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CHAPTER XIII

CLINICAL CASES

            THE fear instinct may become associated with any of the bodily functions, e.g., with the sexual instinct, and may give rise to subconscious states characterized by an abnormally developed suggestibility. These conditions may in turn give rise to somopsychosis and psychoneurosis, according to the temperament, the training, and the critical, final event that forms the last link in the production of definite psychopathic symptoms. In all such cases it is not the particular organic function, whether sexual or other, that produces the psychopathic state; it is essentially the awakening of the most powerful and least controllable of all animal instincts,—the fear instinct, associated with the sense of the mysterious. Psychopathic maladies do not depend on the abnormal functioning of some one bodily organ or function, but on a general reaction common to all bodily and mental functions, viz., the fundamental primitive fear instinct which relates to life in general. The deranged functions, cardiac, respiratory, circulatory, intestinal, glandular, or sexual, fatigue, conflict, shock, are only the occasions. To regard any of these occasions as the source of psychopathic maladies is like regarding the weathercock as the cause of the wind. The fear instinct, rooted in the impulse of self-preservation, is the source of all psychopathic maladies.

            I shall adduce here a few cases which may be taken as fair examples of psychopathic cases in general:—

            N. R. Russian. Student. Age nineteen. Family history good. Patient complains of heart trouble. He has pains around the cardiac region, suffers from palpitation of the heart, and thinks he has some trouble of a serious character. A physical examination shows the patient to be in good condition. Except for rapidity and occasional irregularity of action, the heart is quite normal. An examination discloses the fact that the patient had an early training calculated to instill fears of the supernatural, fear of punishment, pain, sickness, death. The fear of committing a sin was ingrained in the patient from his very tender childhood. When about the age of nine he learned in school the habit of masturbation from his companions. Owing to religious and moral scruples, however, the habit did not get hold of him, and he stopped for several years until, when about the age of thirteen, he entered another school and came in contact with a loose set of boys, older than himself, who talked about women and thus excited his sexual passions. The habit of self-abuse continued with various intermissions for two years, when some quack literature fell into his hands. He read in quack pamphlets about the great dangers of masturbation, how it specially affected the heart, giving rise to serious and fatal cardiac troubles. The boy became alarmed; he began to brood over his condition, to listen to his heart, and became convinced that he really suffered from a very serious heart defect induced by his habit of self-abuse. After some hesitation he decided to consult a heart specialist, who told him that he did have some heart trouble of a nervous character. This frightened the patient, as he thought that the doctor did not wish to inform him of the gravity of his disease. He next went to another physician, who, playing on his fear, told him that his trouble was really serious and that he was going to cure it. This frightened the patient thoroughly, and confirmed him in his fears. The dread of heart disease became fixed. For a few years he kept on suffering from heart trouble with cardiac pains and palpitation,—he became a typical psychosomatic patient. It was the fear instinct—at first aroused by religious and moral fears concerning the sexual function, and then fixed on the heart in an intensified way by the reading of quack literature, and heightened and cultivated by medical examination and unscrupulous medical treatment,—that figured most prominently in this case.

            C. L. Chemist. American. Aged forty-nine. Family history good. Catholic, very religious. Great fear of sin, fear of punishment, fear of disease, fear of suffering, fear of death and damnation. About the age of nine the patient had an attack of malaria, from which he suffered for about four years. This developed a fear of disease and death. When about the age of fifteen he learned from boys in school about sexual relations, and had many talks on the subject, which excited him so that he began to masturbate. The fear of the sin committed terrified him. The first night he masturbated he suffered greatly. After the act the fear was so intense that he prayed the whole night through. A week later he masturbated again, and again passed the rest of the night in prayer. He then read some quack pamphlets and especially quack advertisements. He began to fear the dangerous consequences of his self-abuse. He stopped masturbation, but the fear of disease grew upon him. He was especially alarmed on the nights when he happened to have an involuntary emission; he feared the oozing away of his vitality,—a dangerous consequence of which the quack advertisements particularly warned him. This fear lasted until the age of twenty-five. The state of constant terror affected his appetite and digestion. He went to a physician, who told him, after a careful examination, that he was suffering from gastritis, and a very dangerous form of it; that he was going to be sick in bed for not less than two years, and that he was going to be an invalid the rest of his life. This unfavorable prognosis was duly fulfilled; the patient went to bed, was sick for a couple of years, and has become an invalid,—a confirmed psychosomatic. The fear instinct became cultivated, fixed and centered, by continuous brooding over the function of digestion.

