The following study of a psychopathic case brings out the character of the fear trance dream.
Mrs. A. is twenty-two years old; Russian; married. She suffers periodically from attacks of violent headaches, lasting several days. Family history is good. The patient was brought up in the fear of ghosts, evil spirits, magical influences, and diabolical agencies. Mrs. A. is easily frightened, and has suffered from headaches and pressure on the head for quite a long time, but the pain became exacerbated some five years ago. The attack is sudden, without any premonitory feelings, and lasts from eight hours to two days. The headache often sets in at night, when she is asleep, and she wakes up with frightful pain.
At the time of the first attack she was much run down. Otherwise the patient is in good condition, but complains that her memory is getting bad. Patellar reflex is exaggerated. Field of vision is normal. The eyes show slight strabismus and astigmatism, corrected by glasses which did not in the leastdiminish the intensity as well as the frequency of the headaches.
Mrs. A. suffers from bad dreams and distressing nightmares, the content of which she cannot recall in her waking state. She also often has hallucinations, visions of two women wrapped in white, pointing their fingers at her and running after her. She never had any fall, nor any special worry or anxiety, never suffered from any infectious diseases.
After a persistent inquiry, however, she gave an account of an accident she met with when a child of eight. Opposite her house there lived an insane woman of whom she was mortally afraid. Once when the parents happened to be away, the insane woman entered the house, caught the child, and greatly frightened her. Another time she was sent out by her parents to buy something in a grocery store. It was night and very dark. She bought the things and on the way back she saw two women in white with hands stretched out running after her. She screamed from great fright and ran home.
Mrs. A. is afraid to remain alone, and especially in the dark. She is not so much afraid in the street as in the house. The two women appear to her now and then, and she is mortally afraid of them.
The patient was put into hypnotic state. There was marked catalepsy; the eyes were firmly closed, and she could not open them when challenged. Suggestion of general well-being was given and she wasawakened. On awakening, she could not remember what had taken place in the hypnotic state.
Next day she was again put into hypnosis and went into a deeper state than the day before. She was asked whether she thought of the crazy woman occasionally, she replied in the negative. The patient spoke in a low, suppressed voice, the words coming out slowly, as if with effort and with fear. It was then insisted that she should tell one of her recent dreams. After some pause, she said: “Last night I had a bad dream; I dreamt that I stood near a window and a cat came up to the same window. I saw it was crazy. I ran away, the cat ran after me and scratched me. Then I knew that I was crazy. My friends said there was no help for me.
“I dropped the baby, ran, and jumped down stairs. I remember now that when I fell asleep I saw a woman, maybe the crazy woman. I covered myself; I knew I was only afraid, and that she was not real. Six weeks ago I saw the same woman, when falling asleep or when asleep. I ran away, and she ran after me.”
Mrs. A. in relating these dreams, shivered all over and was afraid, as if actually living the dream experience over again. “It was this woman who caught me in her arms, kissed me, and embraced me, and did not let me go, until my screams brought friends and my father; they took me away from her by force.”
Gradually some more dreams emerged. “I dreamt some time ago that the woman came to me and spilled hot water on me. Another time I dreamed that I was in the insane asylum; she came out, told me she was well; I was greatly frightened and ran away.”
Mrs. A. then became quiet. After a while she began to relate a series of dreams. Some time ago she dreamed that the woman entered the room where her father was and ran up to him, evidently with the intention of hurting him. Her father ran away, and she hid herself in a closet in the next room. “I also dreamt that the woman was shadowing me in an alley. She wanted to get hold of me, while I was trying to get away from her. I turned round, and she gave me such a fierce look. I ran and she could not catch me. I should die, if she catches me. In one of my dreams about her, I saw people putting cold water on her, and I could hear her scream. It was awful. I dreamt I went upstairs, opened the door and met her. I was badly frightened. I jumped out of the window.”
This is an extract from a letter sent to me by the patient’s husband: “ ... She had another attack. It did not last long, and it was not severe. She dreamt several times a week. I shall try to relate them as accurately as possible. She dreamt that I left the room for a while. Our baby was asleep in the next room. All of a sudden she heard baby cry out: ‘Mamma, I am afraid.’ She told the baby tocome to her as she herself was afraid to leave the bed. Baby came to her. The child looked frightened, her face pale with fear, exclaiming ‘Mamma, a devil.’ As the child cried out, my wife heard a noise in the room, something moved close by. She became scared. It seemed to her that something terrible and unknown was after her. She wanted to scream for help, but could not. A hand was stretched out after her to catch her. She woke up in great terror. Another time she dreamt that she was in a hall way. She saw a woman and became frightened. It was the same crazy woman. My wife is exceedingly nervous, and is in fear that something awful is going to happen to her or to the family.”
A rich, subconscious dream-life of agonizing fears was thus revealed, a life of terrors of which the patient was unaware in her waking state. The dreams referred to the same central nucleus, the shock and fears of her early childhood. Worries about self and family kept up and intensified the present fear states.
Her selfishness has no bounds, her fears have no limits. The symptoms of the “fear set,” as in all other psychopathic cases, took their origin in the impulse of self-preservation with its accompanying fundamental fear instinct.
