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THE causation of all psychopathic diseases can be referred to one fundamental instinct, the instinct of fear with its concomitant manifestation, the feeling of anxiety. Fear is one of the most primitive instincts of animal life. As Kipling puts it, "Fear walks up and down the jungle by day and by night." Our life is so well guarded by the protective agencies of civilization that we hardly realize the extent, depth, and overwhelming effect of the emotion of fear. Fear is rooted down deep in the very organization of animal existence, it takes its root in what is the very essence of life,―the instinct of self-preservation. Primus in orbe Deus fecit timor. "We lead,” says Galton, “for the most part such an easy and carpeted existence, screened from the stern realities of life and death, that many of us are impelled to draw aside the curtain now and then and gaze for a while behind it.”1 “The progress from brute to man," says James, "is characterized by nothing so much as by the decrease in frequency of proper occasion for fear. In civilized life in particular it has at last become possible for large numbers of people to pass from the cradle to the grave without ever having had a pang of genuine fear. Many of us need an attack of mental disease to teach us the meaning of the word. Hence the possibility of so much blindly optimistic philosophy and religion. The atrocities of life become ‘like a tale of little meaning though the words are strong'; we doubt if anything like us ever really was within the tiger's jaws, and conclude that the horrors we hear of are but a sort of painted tapestry for the chambers in which we lie so comfortably at peace with ourselves and the world. Be this as it may, fear is a genuine instinct and one of the earliest shown by the human child."2 Similarly Sully says: "Fear appears early in the life of the child as it seems to appear low down in the zoölogical scale. Fear probably appears in the vague form, (i.e., without any distinct representation of a particular kind of evil) in connection with presentation e.g., of strange animals, which have contracted no associations from individual experiences and which derive their emotive force from special inherited associations. Experience is, however, the chief determining factor in the evocation of fear.”3 "Fear," says Darwin, "is the most depressing of all emotions; and it soon induces utter, helpless prostration, as if in consequence of or in association with the most violent and prolonged attempts to escape from the danger, though no such attempts have actually been made.” The fear of coming evil, especially if it is unknown and mysterious, gives rise to the feeling of anxiety. “If we expect to suffer," says Darwin, "we are anxious.” Similarly James regards anxiety, especially the precordial anxiety, as morbid fear. "The anxious condition of mind,” says Bain, "is a sort of diffused terror." Fear often expresses itself through cardiac and circulatory affections giving rise to the feeling of anxiety. Anxiety is nothing else but the working of the instinct of fear. In most men the instinct of fear is controlled, moderated, regulated, and inhibited from very childhood education and by the whole organization of civilized social life. There are, however, cases when the instinct of fear is not moderated by education and civilization, when the instinct of fear is aroused by some particular incidents or by particular objects and states. In such cases, if the instinct has not become controlled and inhibited, fear becomes associated with definite situations, giving rise to morbid fear and anxiety and resulting in the mental diseases known as Psychopathies in general and psychoneuroses in particular. In all such cases we can find the cultivation of the instinct of fear in early childhood. Superstitions, and especially the early cultivation of religion, with its fear of the Lord and of unknown mysterious agencies, are especially potent in the development of the instinct of fear. Even the early cultivation of morality and conscientiousness, with their fears of right and wrong, often causes psychoneurotic states in later life. What we find on examination of the psychogenesis of psychopathic cases, and especially of psychoneurotic cases, is the presence of the fear instinct which may become associated with some important interest of life. This interest may be physical in regard to the bodily functions, or the interest may be sexual, social, it may be one of ambition in life, or it may be of a general character referring to the loss of personality or even to the loss of mind. The fear instinct may become highly particularized and may become associated with indifferent objects giving rise to the various phobias, such as astraphobia, agoraphobia, clausterophobia, crythtrophobia, acmephobia, and an infinite number of other phobias, according to the number of objects with which the fear instinct becomes associated. Of course, objects and situations which