Causation and Treatment of Psychopathic Diseases

THE CAUSATION AND TREATMENT OF PSYCHOPATHIC DISEASES

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

In my Work on “The Symptomatology of Psychopathic Diseases” I pointed out the importance of the various levels of Energy in relation to a classification of nervous and mental diseases. This same doctrine of various levels of energies is also of importance in the study of the causation and treatment of psychopathic maladies. To this we must also add the Principle of Reserve Energy, developed by Professor James and by myself independently. Perhaps a review of these principles will help the student to see the matter in a clear light.

The neuron may be regarded as the reservoir of energy, nervous and mental. The various manifestations of nervous and mental activities may, therefore, be regarded as fluctuations of neuron energy. We may fully agree with Sachs who proposed to term the cell an energid. This designation holds specially true of the neuron.

The total energy of the neuron may be classified into dynamic energy, static energy, and organic energy. The various nervous and mental diseases, classified by me into psychopathies, neuropathies, organopathies, may be correlated with the flow and ebb of neuron energy, with the physiological and pathological processes that take place in the neuron in the course of its activity and reactions to the stimuli of the external and internal environment.

The various portions of neuron energy in the adjustments to the environmental conditions may be represented by the following diagram:

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 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 physiological 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 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 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 individuality against the supposedly terrible dangers that threaten 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 pathological 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 representation 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 monotony 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 excitements; he will be restless and ask for ever new amusements 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 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 pleasures and excitements to still the pangs of the fear instinct 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 reserve 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 indifference 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 stimulations 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 of 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 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 conditions 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 reason.” Mosso gives an account of his own condition during states of fatigue.

“Education, which is wont to curb our reflex movements, 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 psychopathic affection. Almost without exception psychopathic 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 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 disease 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 patients are restless, they cannot sit for a couple of minutes 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 awakening. The patients sleep restlessly; sleep does not give them recuperation, they feel even more fatigued on awakening than on going to sleep. The patients cannot 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 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 consumed. 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 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 correspondence 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 intellectual 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 physiological 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 is 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 overstepped 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 conversation. How different he was in those last years from the time I first knew him on the Alps or in the discussions 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 ofhis 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 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 getting no good from my food, though my muscular energy 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.

“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. Sometimes 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, he felt every outburst of anger as a profound humiliation.”

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 experience, 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. Whenever 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 concentration 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.

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 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 seemingly 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 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 torments 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, I went to southwestern Virginia where I had the promise of work and where I thought 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 tramping 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 11, 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 August 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 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. or the first four days I did not improve at all; in fact, 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 undertaking caused me.

“On the 18th, 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 depression, freedom from cares and anxieties, and also a general return of strength and powers. This improvement 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 different 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 of the improvement I had gained. That is, by degrees I returned to the lowered condition in which I was previous to October 18. I had fully relapsed to the condition in which I could not seem to go lower.”

After six months’ of hypnoidal treatment, disintegration 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 advertisements 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, loss of memory, lack of self-confidence, fatigue, inability to concentrate mind, weakness and lassitude, and r 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 particularly 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 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 everything, 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.

“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 subconscious 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 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. However, I didn’t think he knew anything about psycho therapy. I now wrote to the (to me eminent) psychotherapist 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 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 probably physical, and that I needed a great deal of sleep.

“I had put my whole heart and soul into psychotherapeutic 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 unbearable. 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 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.”

“I have had no illnesses, except several attacks of intestinal impaction. There is no organic trouble.

“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 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 knowledge 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.

“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 1-100 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 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 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-preservation. Social disapprobation terrorizes gregarious man. 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 established 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 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 intensify 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 the basis of many a pathological phenomenon, social and individual, we find the primitive ruling instinct of all life, the impulse of self-preservation with its accompanying fear instinct.