This patient was cured after a long course of hypnotic treatment.
There are cases in which the nature of the psychopathic states stands out more clearly and distinctly than in others. They occur periodically, appearing like epileptic states, in a sort of an explosive form, so that some authorities have mistaken them for epilepsy, and termed them psychic epilepsy. My researches have shown them to be recurrent explosions of subconscious states, which I termedpsycholepsy. They really do not differ from general psychopathic states, but they may be regarded as classicpseudo-epileptic, orpsycholepticstates; they are classicfear-states—states of panic.
M. L. is nineteen years of age, of a rather limited intelligence. He works as a shopboy amidst surroundings of poverty, and leads a hard life, full of privations. He is undersized and underfed, and looks as if he has never had enough to eat. Born in New York, of parents belonging to the lowest social stratum, he was treated with severity and even brutality. The patient has never been to any elementary school and can neither read nor write. Hismathematical knowledge did not extend beyond hundreds; he can hardly accomplish a simple addition and subtraction, and has no idea of the multiplication table. The names of the President and a few Tammany politicians constitute all his knowledge of the history of the United States.
Family history is not known; his parents died when the patient was very young, and he was left without kith and kin, so that no data could be obtained.
Physical examination is negative. Field of vision is normal. There are no sensory disturbances. The process of perception is normal, and so also is recognition. Memory for past and present events is good. His power of reasoning is quite limited, and the whole of his mental life is undeveloped, embryonic. His sleep is sound; dreams little. Digestion is excellent; he can digest anything in the way of eatables. He is of an easy-going, gay disposition, a New York “street-Arab.”
The patient complains of “shaking spells.” The attack sets in with tremor of all the extremities, and then spreads to the whole body. The tremor becomes general, and the patient is seized by a convulsion of shivering, trembling, and chattering of teeth. Sometimes he falls down, shivering, trembling, and shaking all over, in an intense state of fear, a state of panic. The seizure seems to be epileptiform, only it lasts sometimes for more than three hours. Theattack may come any time during the day, but is more frequent at night.
During the attack the patient does not lose consciousness; he knows everything that is taking place around him, can feel everything pretty well; his teeth chatter violently, he trembles and shivers all over, and is unable to do anything.
The fear instinct has complete possession of him. He is in agony of terror. There is also a feeling of chilliness, as if he is possessed by an attack of “fear ague.” The seizure does not start with any numbness of the extremities, nor is there any anaesthesia or paraesthesia during the whole course of the attack. With the exception of the shivers and chills the patient claims he feels “all right.”
The patient was put into a condition close to the hypnotic state. There was some catalepsy of a transient character, but no suggestibility of the hypnotic type. In this state it came to light that the patient “many years ago” was forced to sleep in a dark, damp cellar where it was bitter cold. The few nights passed in that dark, cold cellar he had to leave his bed, and shaking, trembling, and shivering with cold and fear he had to go about his work in expectation of a severe punishment in case of non-performance of his duties.
While in the intermediary, subwaking, hypnoidal state, the patient was told to think of that dark, damp, cold cellar. Suddenly the attack set in,—thepatient began to shake, shiver, and tremble all over, his teeth chattering as if suffering from intense fear. The attack was thus reproduced in the hypnoidal state. “This is the way I have been,” he said. During this attack no numbness, no sensory disturbance, was present. The patient was quieted, and after a little while the attack of shivering and fear disappeared.
The room in which the patient was put into the subconscious state was quite dark, and accidentally the remark was dropped that the room was too dark to see anything; immediately the attack reappeared in all its violence. It was found later that it was sufficient to mention the words, “dark, damp, and cold” to bring on an attack even in the fully waking state. We could thus reproduce the attacks at will,—those magic words had the power to release the pent-up subconscious forces and throw the patient into convulsions of shakings and shiverings, with chattering of the teeth and intense fear.
Thus the apparent epileptiform seizures, the insistent psychomotor states of seemingly unaccountable origin, were traced to subconscious fear obsessions.
The following case is of similar nature. The study clearly shows the subconscious nature of such psycholeptic attacks:[10]
Mr. M., aged twenty-one years, was born in Russia, and came to this country four years previously. His family history, as far as can be ascertained, is good. There is no nervous trouble of any sort in the immediate or remote members of his family.
The patient himself has always enjoyed good health. He is a young man of good habits.
He was referred to me for epileptiform attacks and anaesthesia of the right half of his body. The attack is preceded by an aura consisting of headache and a general feeling of malaise. The aura lasts a few days and terminates in the attack which sets in about midnight,when the patient is fully awake. The attack consists of a series of spasms, rhythmic in character, and lasting about one or two minutes. After an interval of not more than thirty seconds the spasms set in again.
This condition continues uninterruptedly for a period of five or six days (a sort of status epilepticus), persisting during the time the patient is awake, and ceasing only during the short intervals, or rather moments, of sleep. Throughout the whole period of the attacks the patient is troubled with insomnia. He sleeps restlessly for only ten or fifteen minutes at a time. On one occasion he was observed to be in a state of delirium as found in post-epileptic insanity and the so-called Dämmerzustände of epilepsy. This delirium was observed but once in the course of five years.