            A lady aged thirty-seven. From early childhood fear of sickness and death. When about fifteen she suffered from gastric and intestinal troubles; had severe attacks of dysentery. About the same time she had a shock, her little brother, age two, to whom she was much attached, died of some intestinal affection. This aroused fears in regard to herself. The patient was in bed for two months. It was then discovered that she had a slight lateral curvature of the spine. This accentuated the fear of disease and death, and increased the brooding. A few years later the patient suffered from a severe attack of typhoid fever. After convalescence she continued to brood, fearing that she would become an invalid. The fear of death kept on growing and finally gained mastery over her. As the patient puts it: “I have such an unmitigated horror of death. If anyone I have ever seen, dies, I do not sleep for weeks. I am afraid, though my reason tells me how absurd it is.”

            Again, I have had cases in which the fear instinct became attached to the hair. Thus, on one young married lady, aged twenty-five, the hair began to fall out. She began to worry over it and to fear that her beautiful head of hair, of which she had been proud, would be ruined, and that she would become bald. She was in agony over the condition of her hair, and finally gave up all social functions, all pleasures and interests, in life. Like Absalom, she was entangled by the fear instinct in the tresses of her hair.

            There are cases, too, somewhat less pathetic. The fear instinct, like the sausage in the nursery tale, may become attached even to the nose. Thus, one of my patients, a girl of twenty-two, after a series of attacks of “la grippe,” began to worry and fear the depredations of sickness on her beauty. Her attention finally became centered on the irregularities of her nose, on account of coryza. She suffered a good deal in her efforts to correct the supposed nasal defects and then decided to go to a specialist, who took advantage of her ignorance and fear, and performed a slight operation to improve the beauty of the nose. As fate would have it, he apparently infected her during the operation, pimples breaking out all over her face. The fear became a terror, a panic. The fear instinct obsessed her through the intermediation of her nose.

            Mrs. J. A., fifty-eight. Loss of strength in left arm and leg, set in three years ago. Fears great exhaustion, faints. Was not a strong child. Had pneumonia. Married at twenty-four; had one boy; had fear of hemorrhage. Had fear her boy was dying from fractured skull,—beam fell on his head at the age of seven. Patient was in an accident with runaway horse. Patient took care of husband when he suffered from typhoid fever.

            M. C. G., thirty-eight. Liquor dealer. Brother died of heart trouble. Sister has heart trouble. Mother died of pneumonia, when age forty. Nervous temperament since childhood. Spelling troubled him; had difficulty of going into business on account of spelling; too sensitive about it; wants everything in good order, “apple-pie order.” Rarely suffers from headache. Suffers from sleeplessness at present. Has been brooding over fear of poor spelling, which has made him lose confidence in himself. Excessive smoking; after his wife’s death he had accident, fell down unconscious, and fancied knee broken. He has fears that business is going to the dogs; that he is unable to pay his bills; that his second wife may marry after he dies; that people criticise him too much. He has intense fear that some terrible misfortune may happen to him or to his children, or to any of his family. He suffers from fear of incapacity; from fear of fear; constantly asks for “confidence, confidence.”

            Mr. R. Age thirty-six. Married. Professor of mechanical engineering. As a child was timid, full of fears of dark, of sickness, of being dead, of being punished and ill treated. In 1904 stayed in a hotel with tubercular patients. For some time has been worrying over his poor health and worn down condition. That night he became afraid of the seriousness of his present state, and possibly of his having tubercular trouble. He became afraid that his wife might have also suffered from tuberculosis, and may possibly have a serious attack of it. His wife has been in rather precarious health for some time. As a student he attended to a friend of his who suffered from tuberculosis. Recently a friend discussed with him about contagion. The friend was apparently affected with the phobia of contagion,—at the least occasion or suspicion the latter used antiseptics. This fear of tuberculosis has taken possession of the patient, and makes it difficult for him to carry on his teaching,—his mind is full of fear of disease and possible contagion.

