a power which she yielded in the most tyrannical way. The children, when grown up, had to sacrifice themselves for the pleasure of the sick step-mother. They had to stay with her and minister to all her whims and fears. The very individuality of the children became almost obliterated by the persistent, egotistic tyranny of the sick old step-mother. She was like a regular vampire, sucking the life blood of her family.

It goes without saying that the same fear of disease tamed her husband over whom she ruled with an iron hand. The least opposition to her whims or her fears of possible disease made her so sick with all kinds of pains all over the body, and specially in the head and intestines that the family and the husband were driven into submission.

The woman was fat, obese as a hippopotamus, well nourished, with a florid complexion and with an appetite that would shame a Gargantua. The rarest, the best, and the most appetizing dainties had to be on her table. She made of her meals a form of worship, requisite to propitiate the goddess of maladies. She did not hesitate to take the best morsels from the plates of her daughter and son, in order to satisfy her appetite which was supposed to be delicate and small.

Patient was conscious of every square inch in her body; she was afraid that some form of malady may lurk there. She was a typical pronounced case of pathophobia. Fear of disease and quest of health were ever in her mind. She could not talk or think of anything else, but herself and her symptoms. She made of her daughter a poor, colorless being, a day and night nurse, tyrannized her by pitiful whimpering.

When patient happened to wake during the night for ever so short a period of time, she did not hesitate to wake her daughter, tired as the latter was by her constant attendance on this psychopathic shrew. The daughter had to wake up everybody who could in any way bring comfort to that “poor, old, suffering invalid.” After groaning, moaning, and bewailing her bitter lot the invalid took some medicine to appease the fear of disease, also partook of some nourishing food to keep up her strength and health, and went to sleep for the rest of the night.

As soon as the old lady found out that I wanted to send away her daughter and get a regular attendant to her, as soon as she suspected that she was not going to have her own way in my place, as soon as she scented danger, she sent for her son, whimpered before him, and without delay, decamped home.

The patient was many years ago under the care of Weir Mitchell who sent her to me as a last resort. Dr. Weir Mitchell characterized the patient as an “American humbug.” As a matter of fact, the patient herself is really convinced that she is on the verge of death, and is in terrible agony of her fears of disease, fears which make her quest for health a matter of life and death. She is not conscious of the fact that she is obsessed by the impulse of self-preservation with its accompanying fear instinct. The patient has become obsessed by parasitic egotism, the quintessence of psychopathic affections.

Many times during the day she paced the room reciting elevating passages from the Bible, from the great poets, Emerson being her favorite writer.

A man thirty-eight years old, married, highly sensitive, suffers from migraine, is irritable and restless. When about eight years old he wandered in the woods near his house. An Italian ran after him, flourishing a big knife. The boy ran away in terror. When he reached home, he dropped from exhaustion and fear. Once or twice, on account of the fear of sharp objects, he actually hurt himself when handling knives. This increased his terror and fixed his fear. The instinct of fear was still further developed and stimulated by a series of events, such as falling into a river, from which he was saved. He does not like to take baths, is afraid to enter water, especially a river, and is in terror of sharp objects, such as knives and razors.

Patient is extremely irritable, selfish. He insists on playing games which he likes much, irrespective of the pleasure of his friends and acquaintances. All he cares for is to have a good time, forget all his duties to his family. In his business he is exacting of others, although he himself is rather slovenly in his work, and slow in the performance of his obligations, but he is unreasonable with all his associates, and can not get along with them. He always insists on having his own way. Other people’s rights do not trouble him provided his rights are carefully and scrupulously observed. He always demands services from others, especially from his friends. His mind is occupied with himself, with his health, his fears, and his ailments. The interest he takes in his friends and acquaintances is how far they may serve his purposes of pleasure, game, health, and avoidance of fear of disease. Even his own family is treated in the same way. His wife and child are regarded from the personal standpoint of his own good and evil, otherwise they are totally ignored. When they interfere with him or arouse his fears he becomes impatient, angry, and furious. He claims to be the most considerate, and kindest of men, brimful of ideals and humanitarian ideas. He thinks that he can accomplish more than any one else in his circumstances. Nothing is too good for him, nothing is superior to him. As a rule things are badly conducted, he finds fault with everybody and with everything. He is persecuted by the three psychopathic furies,—fear, egotism, and ennui.