The regular attack is not accompanied by any delirious states or Dämmerzustände. On the contrary, during the whole course of the attack the patient’smind remains perfectly clear.
During the period of the attack the whole right side becomes anaesthetic to all forms of sensations, kinaesthesis included, so that he is not even aware of the spasms unless he actually observes the affected limbs.
The affected limbs, previously normal, also become paretic. After the attack has subsided, the paresis and anaesthesia persist (as sometimes happens in true idiopathic epilepsy) for a few days, after which the patient’s condition remains normal until the next attack. After his last attack, however, the anaesthesia and paresis continued for about three weeks.
He has had every year one attack which, curiously, sets in about the same time, namely, about the month of January or February. The attacks have of late increased in frequency, so that the patient has had four, at intervals of about three or four months. On different occasions he was in the Boston City Hospital for the attacks.
There was a profound right hemianaesthesia including the right half of the tongue, with a marked hypoaesthesia of the right side of the pharynx. All the senses of the right side were involved. The field of vision of the right eye was much limited. The ticking of a watch could not be heard more thanthree inches away from the right ear. Taste and smell were likewise involved on the right side. The muscular and kinaesthetic sensations on the right side were much impaired.
The patient’s mental condition was good. He states that he has few dreams and these are insignificant, concerned as they are with the ordinary matters of daily life. Occasionally he dreams that he is falling, but there is no definite content to the dream.
These findings were indicative of functional rather than organic disease. Theprevious historyof the case was significant. The first attack came on after peculiar circumstances, when the patient was sixteen years of age and living in Russia. After returning from a ball one night, he was sent back to look for a ring which the lady, whom he escorted, had lost on the way. It was after midnight, and his way lay on a lonely road which led by a cemetery. When near the cemetery he was suddenly overcome by a great fright, thinking that somebody was running after him. He fell,struck his right side, and lost consciousness. The patient did not remember this last event. It was told by him when in a hypnotic state.
The patient was a Polish Jew, densely ignorant, terrorized by superstitious fears of evil powers working in the dead of night.
By the time he was brought home he regained consciousness,but there existed a spasmodic shaking of the right side, involving the arm, leg, and head. The spasm persisted for one week. During this time he could not voluntarily move his right arm or leg, and the right half of his body felt numb. There was also apparently a loss of muscular sense, for he stated that he was unaware of the shaking of his arm or leg, unless he looked and saw the movements. In other words, there was right hemiplegia, anaesthesia, and spasms.
For one week after the cessation of the spasms his right arm and leg remained weak, but he was soon able to resume his work, and he felt as well as ever. Since then every year, as already stated, about the same month the patient has an attack similar in every respect to the original attack, with the only exception that there is no loss of consciousness. Otherwise the subsequent yearly attacks arephotographic pictures, close repetitions, recurrences of the original attack.
A series of experiments accordingly was undertaken. First, as to the anaesthesia. If the anaesthesia were functional, sensory impressions ought to be felt, even though the patient was unconscious of them, and we ought to be able to get sensory reactions.
Experiments made to determine the nature of the anaesthesia produced interesting results. These experiments show that the anaesthesia is not a trueone, but that impressions from the anaesthetic parts which seem not to be felt are really perceived subconsciously.
Different tests showed that the subconscious reactions to impressions from the anaesthetic hand were more delicately plastic and responsive than the conscious reactions to impressions from the normal hand. We have the so-called “psychopathic paradox” thatfunctional anaesthesia is a subconscious hyperaesthesia.
It is evident then that there could be no inhibition of the sensory centres, or suppression of their activity, or whatever else it may be called. In spite of the apparent, profound anaesthesia, the pin pricks were felt and perceived. Stimulations gave rise to perception, cognition, to a sort of pseudo-hallucinations that showed the pin pricks were counted and localized in the hand. The results of these tests demonstrate that in psychopathic patients all sensory impressions received from anaesthetic parts, while they do not reach thepersonalconsciousness are perceivedsubconsciously.
Inasmuch as the sensations are perceived, the failure of the subject to be conscious of them must be due to afailure in association. The perception of the sensation is dissociated from the personal consciousness. More than this, thesedissociatedsensations are capable of a certain amount of independent functioning; hence the pseudo-hallucinations, andhence the failure of psychopathic patients to be incommoded by their anaesthesia. This condition of dissociation underlies psychopathic states.
For the purpose of studying the attacks, the patient was hypnotized. He went into a deep somnambulic condition, in which, however, theanaesthesia still persisted. This showed that the dissociation of the sensory impressions was unchanged.
In hypnosis he related again the history of the onset of the trouble. His memory became broader, and he was able to give the additional information, which he could not do in his waking state, that at the time he was badly frightened, he fell on his right side. Moreover, he recalled what he did not remember when awake, that throughout the period of his attacks when he fell asleep, he had vivid dreams of an intense hallucinatory character, all relating to terror and fall.
In these dreams he lived over and over again the experience which was the beginning of his trouble. He again finds himself in his little native town, on a lonely road; he thinks some one is running after him; he becomes frightened, calls for help, falls, and then wakes up with a start, and the whole dream is forgotten. After he wakes he knows nothing of all this; there is no more fear or any emotional disturbance; he is then simply distressed by the spasms.