            P. G. B. Age seventeen. Had appendicitis about age fourteen. Suffers colds, and coughs occasionally. Dreams little. Heart irregular; lungs good. Patellar reflex lively.

            Patient feels odd, automatic, things look far, feels faint. He has fear of remaining alone. Heart troubles him a little; has fear of going in car. He is afraid something will happen to him. Thinks he has lost self-control. He is afraid of himself, and afraid of seeing people. Thinks something terrible may happen to him. Patient has few dreams; becomes exhausted in sleep. Everything looks like nonsense, not on the earth; has attacks of fainting and fear after which he feels somewhat better; is afraid of everything. Patient has attacks of dizziness with agoraphobia. He has a fear of doing things, the mere necessity of doing causes fear. Patient was timid, full of fears from his very childhood.

            S. S., thirty-six. Became frightened because he saw a man who had committed suicide. Patient of timid nature, nervous. The same day when he saw the man he heard a voice telling him to commit suicide. Mother had twice an attack of what he called “craziness.” She received a letter that her brother died, the fright brought about an attack. His sister had attack of melancholia.

            Patient kept on thinking about the man who committed suicide. The same night he had the dream that someone told him to commit suicide. He is afraid to go into a barber-shop.

            E. A., twenty-eight, not married, silk worker. Ner-vous; father and mother well.

            As a child was sensitive, timid; headaches ten years old, eyes then corrected by glasses; not much better; began to work when about seventeen; worries about his fortune; did not sleep; feels restless; face drawn; has taken all kinds of medicines; never satisfied with anything; sleeps well; appetite good; mentally he claims he is in hell, feels as if he were dead. Masturbated little; lived a pure life.

            Thinks too much about himself; wanted to be a singer; lost his voice by thinking of himself. “I could begin to cry and weep about myself.”

            Mr. H. W. Married. Age twenty-six. Patient thinks he has consumption. When walking down street, trembles and shakes, feels like fainting away. Cannot go alone, must go with some one. Afraid to go insane or drop dead. The first attack five years ago lasted about seven months. Thought he had consumption before the attack, because of profuse sweat, he was feverish. He used to watch over his consumptive brother, thinks about his health, sleeps restlessly. This worry about consumption began when he was about sixteen or seventeen years old; used to suffer from shaking spells of fear. Things appear to him unreal. Patient reads about people committing suicide, he is afraid of losing his mind. Dreams about sickness and death, had bad nightmares. Attention is poor.

            He told me that he began to masturbate when about eleven and that it continued for four years. He was afraid that it would undermine his powers, energies. Fear instinct associated with sex.

            Mrs. M. F., age thirty-eight. Patient suffers from digestive disturbances. “Never had any luck”; patient complains of “liver disorder”; headaches and pain during menstruation; the feeling of unreality becomes more intense during menstruation; does not suffer from bad dreams. Suffers from severe headaches, from feeling of unreality. Patient has fear of unreality, afraid of it. She is afraid of losing her mind; has a kind of dizzy sensation in head; she is afraid of going on the street, because she is afraid of an attack of “epilepsy or apoplexy.” Father had a stroke of paralysis, and mother had a stroke of apoplexy. Both parents were paralyzed, and patient attended on them. Patient suffers from fear fatigue. The whole state is one of intense worry about herself, and about her health. Intense pathophobia.