are in themselves dangerous, or are apt to bring about pain and misery to the individual, such as strange animals, unfamiliar conditions, or diseases, such as epidemics, or any other physical and mental maladies, are apt to be associated with and arouse the fear instinct. This, however, is not always the case. Objects otherwise indifferent and even pleasant may by association arouse the fear instinct and give rise to morbid states. James makes an attempt to enumerate the various objects of fear in men, and especially in children. Among these he regards "strange animals, strange men, strange places, such as the fear of the sea in children who have not seen the sea before. The great source of terror to infancy is solitude. Black things, and especially dark places, holes, caverns, etc., arouse a peculiarly gruesome fear. This fear, as well as that of solitude, of being ‘lost,’ are explained after a fashion by ancestral experience. High places cause a fear of a peculiarly sickening sort. Fear of the supernatural is one variety of fear. This horror is probably explicable as the result of a combination of simple horrors. To bring the ghostly terror to its maximum many unusual elements of the dreadful must combine, such as loneliness, darkness, moving figures, inexplicable sounds, especially of a dismal character, moving figures half discerned, or if discerned, of dreadful aspect and a vertiginous baffling of expectation. This last element, which is intellectual, is very important. It produces a strange emotional curdle in our blood to see a process with which we are familiar deliberately taking an unwonted course. Any one's heart would stop beating if he perceived his chair sliding unassisted across the floor. The lower animals appear to be sensitive to the mysteriously exceptional, as well as ourselves. My friend, W. K. Brooks, of the Johns Hopkins University, told me of his large and noble dog being frightened into a sort of epileptic fit by a thread which the dog did not see. Darwin and Romanes have given similar experiences. The idea of the supernatural involves that the usual should be set at naught. In the witch and hobgoblin, other supernatural elements, still of fear, are brought in―caverns, slime and ooze, vermin, corpses, and the like. A human corpse seems normally to produce an instinctive dread which is no doubt somewhat due to its mysteriousness, and which familiarity rapidly dispels.''4 The fear of the unknown, of the unfamiliar, of the mysterious is quite common with children, with savages, and barbaric tribes. We know how in the case of the ancient nations omens, whether religious or meteorological, such as storms, thunders, lightnings, comets, and eclipses, were regarded with great terror. Armies used to throw away their arms and run panic-stricken at the occasion of the appearance of a comet or of an eclipse. Even in the civilized times of the Athenian republic there was a terror of eclipses and of other unfamiliar natural phenomena. Thucydides, in his history of the Peloponnesian wars, puts the appearance of comets among national disasters. The fear of coming unknown, unfamiliar evil is especially a source of anxiety to the young or untrained, uncultivated minds. This fear of some unknown evil befalling a person may become a source of great fear and anxiety when developed in early childhood. This fear of strangeness, of unfamiliarity, a feeling of being lost, developed in early childhood may in unassociated and thus give rise to a state of vague fear. Different forms of epilepsy are often associated with the fear instinct. The instinct, however, may through experience, through some trauma, find for itself an object, and become associated with it and thus give rise to the various forms of psychopathic diseases. "Anxiety, fear, horror," says Mosso, "will twine themselves perpetually around the memory, like deadly ivy choking the light of reason.”5 The fear instinct is at the basis of all psychopathic diseases. All the symptoms in their infinite variety are so many different manifestations of the one fundamental fear instinct. The inner conflict and introspection characteristic of psychopathic troubles, and especially of psychoneurosis, are pathological, solely because of their association with the fear instinct. Mental conflict and introspection never give rise to a mental malady. They are rather favorable to a speculative and philosophical turn of mind. When, however, introspection and mental conflict are associated with the fear instinct, then the result is a psychopathic malady. In the same way a physical sickness in itself, or the thought of suffering, physical or mental, does not give rise to a psychopathic affection. It is only when the sickness, or the thought of disease, becomes associated with the fear instinct, it is only then that a psychopathic malady arises. The sole source of psychopathic affections is the fear instinct, a development of which in early childhood predisposes to all forms of functional psychosis and neurosis.