While testing the anaesthesia during hypnosis, anattack developed, his right arm and leg began to shake, first mildly and then with increasing intensity and frequency. His head also spasmodically turned to the right side. The movements soon became rhythmic. Arm and leg were abducted and adducted in a slow rhythmic way at the rate of about thirty-six times per minute. With the same rate and rhythm, the head turned to the right side, with chin pointing upward. The right side of the face was distorted by spasm, as if in great pain. The left side of the face was unaffected. Pressure over his right side (where he struck when he fell) elicited evidences of great pain. Respiration became deep and labored, and was synchronous with each spasm. The whole symptom-complex simulated Jacksonian epilepsy.
Consciousness persisted unimpaired, but showed a curious and unexpected alteration. When asked what was the matter, he replied in his native dialect, “I do not understand what you say.” It was found that he had lost all understanding of English, so that it was necessary to speak to him in his native dialect. His answers to our questions made it apparent that during the attack, as in his dreams, he was living through the experience which had originally excited his trouble.
The attack washypnoidic, a fear attack, hallucinatory in character. He said that he was sixteen years old, that he was in Rovno (Russia), that hehad just fallen, because he wasfrightened, that he was lying on the roadside near the cemetery, which in the popular superstitious fear is inhabited by ghosts. At that hour of the night the dead arise from their graves and attack the living who happen to be near.
The hypnoidic state developed further, the patient living through, as in a dream, the whole experience that had taken place at that period. He was in a carriage, though he did not know who put him there. Then in a few moments he was again home, in his house, with his parents attending on him as in the onset of his first epileptiform seizures.
The attack terminated at this point, and thereupon he became perfectly passive, and when spoken to answered again in English. Now he was again twenty-one years old, was conscious of where he was, and was in absolute ignorance of what had just taken place.
It was found that an attack could regularly and artificially be induced, if the patient in hypnosis was taken back by suggestion to the period when the accident happened.
The experiment was now tried of taking him back to a period antedating the first attack. He was told that he was fifteen years old, that is, a year before the accident occurred. He could no longer speak or understand English, he was again in Rovno, engaged as a salesman in a little store, had never been inAmerica, and did not know who we were. Testing sensation, it was found that it had spontaneously returned to the hand.There was not a trace of the anaesthesia left.The hands which did not feel deep pin pricks before now reacted to the slightest stimulation.Spontaneous synthesis of the dissociated sensory impressions had occurred.Just as formerly before the accident, sensation was in normal association with the rest of his mental processes, so now this association was re-established with the memories of that period to which the patient was artificially reduced.
The patient was now (while still believing himself to be fifteen years old) taken a year forward to the day on which the accident occurred. He says he is going to the ball tonight. He is now at the ball; he returned home; he is sent back to look for a ring. Like a magic formula, it calls forth an attack in which again he lives through the accident,—the terror and the spasms.
It was thus possible to reproduce an attack at any time with clock-like precision by taking him back to the period of the accident, and reproducing all its details in a hypnoidic state. Each time the fear and the physical manifestations of the attack (spasms, paresis, and anaesthesia) developed. These induced attacks were identical with the spontaneous attacks, one of which we had occasion to observe later.
At periodic intervals, as under the stress of fear,the dormant activity is awakened and, though still unknown to the patient, gives rise to the same sensori-motor disturbances which characterized the original experience. These subconscious dissociated states are so much more intense in their manifestations by the very fact of their dissociaton from the inhibitory influences of the normal mental life.
The psychognosis of such cases reveals on the one hand a dissociation of mental processes, and on the other hand an independent and automatic activity of subconscious psychic states, under the disaggregating, paralyzing influence of the fear instinct.
A patient under my treatment for four months during the year of 1922 presents interesting traits. I regard the case as classic as far as the fundamental factors of neurosis are concerned.
Patient, male, age 32, married, has two children. He lives in an atmosphere of fear and apprehension about himself. He comes from a large, but healthy family. The patient is of a rather cowardly disposition especially in regard to his health. He worked hard in a store during the day, and led a life of dissipation at night. One day, after a night of unusual dissipation, or orgy, when on his way to his work, he felt weak, he was dizzy, he became frightened about himself; he thought he had an attack of apoplexy, and that he was going to die. His heart was affected, it began to beat violently, and he trembledand shivered in an “ague” of intense fear. The palpitation of the heart was so great, the trembling was so violent, and the terror was so overwhelming that he collapsed in a heap. He was taken to his father’s store in a state of “fainting spell.” A physician was called in who treated the patient for an attack of acute indigestion.
For a short time he felt better, but the attacks of terror, trembling, shivering, weakness, pallor, fainting, palpitation of the heart and general collapse kept on recurring. He then began to suffer from insomnia, from fatigue, and is specially obsessed by fear fatigue. He is in terror over the fact that his energy is exhausted; physical, mental, nervous, sexual impotence. This was largely developed by physicians who treated him for epilepsy, putting him on a bromide treatment; others treated and diagnosed the case as cardiac affection, kidney trouble, dementia praecox, and one physician operated on the poor fellow for tonsillitis. The patient was terrorized. He was on a diet for toxaemia, he was starved. He took all sorts of medicine for his insomnia.