            M. Jeff., twenty-five. Russian Jew. Florist. He always was very nervous, timid. A year ago contracted gonorrhoea. Got greatly frightened. Then he had nose-bleed. He bought books, read on the subject, became terrorized. He was afraid of falling to pieces. He went to a physician, who gave some medicine; he inhaled the medicine which hurt him. Began to cry, he was falling to pieces. He thought he was burning, his brain was on fire. He is now in constant terror of ruin. Fears that his body will rot away. This fear he contracted from hearsay about people infected with venereal diseases. The fear was strongly impressed on the patient in his early youth.

            Mr. H. L., twenty-eight. Three years ago began to complain of heart trouble, body trouble; suffers from agoraphobia; impulsive ideas to do things. Insistent ideas: What is mind? What is body? Why did I say this? Questions himself constantly. Tries to remember things; he cannot remember. Suffers from anxiety and fear. Complains of visual troubles. Suffers from moral and religious fears; full of fear of everything. Thinks of eyes, mouth, tongue; wants to know cause of every movement of the body. Listening to breathing. Everything gives rise to thoughts full of fear and anxiety. Picks up things, forms new fears; has an overwhelming fear of death. Drank whiskey for stimulation; fear tortures him.

            When he spits he wants to know why; when he walks he wants to step over pieces of paper; picks up papers. When habit is broken he gets scared. He is scared all the time. Keeps on counting. Whatever he sees he wants to touch. Everything a person talks about enters into his mind and excites fear. The fear instinct and the impulse of self-preservation have obtained an overwhelming control over the patient’s mind.

            Mr. M. F., twenty-four. (Spanish, Porto Rico.) When fourteen had attack of fear, sudden fright of devil. The fear lasted a few minutes. Three years ago had a similar attack, fear of devil with fright of insanity. Has attack and then has a fear of committing suicide. The actual attack lasts a few minutes, but patient keeps on worrying a long time afterwards. Has fear of eternal damnation. The attack comes first, and then fear of committing suicide and being damned forever. Dreams, nightmares, leave emotional aftereffects during the day and waking life. Education religious. Patient lived in insane asylum since early childhood.

            Mrs. A. F., age forty-three. Husband has been drinking more than usual, has been very unpleasant; she became nervous and began to worry about it. Worries about herself; is afraid of going insane, is afraid will never get out of it. She was kept in bed for two or three months. Got some drugs. She feels that a stream is going down her back. Heart in good condition. Has an idea that her brain had given away. Complains of intense fear. When put into hypnoidal state she became very much frightened; intense fear since childhood. Patient is afraid, does not know of what.

            Mr. W., age sixty-one. Neurasthenia, internal troubles, his own diagnosis—catarrh of the stomach, lost forty pounds. Suffers from hyperaesthesia of the intestinal tract; feels depression; worries about every thing. Fears he is going to be ruined, afraid to go out, he might die. Has fear dreams, reproduction of waking fears; cannot concentrate his attention. At daytime obsessed with fear of death. When young was very nervous, he had his mind upon sickness and death. Has also fears about various bodily organs, and about his children. Afraid he may take the wrong train or the wrong trolley.

            Mr. D. S. When a child of five had scarlet fever; no other diseases. Began to have headaches some two years ago; troubles of indigestion began about ten years ago; bad feelings in the throat and heart. Troubles began after father's death which preyed on his mind for years. Began to feel the present symptoms about 3½ years ago, in New York, when he fainted and was afraid of dying. Since that time he has attacks of fear, has feeling of anxiety. When he gets up he feels as if sleep did not refresh him. Has dreams about his father. His sleep is disturbed.

            In hypnotic state cried out: “I am afraid I am getting crazy.” Gradually got him out of this condition and he began to feel well, though he complained of sensation of lightness in the head.

            Ed. H.  Age 43, lawyer. Was irritable in childhood, used to kick and scream; as a child had to have his own way. Had idea that he was left-handed (though he was not); had “stubborn” ideas. Has fears about drugs. When riding bicycle was afraid about falling; the same about horses when he fell down. Fears are formed whenever accident occurs. When older, formed apprehension about many matters. Worried over his business. Patient began to speculate on the exchange and lost, became nervous, and did not improve since.