II There is another factor which helps to arouse the fear instinct, and thus plays an important rôle in the causation of psychopathic maladies. This factor is a narrow, suggestible personal life. In my work, "The Psychology of Suggestion," I proved by a series of experiments that the conditions of suggestibility are: Fixation of attention, monotony, limitation of voluntary movements, limitation of the field of consciousness, inhibition. I have shown that these conditions are favorable to disaggregation of consciousness. I have pointed out that a disaggregation of consciousness with an inhibition of the controlling, waking consciousness is one of the important conditions in the causation of subconscious states with their accompanying abnormal suggestibility. In other words, the inhibition of the personal self, or even the limitation of the personal self, helps the formation of dissociations which constitute the soil of all psychopathic diseases. When the person therefore, is limited in his interests, is narrow in his range of knowledge, is ignorant and superstitious, and his critical personal self is embryonic and undeveloped, the predisposition to mental disaggregation is pronounced. The fear instinct has full sway in the production of psychopathic states. With the limitation and inhibition of the critical personal self, with the limitation and narrowness of personal life interests, there goes an increase of the sense of unknown, and the mysterious, cultivated by religion and superstition, with the baneful consequence of the development of the fear instinct,―the cause of psychopathic affections. In the embryonic personality of' the child as well as in the undeveloped or narrowed individuality of the adult the sense of the strange, of the unknown, and the mysterious is specially apt to arouse the fear instinct. In fact, the unfamiliar arouses the fear instinct even in the highly organized mind. "Any new uncertainty," says Bain, "is especially the cause of terror. We become habituated to a frequent danger, and realize the full force of apprehension only when the evil is previously unknown.” Such are the terrors caused by epidemics, the apprehensions from an unexperienced illness, the feeling of a recruit under fire." "The mental system in infancy is highly susceptible not merely to pain, but, to shocks and surprises. Any great excitement has a perturbing effect allied to fear. After the child has contracted a familiarity with the persons and things around it, it manifests unequivocal fear on the occurrence of anything very strange. The grasp of an unknown person often gives a fright. This early experience very much resembles the manifestations habitual to the inferior animals." In another place Bain rightly says, "Our position in the world contains the sources of fear. The vast powers of nature dispose of our lives and happiness with irresistible might and awful aspect. Ages had elapsed ere the knowledge of law and uniformity prevailing among those powers was arrived at by the human intellect. The profound ignorance of the primitive man (and we may add of the undeveloped, limited, and superstitious adult) was the soil wherein his early conceptions and theories sprang up; and the fear inseparable from ignorance gave them their character. The essence of superstition is expressed by the definition of fear. An altogether exaggerated estimate of things, the ascription agency to the most harmless objects, and false apprehensions everywhere, are among the attributes of the superstitious man.6 Compayré, in speaking of the fear of the child, says, ”In his limited experience of evil, by a natural generalization, he suspects danger everywhere like a sick person whose aching body dreads in advance every motion and every contact. He feels that there is a danger everywhere, behind the things that he cannot understand, because they do not fit in with his experience. The observations collected by Romanes in his interesting studies on the intelligence of animals throw much light on this question; they prove that dogs, for instance, do not fear this or that, except as they are ignorant of the cause. A dog was very much terrified one day when he heard a rumbling like thunder produced by throwing apples on the floor of the garret; he seemed to understand the cause of the noise as soon as he was taken to the garret, and became as quiet and happy as ever. Another dog had a habit of playing with dry bones. One day Romanes attached a fine thread which could hardly be seen, to one of the bones, and while the dog was paying with it, drew it slowly toward him; the dog recoiled in terror from the bone, which seemed to be moving of its own accord. So skittish horses show fright as long as se of the noise that frightens them remains unknown and invisible to them. It is the same with the child. When in the presence of all these things around him, of which he has no idea, these sounding objects, these forms, these movements, whose cause he does not divine, he is naturally a prey to vague fears. He is just what we should be if chance should cast us suddenly into an unexplored country before strange objects and strange beings―suspicious, always on the qui vive, disposed to see imaginary enemies behind every bush, fearing a new danger at every turn in the road.”7 Similarly Sully says, "The timidity of childhood is seen in