The patient became a chronic invalid for ten years. He was in terror, scared with the horrors of sleepless nights. He has been to neurologists, to psychoanalysts, and he tried Christian Science, New Thought, Naturopathy, and Osteopathy, but of no avail. The condition persisted. The attacks cameon from time to time like thunder storms. There were trembling, shivering, chattering of teeth, palpitation of the heart, weakness, fainting, and overwhelming, uncontrollable terror.
The first time I tried to put the patient into a hypnoidal state was nine at night. I put out the electric light, lighted a candle, and proceeded to put him into a hypnoidal condition. The patient began to shiver, to tremble, to breathe fast and heavily, the pulse rose to over 125, while the heart began to thump violently, as if it were going to jump out. He was like one paralyzed, the muscles of the chest labored hard, and under my pressure the muscle fibers hardened, crackled, became rigid, and he could not reply when spoken to. It took me some time to quieten him. He was clearly in a state of great panic. I opened his eyelids and found the eye ball turned up. The whole body was easily put in a state of catalepsy. Clearly the patient was not in a hypnoidal state, he was in a state of hypnosis. Night after night he fell into states of hypnosis with all the symptoms of intense fear attacks. When the fear attacks subsided the depths of the hypnotic state proportionately diminished.
In my various clinical and laboratory experimental work, covering a period of a quarter of a century, I have gradually come to the conclusion that fear and hypnosis are interrelated. In fact I am disposed to think that the hypnotic state is an ancientstate, a state of fear cataplexy, or rather trance obedience. While the hypnoidal state is a primitive sleep state, the hypnotic condition is a primitive, fear condition, still present in lowly formed organisms.
After some time the general fear instinct becomes alleviated. The patient goes by habit into a trance hypnotic state under the influence of the hypnotizer in whom he gains more confidence. The patient gets into a state of trance obedience to the hypnotizer of whom he is in awe, and who can control the patient’s fear instinct.
Man obeys the commands, “the suggestions” of the hypnotizer, of the master whom he subconsciously fears, and who inspires him with awe, with “confidence-fear”. The crowd, the community, “public opinion,” the mob, the leader, the priest, the magician, the medicine man, are just such forces, such authorities to procure the slavish obedience of the subconscious described as hypnosis. Soldiers and slaves fall most easily into such states.
Man has been trained in fear for milleniums, in fear of society, custom, fashion, belief, and the authority of crowd and mob. He fears to stand alone, he must go with the crowd.
Man is a social being, a hypnotized, somnambulic creature. He walks and acts like a hypnotized slave. Man is a social somnambulist who believes, dreams, and acts at the order of the mob or of itsleader. Man belongs to those somnambulists who become artificial, suggested, automatic personalities with their eyes fully open, seeing and observing nothing but what is suggested to them.
The hypnoidic states, observed and described by me in the classical Hanna case, belong to the same category. The hypnoidic states are essentially fear cataleptic states of a vivid character, closely related to hypnotic conditions of primitive life.[11]
FOOTNOTES:[10]Dr. Morton Prince and Dr. H. Linenthal coöperated with me in the study of the case published in full in the “Boston Medical and Surgical Journal.”[11]See my works, “The Psychology of Suggestion,” “Multiple Personality,” and others.
[10]Dr. Morton Prince and Dr. H. Linenthal coöperated with me in the study of the case published in full in the “Boston Medical and Surgical Journal.”
[10]Dr. Morton Prince and Dr. H. Linenthal coöperated with me in the study of the case published in full in the “Boston Medical and Surgical Journal.”
[11]See my works, “The Psychology of Suggestion,” “Multiple Personality,” and others.
[11]See my works, “The Psychology of Suggestion,” “Multiple Personality,” and others.
S. R. Age 25. Russian Jewess; married; has four children. Patient was brought to me in a state of helplessness. She could not walk, and was unable to utter a word. When spoken to she replied in gestures. When challenged to walk, she made unsuccessful attempts. The step was awkward, the gait reeling, the body finally collapsing in a heap on the floor. When I shut her eyelids, the eyeballs began to roll upwards, the lids soon became cataleptic, and the patient was unable to open them. When I insisted that she should open the lids, she strained hard,—the muscles of the upper part of the body became painfully tense,—wrinkled her forehead, and contorted violently her face. After long insistence on her replying to my questions, and after long vain efforts to comply with my request, she at last succeeded in replying in a barely audible voice. When whispering she kept on making incoordinate movements with jaws and lips, began to shut her eyelids, rolled up the eye-balls, forced the tongue against the teeth, stammered badly on consonants, uttering themwith great difficulty after long hesitation, the sound finally coming out with explosive force.
I insisted that she must stand up, she raised herself slowly and with effort, took a couple of steps, and sat down at once on the chair. During the period of effort there was marked tremor in her left arm. When she sat down, she threw her head backward, rolled up her eyeballs, and began gradually to close her eyelids. She remained in this position for a couple of minutes, and then began spasmodically to open and shut the eyelids. When taken to her room, the patient walked up, though with some difficulty, three flights of stairs without the nurse’s support.