            Mrs. L. A., age forty-two, married. Two children. Had fears of paralysis. Was very suggestible in regard to fear. Sleep was good, menstruated about age of fourteen.

            Was afraid to remain alone. Became interested in Christian Science. Felt revulsion at A’s proposal; cannot account for it. Patient thinks husband is concealing something from her. Suffered agony every day during first pregnancy; imagined husband behind prison bars. “This frightful barrier has always been between them.” Patient suffered from insomnia and from extreme nervousness. There was a woman who influenced her in regard to marriage. Husband drinks and to excess. Read about a young woman who committed suicide. Intense fear state.

            Miss A. A. Age thirty-seven. At sixteen fell down from horse, has been ailing since; then had an operation for internal tumor. In a sanitarium for four years; sunstroke, dizziness, fear (agoraphobia), and clausterophobia.        Heart good, normal; reflexes normal; anemia and insomnia.

            Indigestion, constipation. Has been taking bromides; dizziness. Pathophobia; fears from early childhood.

            Mrs. M. C., aged thirty-two years, American. Family history good; well developed physically and mentally. A year before the present trouble set in, patient suffered from a severe attack of the grippe. Menstruation, which was before painless and normal in amount, became painful and scanty, accompanied by headaches, indisposition, irritability, crying spells, and backache which lasted long after the menstrual period was over. There was a slight, somewhat thick, leucorrheal discharge. The family physician ascribed the symptoms to endometritis, mainly cervical, and treated her with absolute rest, fomentations injections, scarification and dilatation of the cervix, and finally curetted the uterus. As the patient grew worse under the treatment, she was taken to a gynecologist, who, after an examination, declared the whole trouble to be due to retroflexion of the uterus, and suggested an operation for reduction. The operation was duly performed, with the result that the nervous symptoms became intensified and the attacks increased in violence and duration. The turn of the nerve specialist came next. Hysteria, neurasthenia, and the more fashionable “psychasthenia” have been diagnosed by various neurologists. A year of psychoanalysis made of the patient a complete wreck, with depression, introspection, and morbid self-analysis. Patient was put by neurologist under Weir Mitchell’s treatment.

            When the patient came under my care, she was in mental agonies, a complete wreck. A study of the case traced the fear instinct to experiences of early childhood, fears accentuated and developed into morbid states by the deleterious tendencies of the treatment, giving rise to a somatopsychosis.

            A lady, age fifty-nine, suffered from kynophobia. When about the age of twenty-nine she was bitten by a dog; since then she was afraid of hydrophobia. She kept on reading in the papers about cases of hydrophobia until the fear became developed to an extraordinary degree and became fixed and uncontrollable. According to the principles of evolution of psychopathic states, the fear kept on extending. The fear psychosis included all objects that might possibly carry the germ of hydrophobia. The neurosis became a mysophobia.

            As in all other cases of psychopathic states the psychosis was traced to the fear instinct the germ of which was laid in the patient's early history. The patient was a very timid child and was afraid of strange animals. In the village where she lived there were a few cases of hydrophobia which impressed her when a child. This germ was in later life developed by thirty years’ cultivation.

            A well-known physiologist reports to me that his little child up to three and a half was not afraid of anything, not even of the dark. At that age she was taken to the country and there associated with servant girls who were afraid of the dark and especially of storms and thunders. One of the girls who was Nova Scotian and extremely superstitious, was in terror of thunder. Since that time the fear of darkness and especially the fear of thunder took possession of the little child by imitation and suggestion. In fact, the girl who takes care of the child is also afraid of the thunder, and this is communicated to the child. There is absolutely no other cause to the fear as the parents had the child under their direct and strict observation and care.

            Similarly I have known a number of cases where people had accidents, thunderstorms, the lightning striking close to them, and who have become afraid of thunderstorms the rest of their life. The interesting point about it is the fact that the people who happened to live with them in the same house, and who before have not been afraid of lightning and thunder, have acquired the fear and were in terror of storms, lightning, and thunder.