the readiness with which experience invests objects and places with a fear-exciting aspect, in its tendency to look at all that is unknown as terrifying, and in the difficulty of the educator in controlling these tendencies." Sully is right in thinking that intellectual culture tends greatly to reduce the intensity of fear. "This it does by substituting knowledge for ignorance, and so undermining that vague terror before the unknown to which the child and the superstitious savage are a prey, an effect, aided by the growth of will power and the attitude of self-confidence which this brings with it."8 An uncultivated personality with a limited mental horizon, with a narrow range of interests, a personality sensitive to the moral categorical imperative, a personality trained in the fear of the Lord and mysterious agencies is a fit subject for obsessions. In certain types of functional psychosis and neurosis the patient has an inkling of the fear instinct in his dread of objects, or of states of mind, moral scruples, lack of confidence, blushing, religious or social expectations of some coming misfortune and some mysterious evil, but he is not aware of the fear instinct as developed in him by the events and training of early childhood. The fears of early childhood subconscious. At any rate, the patient does not connect them with his present mental affection. In other types psychopathic affections the patient is entirely innocent of the whole situation, he is entirely engrossed by the symptoms which he regards as the sum and substance of his trouble, the fear is entirely subconscious. The fear instinct fostered by frights, scares, dread of sickness, by religious instruction with its fear of the Lord, by moral and religious injunctions and duties with fear of punishment or failure in the moral standard and duties, the enforcement of social injunctions with the consequent dread of failure and degradation, all go to the cultivation of the fear instinct which in later life becomes manifested as functional psychosis. All functional psychosis is nothing else but an obsession of the fear instinct, conscious and subconscious. Thus one of my patients became obsessed with fear of tuberculosis, manifesting most of the symptoms of "consumption" after a visit of a tubercular friend. Another patient became possessed with the fear of death after visiting a sick relative of his in one of the city hospitals. Another became obsessed with the fear of syphilis after having been in contact with a friend who had been under syphilitic treatment. Still another of my patients, in addition to the fear of darkness, became obsessed with the fear of stars and with fear of the comet, which was regarded by many people as poisoning the air with its highly noxious gases. In all such cases there was anxiety and dread of some symptom state of an external object, but in none of the cases have I found that the patient had an insight into the real state of the mind, in all of them the fear was traced to early childhood, to early experiences of the fear instinct fostered and fortified by religion, morality, and social tradition. In all those fears lying on the surface of functional psychosis there was a long history of a well-developed subconscious fear instinct. I may assert without hesitation that in all my cases of functional psychosis, and that without a single exception, I find the presence of the fear instinct to be the sole cause of the malady. Take away the fear and the psychosis or neurosis disappears. The fear instinct arises from the impulse of self-preservation, without which animal life cannot exist. The fear instinct is one of the most primitive and most fundamental of all instincts. Neither hunger nor sex nor maternal instinct nor social instinct can compare with the potency of the fear instinct, rooted as it is in self-preservation,―the condition of life primordial. When the instinct of fear is at its height it sweeps before it all other instincts. Nothing can withstand a panic. Functional psychosis in its fun development is essentially a panic―it is the emergence of the most powerful of all instincts, the fear instinct. Functional psychosis is a veiled form of the fear of death, of destruction, of loss of what is deemed as essential to life, of fear of some unknown impending evil. How many times has it fallen to my share to soothe and counteract the fear instinct of panic-stricken psychopathic patients! A psychogenetic examination of every case of functional psychosis brings one invariably to the fundamental fear instinct.