The patient was greatly emaciated,—she lived in extreme poverty. She was married five years, and had given birth to four children. Patient was suffering from severe headaches which set in soon after the birth of the second child. At first the headaches came at intervals of a few weeks, and lasted about a day, then with the birth of the other children the headaches grew more severe and more frequent, and finally became continuous. From time to time the attacks were specially exacerbated in violence, she then complained of violent pains in the head, excruciating agony toward the vertex. The face was deadly pale, the hands and feet were ice-cold, the pulse weak and sluggish. During the attack the head had to be raised, since in any other position the pain was unbearable. The pain was originally unilateral,starting on the left side of the head. Of late the pain spread from left to right. The whole head felt sore, like a boil, the scalp was highly sensitive. The intense attacks, sweeping over the patient unawares, were accompanied by twitchings of the eyelids, rolling of the eyeballs, dizziness, sparks before the eyes, pains in the left side of the chest, and by numbness and hypoaesthesia of the face, arms and legs. The patellar reflex was markedly exaggerated, no clonus was present; the pupils reacted well to light and accommodation.
The patient was admitted to a local hospital, and was allowed to nurse her one year old baby. Three days after admission, while nursing her baby, she was seized with a violent attack of headache and pain in the left side. The arms felt numb and “gone.” The patient was seized with a panic that the child might fall; hugging the baby to her left breast she screamed for help in agony and terror. Immediately following this seizure the patient lost her voice, speech, and power of walking.
After staying in the hospital for two weeks, the patient was put under my care.
The patient was an extremely timid creature. She lived in Russia in a small town where the religious persecutions of the neighbors were persistent and unremittent. To this were joined the petty annoyances by the village police, the representatives of which acted with all the cruel tyranny characteristicof the old Russian regime. The patient’s family was in constant terror. In childhood the patient has undergone all the horrors of thepogromiwith all the terrors of inquisitorial tortures. A highly sensitized impulse of self-preservation and intense easily stimulated fear instinct were the essence of the patient’s life. She was afraid of everything, of her very shadow, of anything strange, more so in the dark, and at night. With this morbid self-preservation and intensified fear instinct there were associated superstitions to which her mind was exposed in early childhood, and in her later life. The patient lived at home in the fear of the most savage superstitions and prejudices, characteristic of the poor ignorant classes of Eastern European countries, and outside the house she was in fear of her life. The patient was brought up on fear and nourished on fear. No wonder when she was run down, and met with a fear shock, that the fear instinct seized on her and gave rise to the symptoms of physical and mental paralysis.
To this life of terror we may add the extreme poverty in which the patient lived in Russia and afterwards in this country. The hard work in a sweat-shop and the ill nutrition ran down the patient and further predisposed her to disability and disease. Patient lived in constant dread of actual starvation, with fear of having no shelter, with fear of no roof over her head. She was so timid that shewas scared by any sudden movement, or by a severe, harsh, threatening voice. She was extreme suggestible, imitative, and credulous. She was like a haunted animal, like a scared bird in the claws of a cat. Fear often threw her into a state of rigidity.
The patient suffered from a fear of fatigue, from fear of exhaustion, from fear of disability, from fear of paralysis, pain, sickness, and death, fear of the negative aspect of the most primitive, and most fundamental of all impulses, the impulse of self-preservation. The fear psychosis, based on an abnormally developed fear instinct which formed the main structure of her symptom complex, had a real foundation in the psycho-physiological condition of her organism. The patient actually suffered from fatigue due to exhaustion, underfeeding, and overworking.
Married at the age of twenty, she bore four children in succession. This was a drain on the poor woman, and further weakened her feeble constitution. Her husband was a poor tailor working in a sweat-shop, making but a few dollars a week. The family was practically kept in a state of chronic starvation. The wolf was hardly kept away from the door. The family was in constant dread of “slack time” with its loss of employment and consequent privations and suffering.
The husband was a hard worker, did not drink, but the long hours of work, the low wages, the poornutrition, the vicious air, and the no less vicious environment, cheerless and monotonous, sometimes gave rise to moods, discontent, anger, and quarrels, of which the patient with her timidity stood in utter terror.
The patient’s dream life was strongly colored by a general underlying mood of apprehension. The fear instinct of self-preservation formed the soil of the whole emotional tone of the psychosis, waking, sub-waking, dreaming, conscious, and subconscious. Again and again did the nurses and attendants report to me that, although the patient was aphonic and it was hard to elicit from her a sound, in her sleep she quite often cried out, sometimes using phrases and words which were hard to comprehend, because they were indistinct, and because they were sometimes in her native language. When awakened immediately, it was sometimes possible to elicit from her shreds of dreams in regard to scares and frights about herself, about her children, about her husband, relatives, and friends. When she came under my care the patient often used to wake up in the morning in a state of depression due to some horrible hallucinatory dreams in which she lived over again in a distorted form, due to incoordination of content and to lack of active, guiding attention, dreams in which the dreadful experience of her miserable life kept on recurring under various forms of fragmentary association and vague synthesis, broughtabout by accidental, external and internal stimulations.