            Psychopathic symptom complexes I observed in children whose early training was favorable to the awakening and development of the fear instinct. In children affected with fear of animals I traced the fear psychosis to the parents who were afraid of animals, on account of actual traumas in their life history, the child being influenced by imitation, by suggestion, often subconscious, by the behavior of the parents in the presence of animals. Such children are predisposed to recurrent psychopathic states.

            In all such cases the etiology is easy to find, if the patient is carefully examined. In many cases the fear instinct with its symptom complex is associated with external objects, giving rise to the so-called phobias. Instead, however, of being associated with external objects, the fear instinct is frequently associated with somatic functions (pathophobia) or with mental activities (phrenophobia).

            Man, age forty-seven; actor; family neurotic. Patient suffered from anorexia, indigestion, choking, vomiting, gagging, eructation, gastralgia, and occasional pains in the limbs. He led a rather gay and irregular life up to the age of thirty-two, when he had syphilis, for which he was under treatment for two years. This scared him, because he had the opportunity to see the consequences of syphilis in many of his friends. He had been under continual fear of the possibility of development of parasyphilitic diseases. Seven years ago, at the age of forty, he had to watch at the bedside of an intimate friend, who had been suffering from severe gastric crises of tabes dorsalis. After one specially exhausting night of vigil, worry, and fear, he went to bed for a short nap and woke up with the idea of general paresis and intense fear. Since that time he began to suffer from symptoms of tabes with fear of general paresis.

            Patient had been a very imaginative child; had his fear instinct cultivated from early childhood by stories of frights, scares, and horrible accidents. When ten years old, grandfather gave him Faust to read. Since then patient was troubled with the fear of selling his soul to Satan. Was very religious in his childhood, prayed much, was possessed by the fear of committing sins. “It has now all come back,” he complained. A great number of fears could be traced to his early childhood. The somatic symptoms were the manifestations of association of experiences of parasyphilitic diseases, based on the pathological state of the fear instinct, a case of pathophobia, a somatopsychosis.

            H. M., age twenty-seven, male, Canadian. Family history good; looked pale, anemic, and frail; very intelligent, sensitive, restless, and had a tendency to worry. About a year ago, he began to feel depressed, to worry about his health; thought he suffered from tuberculosis. His physician assured him that nothing was the matter, but he had uncontrollable fear of consumption, and the fear kept on recurring. Up to the age of nineteen he was perfectly well. He was then laid up with a sore knee for a few weeks. He had time enough to brood over the knee and read some literature on the subject. He thought it was tuberculosis and worried very much. The knee, however, got well, and gradually he forgot all about it, although the fear of tuberculosis often made him feel uncomfortable, and the fear of “water in the knee” used to flash through his mind, to pass away the next moment. A year ago, however, he happened to lose his work, became despondent, began to worry and to brood over his financial troubles, slept restlessly, suffered from anorexia, and began to lose flesh. The fear of the knee and the fear of tuberculosis got possession of him. He could not rid himself of the fear of tuberculosis. If in the clinic, the physician assured him that he was all right, he felt better for a couple of hours; but often it did not last even as long as that. The least pain, cough, heart beat, a feeling of chill or heat, and the like, brought the fear of tuberculosis back to his mind with renewed energy. He was obsessed by the fear of tuberculosis and felt he was doomed to certain death, a psychosomatic pathophobia.

            Man, age forty-three, suffered from palpitation of the heart, fainted easily, especially on physical examination by physician, or at the beginning of medical treatment. He suffered from indigestion for which he had been under treatment for a number of years by physicians who gave him medicine for his bowels, and also from time to time kept on washing his stomach. He had a great fear of becoming a victim of cardiac troubles, especially of some unknown, terrible, valvular affection. When under my care he kept on asking to be taken to heart and stomach specialists to be examined, and have some radical operation performed. Frequently under the influence of the fear states and obsession of heart and stomach trouble, especially the heart, he would collapse suddenly, be unable to walk, and be afraid that he suffered from some paralysis.

            On examination, the patient revealed a history full of various traumas which, from his very childhood until he came under my care, helped to bring about his psychopathic condition, and developed the fear instinct to an extraordinary degree.