III If we examine closely the symptoms of fear, we invariably find the symptoms of functional psychosis. Fear affects the muscular and sensory system, the vasomotor system, the respiratory system, the sudorific glands, the viscera, the heart, the intestines, etc. Bain, in describing the emotions of fear or terror, says, "The appearances may be distributed. Terror on the physical side shows both a loss and a transfer of nervous energy. The appearances may be distributed between the effects of relaxation and effects of tension. The relaxation is seen as regards the muscles, in the dropping of the jaw, in the collapse overtaking all organs not specially excited, in trembling of the lips and other parts, and in the loosening of the sphincters. Next, as regards the organic processes and viscera. The digestion is everywhere weakened; the flow of saliva is checked, the gastric secretion arrested (appetite failing), the bowels deranged, the expiration is enfeebled. The heart and circulation are disturbed; there is either a flushing of the face or a deadly pallor. The skin shows symptoms―the cold sweat, the altered odor of the perspiration, the creeping action that lifts the hair. The kidneys are directly or indirectly affected. The sexual organs feel the depressing influence. The secretion of milk in the mother's breast is vitiated.”9 Darwin gives the following description of fear: "The frightened man at first stands like a statue, motionless and breathless, or crouches down as if to escape observation. The heart beats quickly and violently; but 'it is very doubtful if it then works more efficiently than usual so as to send a greater supply of blood to the body; for the skin instantly becomes pale, as during incipient faintness. The paleness of the surface, however, is probably in large part or is exclusively due to the vasomotor center being affected in such a manner as to cause the contraction of the small arteries of the skin. That the skin is much affected under the sense of great fear we see in the marvellous manner in which the perspiration immediately exudes from it. This exudation is all the more remarkable as the surface is then cold, and hence the term, a cold sweat; whereas the sudorific glands are properly excited into action when the surface is heated. The hairs also on the skin stand erect, and the superficial muscles shiver. In connection with the disturbed action of the heart the breathing is hurried. The salivary glands act imperfectly; the mouth becomes dry and is often opened and shut. I have also noticed that under slight fear there is a slight tendency to yawn. The voice becomes husky or indistinct, or may altogether fail. One of the best symptoms is the trembling of all the muscles of the body. From this cause and from the dryness of the mouth, the voice becomes husky or indistinct, or may altogether fail.”10 If we turn now to the manifestations of psychopathic maladies, we meet with the same symptoms: (a) The attacks may be muscular, such as trembling, shaking, paresis, paralysis, or rigidity; there may be affection of locomotion or of muscular co-ordination. (b) There may be sensory disturbances, anesthesia, paresthesia, analgesia or hyperalgesia, as well as affection of muscular sense and kinesthesis. (c) There may be skin disturbances, such as check of perspiration or profuse perspiration, especially under the influence of emotions, worry, and fatigue; such perspiration may also occur at night, and in some cases the fear of tuberculosis may be associated with such conditions. (d) The lungs may become affected functionally and here may occur respiratory disturbances, coughing, hawking, apnea, and dyspnea, and asthmatic troubles may result. (e) The heart becomes affected, bringing about precordial pain, palpitation of the heart, bradycardia, tachycardia, and cardiac arrhythmia may result. (f) The stomach and intestines become affected, indigestion and vague fugitive soreness and pain may be experienced all over or in special regions of the abdomen, constipation or diarrhea may ensue. (g) The renal apparatus may become affected and arrested, or what is more often the case in the milder forms of psychopathic troubles, there is present an increase or frequency of micturition, such as found in the conditions of anuria and polyuria. (h) Menstruation becomes disturbed and we may meet with conditions of dysmenorrhea, amenorrhea, menorhagia and other disturbances of tubes, ovaries, and uterus: (i) There are disturbances of the nervous system, such as headache and general dull sensation of fatigue and paresis of all mental functions~ dizziness, and vertigo. On the mental side we find in the psychopathies the following disturbances: (a) Affections of perceptual activity, illusions, and hallucinations. (b) Affections of intellectual activity, argumentativeness in regard to insignificant things, metaphysical and theological disputations. (c) Affections of the moral sense, scrupulousness, over-conscientiousness, not living up to ideal states.(d) Affections of religious life, committal of sins and fear of punishment. (e) Affections of social life, timidity, blushing, etc. (f) Affections in regard to objects, such as astrophobia, acmephobia, agoraphobia, clausterophobia, etc. (g) Affections of conceptual life, insistent ideas. (h) Affections of the attention, aprosexia. (i) Affections of the will, states of aboulia and uncontrollable impulses. (j) Affections of the memory, amnesic and paramnesic states. (k) General mental fatigue. (l) Affections of sexual life, perversion and inversion. (m) Affections in regard to marital relations. (n) Affections in regard to personal life, diffidence, self-condemnation, self-depreciation. (o) Affections of apparent loss of personality, feeling of self gone. (p) Formation of new personalities, dual and multiple personality. In connection with all such psychoneurotic affections we find invariably present a feeling of unrest, of uneasiness, a feeling of anxiety, conscious or subconscious, an anxious feeling of some impending evil. In all such affections we find the brooding spirit of the most powerful of all animal instincts,―the fear instinct.