The patient was taken to her room in the evening, and put to bed. During the night she was somewhat restless, kept on waking up, but on the whole, according to the nurse’s account, she slept quite well. In the morning the patient had a hearty breakfast, and felt better than the day before when she was brought to me. The voice improved somewhat in strength and volume. During the day she rested, felt well, and enjoyed her meals. Speech was still in a whisper barely audible, but there was no stammering, no muscular incoordination, no twitchings of the face. About four in the afternoon patient sat up in bed, her voice became somewhat stronger, though speech was still in a whisper. This improvement lasted but a few minutes. When her arms were raised, the left hand manifested considerable tremor and weakness as compared with the right arm. After having made a few remarks which apparently cost her considerable effort, she had a relapse, she again lost her voice, and was unable to whisper. I insisted that she should reply to my questions; she had to make a great effort, straining her muscles and bringing them into a state of convulsive incoordination before she could bring out a few sounds in reply. A little later, about ten or fifteen minutes after I left the room, the nurse came in and quietly askedher a question, the patient answered in a whisper, with little strain and difficulty. An hour later the patient regained her speech for a short period of a few minutes. These changes went on during the patient’s waking period. Once towards evening the patient regained her voice and speech to such an extent that she could talk with no difficulty and little impediment; the voice was so resonant and strong that it could be heard in the hall adjoining the room. This however lasted but a few moments.
After having had a good night’s sleep the patient woke up in good condition; appetite was good. Voice was clear, though low. She was in a state of lassitude and relaxation. I attempted to examine her and kept testing her condition, physical and mental. I was anxious to make a psychognosis of the patient’s case. The tests and the questions strained her nervous system by requiring to hold her attention, and by keeping her in a state of nervous and mental agitation. She looked scared, anxious,—the scared, haunted look in her face reappeared. The patient was no more than about twenty to twenty-five minutes under experimentation when a severe headache of the vertex and of the left side of the head set in. The eyeballs began to roll up, eyelids were half closed; lids and eyeballs were quivering and twitching. The hands were relaxed and looked paralyzed. When raised theyfell down by her side in an almost lifeless condition. There was marked hypoaesthesia to pain and heat sensations. The anaesthesia was more marked on the left than on the right side. The left arm when raised and kept for a few seconds showed marked tremor as compared with the right arm. This is to be explained by the fact that the exacerbations of the headache, of pain, and the general cataleptic seizures set in usually during or after the nursing periods. The infant while nursing was kept by the mother on the left arm, the left side thus bearing the pressure, weight, and strain,—it was with the left side that fear became mainly associated.
During the height of the attack the patient was quietened, her fears allayed, and a five-grain tablet of phenacetine was given her with the authoritative remark that the drug was sure to help her. As soon as she swallowed the tablet the patient opened her eyes, and said she felt better. About an hour later, when another attempt at an examination was made, patient had an attack of headache, cried, said she was afraid, but she answered in a whisper when spoken to. She talked slowly, in a sort of staccato way. I insisted that she should talk a little faster and pronounce the words distinctly. She made violent attempts to carry out my command, but got scared, began to hesitate, and stammer, her voiceand speech rapidly deteriorating with her efforts, ending in complete mutism.
During the day I tried from time to time to keep up the experiment of insisting that the patient should speak, and every time with the same result of bringing about an attack.[12]The patient began to stammer and stutter, becoming more and more frightened the more the nurse and myself insisted that she should make an effort and reply to our questions. Still, when the patient’s attention became distracted, when she was handled gently, when her fears were allayed, the speech and sound improved in quality and in loudness, and at times her sentences were quite fluent, her enunciation quite distinct.
This state of instability lasted for several days until the patient became somewhat familiar with the surroundings. In one of her better moments the patient told me that she thought her stammering began with a definite event. One evening when she was fatigued with the labors of the day for her family, a stammerer came in to see her. The stammering made a strong impression on her. She felt the strain of the stammerer; she could not control the sympathy and the strain, and involuntarily began to imitate stammering. She began to fear that she might continue to stammer and beunable to enunciate sounds and words. The more she feared the harder it was for her to speak or even to use her voice.
A few days later the patient began to improve, she began to adapt herself to her surroundings, and did not get so easily scared.
About eight days after the first examination the patient woke up one morning in a state of depression; she cried a good deal. She did not sleep well the night before, dreamt and worried on account of her children. She was afraid that something might have happened to them in her absence, perhaps they were sick, perhaps the husband could not take good care of them. She talked in a whisper, her eyes were shut. When I insisted on opening the eyelids, she opened them, but did it with difficulty. I put her into a hypnotic state. In about a minute her eyes rolled up, and the eyelids shut spasmodically. There was present a slight degree of catalepsy. Mutism was strongly marked. Upon sudden and unexpected application of an electric current, the patient opened her eyes, cried out, but soon relapsed into a state of lethargy. Gradually patient was brought out of the lethargic state.
A couple of hours later, after she had a good rest a few more experiments as to her sensori-motor life were attempted. I asked her to raise objects, tested her sensitivity to various stimulations, her concentration of attention, asked her questionsabout her life, about her family, took again her field of vision. All that was a great effort to her. While I was taking her field of vision the patient’s eyes began to close, and it took about twenty seconds before she could open them. She opened them with effort, but shut them again. This time it took her about 45 seconds before she could open the lids. Fatigue, or rather fear fatigue, set in sooner with each repetition of experiment and test, and lasted a longer time.