            Physicians had the lion’s share in this special case by their rearing of the fear instinct, and by their favoring the patient’s phobias by their examinations, by their prescriptions, and by the diet and treatment. The patient was in such a panic that he kept on taking his pulse at the least occasion, was feeling his heart, stomach, and intestines at every opportunity. The hypertrophied growth of the fear instinct had invaded and dominated the patient’s whole personality, developed a typical psychosomatic pathophobia with its recurrent states.

            In the Trudi for 1913 of the Imperial University of Moscow, Russia, Doctor Ribakov makes an extensive study of a series of cases of psychopathic asthma and arrives at a conclusion similar to my own, although he is, no doubt, unaware of my work and publications on the same subject. He comes to the same conclusion with me that the etiology of neurosis is to be found in fear which alone forms the basis of psychopathic neurosis. All other factors, social, professional, sexual, religious, are only occasions of the disease. It is fear and the morbid impulse of self-preservation that form the pathology of the psychopathic symptom complex.

            A young lady was afflicted with ornithophobia, fear of birds, fear of chickens. The sight of a chicken set her into a panic. The patient is very timid, and this timidity can be traced to her early childhood. When at the age of six years, a playmate threw at her in the dark a live chicken. The child was terribly frightened, screamed, and fainted. The mother used to tell her fairy stories full of adventures, of ghosts, of dragons, and of monsters. This prepared the patient to react violently to the sudden attack made by the flight, struggling, and feel of the chicken in the dark. Since that time patient has formed an uncontrollable fear of live birds.

            Another patient of mine, a lady of forty-nine years, single, suffered from potamophobia, a fear of going into rivers, or into the ocean. When about seven years old she was thrown into water by one of her elder sisters. She was nearly drowned, and was half dead with fear when rescued. Since then she has been in terror of water, or rather of rivers and oceans. Several times she made conscious efforts to get rid of the fear, but the attempts were unsuccessful. In fact, the more she was forced or forced herself consciously to get into water, the greater was the fear. This fear became all the more intensified, when some of her intimate friends were drowned in a boat. This fixed the fear which became uncontrollable.

            A man of thirty-five years was afraid of going out in the dark. This was traced by me to early associations of fears of the dark, to superstitious beliefs in ghosts and spirits, cultivated in the patient’s early childhood. He was afraid to remain alone in the dark or to go down at night into cellars or other secluded places. This fear was unfortunately still more intensified by an accident. At the age of twenty-seven, one night when returning late from a visit, he was assaulted from behind by foot-pads. This accident fixed the fear of darkness.

            A lady of sixty-seven years, with pronounced arteriosclerosis, had an attack of hemiplegia of the left side. She suffered from motor aphasia, but did not lose consciousness. The paralysis cleared up in a few days, but the sudden attack demoralized her. Since that time she is in terror of another attack. She watches for symptoms, and the least sensation of faintness throws her into a panic. The patient is the wife of a general and was in China during the Boxer riots, in the Spanish American war, in the Philippines and other military engagements. The fear instinct was cultivated in her by all such conditions. In her early childhood there were fears and frights of child character, enough to arouse the fear instinct which was gradually developed and cultivated by the circumstances of life and by worries in the course of the various wars in which she participated or of which she was a witness. Finally the fear culminated by the stroke of paralysis.

            Similarly, I had other patients who suffered from tuberculosis, from asthma, from heart trouble, and from all kinds of intestinal affections which specially abound in psychopathic cases. All such cases can be clearly traced to various somatic symptoms, based on the fear instinct. The etiology is fear, the arousal and development of the fear instinct in respect to the special symptom complex.

            A patient, age twenty-five, suffered from agoraphobia at various intervals. As a child of nine years, he was attacked by rough boys. He freed himself and ran in great terror. The boys threatened him with another “licking” when he appeared again on the street. He was afraid to go out for several weeks. The parents forced him to go and buy some things. Living in a rough neighborhood, on account of his father’s reduced circumstances, he has been many times subjected to knocks, blows, and assaults by rough boys, until the fear of the open street became fixed into the well-known form of agoraphobia.