IV The teleology of fear is quite clear. Fear is the guardian instinct of life. The intensity of the struggle for existence, the preservation of life of the animal is expressed in the instinct of fear. The fear instinct in its mild form, when connected with what is strange and unfamiliar or with what is really dangerous to the animal is of the utmost consequence to the life existence of the animal. What is strange and unfamiliar may be a menace to life and it is a protection, under such conditions the fear instinct is aroused. It is again of the utmost importance in weak animals, such as hares or rabbits, to have the fear instinct easily aroused by the slightest strange stimulus: the animal is defenceless, and its refuge, its safety, is in running. The unfamiliar stimulus may be a signal of danger and it is safer to get away from it, the animal cannot take chances. On the other hand, animals that are too timid, so that even the familiar becomes too suspicious, cannot get their food and cannot leave a progeny,―they become eliminated by the process of natural selection. There is a certain amount of trust that nature demands, even of its most defenseless and timid children. The business of life cannot go on without a certain amount of credit. Animals in whom the fear instinct can be aroused to a high degree become paralyzed and perish. Under such conditions the fear instinct not only ceases to be of protective value, but is the very one that brings about the destruction of the animal possessed by it. Intense fear paralyzes the animal. "One of the most terrible effects of fear, says Mosso, "is the paralysis which allows neither of escape nor defense." "Not all the phenomena of fear can be explained on the theory of natural selection. In their extreme degree they are morbid phenomena indicating imperfection of the organism. One might almost say that nature had not been able to find a substance for brain and spinal cord which should be extremely sensitive and yet should never, under the influence of exceptional or unusual stimuli, exceed in its reactions those physiological limits which are best adapted to the preservation of the animal.”11 Mosso quotes Haller, to the effect that "all phenomena of fear common to animals are not aimed at the preservation of the timid, but at their destruction." The fear instinct is no doubt one of the most fundamental and one of the most vital of animal instincts, but when it rises to an extreme degree, or when associated with familiar instead of strange and unfamiliar objects, then we may agree with Haller that the phenomena are not aimed at the preservation of the animal, but at its destruction; or, as Darwin puts it, are of "disservice to the animal." That is just what is found in the case of psychopathic affections. The fear instinct becomes aroused and cultivated in early childhood and becomes associated in later life with particular events, objects, and special states. When the instinct of fear is aroused in connection with some future impending misfortune, the feeling of expectation with all its physiological changes, muscular, respiratory, cardiac, epigastric, and intestinal, go to form that complex feeling of anxiety so highly characteristic of the acute form of psychopathic maladies. When fear reaches its acme, the heart is specially affected, the cardiac, circulatory and respiratory changes become prominent and give rise to that form oppression which weighs like an incubus on the patient, the feeling is known as precordial anxiety. The fear instinct is the ultimate cause of functional psychosis,―it is the soil on which grow luxuriantly the infinite varieties of psychopathic affections. The body, sense, intellect, and will are all profoundly affected by the irresistible sweep of the fear instinct as manifested in the overwhelming feeling of anxiety. The fear instinct and its offspring―anxiety―weaken, dissociate, and paralyze the functions the body and mind, giving rise to the various symptoms psychopathic diseases. The fear instinct keeps on gnawing at the very vitals of the psychopathic patient. Even at his best the psychopathic patient is not free from the workings of the fear instinct, from the feeling of anxiety which, as the patients themselves put it, "hangs like a cloud on the margin or fringe of consciousness." The patient's life is overshadowed by a gloomy feeling of anxiety which hangs on his mental horizon. From time to time he can hear the distant threatening rumbling of the fear instinct. Even when the fear instinct is apparently stilled the pangs of anxiety torment the patient like a dull toothache. Montaigne, the great anatomist of human passions, in writing of fear, says, "I am not so good a naturalist (as they call it) as to discern by what secret springs fear has its motion in us; but be this as it may, it is a strange passion, and such a one as the physicians say there is no other whatever that sooner dethrones our judgment from its proper seat; which is so true, that I myself have seen very many become frantic through fear; and even in those of the best settled temper, it is most certain that it begets a terrible astonishment and confusion during the fit. I omit the vulgar sort, to whom it one while represents their great-gandsires risen out of their graves in their shrouds, another while hobgoblins, spectres, and chimeras; but even among soldiers of a sort of men over whom, of all others, it ought to have the least power, how often has it converted flocks of sheep into armed squadrons, reeds and bullrushes into pikes and lances, and friends into enemies. . . . adeo pavor etiam auxilia formidat. . . . The thing in the world I am most afraid of is fear, that passion alone, in the trouble of it, exceeding all other accidents. . . . Tum pavor sapientiam omnem mihi ex animo expectorat. Such as