For several days the patient kept on improving slowly. She then had another relapse. She slept well the night before, but woke up early about six in the morning; she began to worry about her family, and complained of headache. About half past eight the headache became severe, there was again pain in the left side, the left hand began to tremble, and felt anaesthetic, the eyelids closed, and could not open, aphonia returned, in fact she fell into a state of mutism. About ten o’clock patient opened her eyes, but she was unable to talk. After long insistence on her reply to my question as to how she was, she finally replied in a whisper: “Well,” then added “I have a bad headache.” She had great difficulty in replying to my questions, moved her jaws impotently before she was able to emit a sound, her muscles were strained, the face was set, tense, and drawn, the brow was corrugated, the eyeballs rolled up, and the eyelids shut tightly. The patientwas unable to raise her hands, they lay powerless at her side. When raised the arms were found to be lethargic, fell to her side, only the left hand manifested light, fibrillary twitchings and a gross tremor. When insisted upon that she must raise her arms, she became agitated, scared, began to moan and cry. Claimed severe pain in head, in chest, in heart. “Pain in heart, in head, I am afraid,” she moaned in a whisper. There was loss of kinaesthetic sensibility, patient complained that she did not feel her arms, “they are not mine.” She had to look at the arm in order to find it. There was also present anaesthsia to other sensations such as pain, touch, heat, and cold. After a couple of hours’ rest the sensibility returned. The sensibility was affected more on the left side than on the right, and also returned earlier on the right side.
When the fatigue and the scare subsided the patient was tested again. This time the reactions to sensory stimulations were normal. The patient was touched, pinched, and pricked, she reacted to each stimulus separately, and was able to synthesize them and give a full account of their number. Kinaesthetic sensibility was good,—she was fully able to appreciate the various movements and positions in which her limbs and fingers were put.
The patient was left to rest, quietened, treated carefully, avoiding sudden stimulations, allaying her fears and suspiciousness of danger, lurking in thebackground of her mind. After a few hours she sat up, made an attempt to raise herself from bed, got up with some effort, and sat down in an easy rocking chair next to her. Her eyes were wide open. Asked how she was, she replied in a whisper that she felt quite well. The effort however fatigued her, her head began to drop, eyelids began to close, and the eyeballs began to roll up. Twitchings were observed in the eyelids, and tremors in the left arm. She was again put to bed and given a rest of a few hours. She opened her eyes, and told me that she was weak. This statement she herself volunteered. I found that she could move her hands easily, and that the numbness was completely gone.
For a whole week the patient kept on growing in health and in strength, her sensori-motor reactions improved, she walked round the room for a few minutes, talked in a low voice for a quarter of an hour at a time without manifesting her symptoms of fatigue; her appetite and sleep improved accordingly. At the end of the week there was again a relapse,—she did not sleep well the night before, dreamt of being hunted and tortured, woke up depressed, had no appetite for breakfast, complained of headache, pains, worries, and fears. The headaches have abated in their virulence during last week, but now they seemed to have reappeared in their former vigor. When I began to examine her shelooked frightened, her eyeballs rolled up, her eyelids closed. The aphonia was severe, patient lost speech and voice. When spoken to she could not answer. Asked if she heard me, she nodded her head affirmatively. There were slight twitchings of her left hand and also of the muscles of her face. When attention was attracted to the arm the twitchings increased in violence and rapidity. With the distraction of the attention the twitchings disappeared. When the left hand was put in the patient’s field of vision, thus making her attention concentrate on that limb, the tremors increased again, becoming finally convulsive in character.
I insisted she should try to open her mouth, and say something,—she made fruitless efforts, moving incoordinately the muscles of the face and of the forehead, but she could not utter a sound. She could not move her arms on command, could hardly wriggle the fingers of her hand. She appeared like a little bird paralyzed by fear. When the arm was raised passively it fell down slowly being in a cataleptic state.
I allayed the patient’s fear. I strongly impressed her with the groundlessness of her fears, and also with the fact that everything was well with the children, and that her husband will be good and gentle with her. The patient was permitted to see her family. The husband was made to realize that he must treat her with more consideration. Hecame often to visit her, and learned to treat her well. He soon found a better position, was advised to remove to a healthy locality and to more cheerful surroundings. The children were well cared for. The patient found deep satisfaction in the midst of this family happiness. The fear state abated,—the patient became more confident, more hopeful for the future, and began to improve. The infant was weaned so that the strain of nursing was removed. The patient’s appetite began to improve; she gained several pounds in a few days. Long periods of examination and investigation of her nervous and mental state no longer exhausted or terrified her. Her concentration of attention could be kept up from a quarter to half an hour at a stretch without giving rise to fatigue, headache, or to a seizure with its consequent psychomotor effects. The haunted look of fear disappeared, and along with it were also gone the fatigue and dread of physical and mental exercise or work. She could work and walk with ease the whole length of the room and of the hall. She began to take more and more interest in her appearance and in dress. For many minutes at a time she looked out on the street taking an interest in all that was done and what was going on.
The case was discharged, and was sent home. She continued to stay well.