            Another case, that of a lady of thirty-eight years, married, suffers from ailurophobia, or fear of cats. This can be traced to the patient’s early childhood. When she was a child, her brothers and sisters went through attacks of diphtheria, which were ascribed to infection, caused or transmitted by cats. The patient was specially impressed with the danger from cats. Under such training and suggestion given in early childhood, the patient gradually formed a fear of cats. This fear was still more intensified and became a panic when she was put into a dark room and a cat was let loose on the poor victim by her mischievous companions who knew of the patient’s fear. When the patient had children of her own, she was still more affected by the fear of cats, on account of the subconscious and conscious fear of infection that may have been transmitted by cats to her children.

            P. J. Male. Age thirty-five. Patient is run down, much under weight; digestion poor; suffers from nausea and vomiting. Occasionally suffers from headaches. He is suspicious; afraid he may become insane. Anything in the remotest way associated with insanity is apt to excite and depress him. He is successful in his profession as lawyer; has been elected to responsible offices. He is well connected socially and politically. The present malady he keeps well under control so that only his wife has any inkling of his illness.

            The central fear is hematophobia, a fear of blood. This hematophobia kept on growing and spreading until it now occupies his whole field of mental vision. The hematophobia kept on extending, involving more and more remote associations. Anything that may possibly remind the patient of blood is an object of intense fear and anxiety, accompanied with intense suffering, nausea, vomiting, paleness, fainting, and extreme weakness of the whole body. An attack or a paroxysm of fear is often followed by a couple of hours of deep sleep. After such a sleep the patient usually feels well. The attack simulates larval or psychic epilepsy.

            Patient’s parents suffered from some form of hematophobia which seemed to have strongly impressed the children. Patient's brother was affected with similar phobia though not so intense in character.

            When about the age of six, patient remembers that his brother cut his finger. The bleeding greatly frightened the parents and the two boys. The bleeding finger was put in something that smelt like iodoform. Since then that smell is hateful to the patient. Patient cannot trace his fear to anything before the age of six, but he thinks that the attacks may date to still earlier experiences. Since that time of the bleeding finger patient can trace clearly his attacks which became more frequent, more persistent, and more uncontrollable. Anything reminding of blood in the remotest way sets the patient in a paroxysm of fear which he has great difficulty to conceal. When he takes a shave he must be extremely careful not to cut himself. The sight of a drop of blood causes him to faint. He cannot read physiology, anatomy, or any description of blood or circulation of blood. The patient is in terror of some vague evil. The fear spreads and grows to an extraordinary degree. He is afraid to address a jury,—something awful, some evil may happen.

            When I wanted to put my stethoscope on his chest, he became scared. When I tried to take his blood pressure, he became frightened, objected strongly, then agreed. The examination was followed by a typical attack characterized by paleness, nausea, vomiting, fainting, a paroxysm of wild fear. The attack was followed by an hour’s sleep.

            Patient is afraid that this hematophobia may prove hereditary. He claimed it was in the members of his family, and that he observed it in his little boy of three.

            If the investigating psychopathologist digs deep down, by the various psychognostic methods at his disposal, into the patient’s consciousness and subconsciousness, so as to reach the very roots of the symptom complex of psychopathic affections, he invariably finds a morbid condition of the impulse of self-preservation and a diseased state of an intensified, exaggerated reaction, central and efferent, of the fundamental fear instinct, the psychogenesis dating to events and experiences of early childhood.

            The practical physician, to whom treatment is no less important than causation, psychognosis, and diagnosis of psychopathic maladies, may be interested to learn that almost all the cases of the type reported here have been treated by me by hypnoidization, described in “Symptomatology,” and also further on in this volume. Some of the cases were also treated by other methods described in a further chapter in this work.

            Most of the patients, about seventy-five per cent, were cured. About twenty per cent of the cases greatly improved. The remainder, about five per cent, did not respond, on account of the short time of the treatment.

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