have been well banged in some skirmish, may yet, all wounded and bloody as they are, be brought on again the next day to the charge; but such as have once conceived a good sound fear of the enemy will never be made so much as to look the enemy in the face. Such as are in immediate fear of losing their estates, of banishment or of slavery, live in perpetual anguish, and lose all appetite and repose; whereas such as, are actually poor, slaves or exiles, ofttimes live as merrily as other folks. And the many people who, impatient of perpetual alarms of fear, have hanged or drowned themselves, or dashed themselves to pieces, give us sufficiently to understand that fear is more importunate and insupportable than death itself.”12 That fear is a fundamentally important element in neuroses and psychoses has been fully acknowledged by many a neurologist and psychiatrist. Thus Oppenheim says, "Fear is a common symptom in the neuroses. It may be an indefinite feeling of anxiety not awakened by any particular cause, or it may be definite concepts and external influences which call the fear into action. The sensation is variously described. It has its seat, as a rule, in the cardiac region, at other times in the head. The patient feels as if his heard! were standing still; he thinks that he must fall or that he will get a stroke. Some explain the condition thus: 'It seems to me that I have done something wrong, as if something terrible is going to happen.' The expression of the face reveals a condition of anxiety, the fear often producing vasomotor, secretory, and motor disturbances; the face reddens or becomes pallid, perspiration breaks out, the saliva ceases to flow, the lips and tongue become dry, the pulse and respiration become accelerated.''13 "A materially different picture," says Kirchoff, "is presented when the feeling of fear enters the symptom group (of melancholia). This feeling is referred to the cardiac region (precordial fear), and is one of the most important and frequent accompaniments of severe melancholia. The external quiet of severe simple melancholia becomes converted into anxious restlessness. From the start sleep is almost always disturbed, because the patient is tormented by the pressure in the cardiac region. Other disagreeable sensations soon follow, such as constriction of the neck or a dull feeling in the head, bad dreams and anxious thoughts become more numerous. The daily work may make the condition endurable during the day for a time, but in the stillness of the night it is rapidly intensified, and if sleep does not refresh the excited brain, the days likewise are filled more and more with disheartening fears. The implication of the organs of the body is much more distinct in anxious than in simple melancholia. The appetite is lost, the nutrition is rapidly impaired. Respiration is superficial, the heart's action is accelerated and often irregular, the pulse is small, the skin is cool. When the terror 'shows variations or occurs in paroxysms, its increase is shown by suppression of the urine and perspiration, its subsidence by increase in these secretions. The more chronic the precordial fear the more indistinct do these symptoms become. . . . Religious notions are often a waked and are then explained as the dread of being possessed evil spirits. . . . In more severe cases the internal life comes a real dreamy condition in which external expressions are received in a confused shadowy and inimical manner. A terrible, baseless, but paralyzing fear takes possession of consciousness.”14 The anxiety states of neurosis and psychosis are essentially the offspring of fear. The anxiety states are due to the awakening of the fear instinct normally present in every living being. The fear instinct is a fundamental one, it is present in every normal human being, it is only inhibited by the whole course of civilization and by the training and education of social life. Like the jinn of the Arabian nights, it slumbers in the breast of every normal individual and comes fully to life in the various neuroses a psychoses. Kraepelin and his school lay, with right, special stress on the fact that "Fear is by far the most important persistent emotion in morbid conditions. . . . Fear is manifested by anxious excitement and by anxious tension.” "Experience," says Kraepelin, "shows an intimate relationship between insistent psychosis and the so-called ‘phobias,’ the anxiety states15 which in such patients become associated with definite impressions, actions, and views. They are associated with the thought of some unknown great danger, although the patient may be aware that in reality nothing of the kind will befall him. Intense heart beat, pallor, feeling of anxiety, tremor, cold sweat, meteroismus, diarrhea, polyuria, weakness of legs, attacks of fainting, so that the patient loses control of his limbs and occasionally simply collapses. "These states," says Kraepelin, with his usual insight into abnormal mental life, "remind one of the feeling of anxiety which in the case of healthy people may in view of a painful situation or of a serious danger deprive one of the calmness of judgment and confidence in his movements.”16 Thus we find from different standpoints that the feeling of anxiety with all its accompanying phenomena is one of the manifestations of the most fundamental, the most potent of animal instincts, the fear instinct which is at the basis of all psychopathic maladies.17 The fear instinct as the most subtle and most fundamental of all instincts is well described by Kipling:
_________
1. Inquiries into
Human Faculty, p. 58. 14. Kirchoff. Handbook of Insanity, p. 89. 15. My italics. 16. Psychiatrie, Vol. II, p. 541. 17. I shall develop this in detail in my forthcoming work on Psychopathology.
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