The causation and treatment of psychopathic diseases

Front matter

:ausation and treatment of sychopathic disease

BORIS SIDIS

EMCAL SCHOOL

Introduction

Psychopathic diseases are not hereditary — they are acquired characteristics. "Weak nerves," "a run down, exhausted nervous system," whatever the terms may mean, may overlap psychopathic conditions, but the two are by no means equivalent, much less identical. Psychopathic states are not "weak nerves" or "fatigued nerves." Above all, there is no need to obscure the matter and resort to the much abused, mystical and mystifying factor of heredity. It is easy to shift all blame on former generations, where in most cases the fault is close at hand, namely, a debased environment, a defective training, and a vicious education.

Under the rigorous conditions of primitive life individuals who have been unfortunate, and have become affected with mental troubles and emotional afflictions are mercilessly exterminated by the process of tribal and social selection. Each generation weeds out the individuals who have been unfortunate enough to fall under unfavorable circumstances, and have become mentally sick, suffering from acquired psychopathic disturbances. In primitive life the crippled, the maimed, the wounded, the sick fall by the way, and are left to perish a miserable death. In fact, the less fortunate, the wounded and the stricken in the battle of life, are attacked by their own companions — they are destroyed by the ruthless social brute. The gregarious brute has no sympathy with the pains and sufferings of the injured and the wounded. The faint and the ailing are destroyed by the herd.

Civilization, on the other hand, tends more and more towards the preservation of psychopathic individuals. We no longer kill our sick and our weak, nor do we ii Introduction

abandon them to a miserable, painful death — we take care of them, and cure them. Moreover, we prevent pathogenic factors from exercising a harmful, malign social selection of the "fit." We do our best to free ourselves from the blind, merciless, purposeless selection, produced by pathogenic micro-organisms and by other noxious agencies. We learn to improve the external environment.

We do not condemn people to death, because they are infected with smallpox, typhus, typhoid bacilli, or because of an infected appendix. We no longer regard them as sinful, unclean, accursed and tabooed. We vaccinate, inoculate, operate, and attempt to cure them. By sanitary and prophylactic measures we attempt to prevent the very occurrence of epidemics. Our valuation of individuals is along lines widely different from those of the stone age and the cave man. We value a Pascal, a Galileo, a Newton, a Darwin, a Pasteur, and a Helmholtz far above a Milo of Croton or an African Johnson.

Civilization is in need of refined, delicate and sensitive organizations, just as it is in need of galvanometers, chronometers, telephones, wireless apparatuses, sensitive plates, and various chemical re-agents of a highly delicate character. We are beginning to appreciate delicate mechanisms and sensitive organizations. We shall also learn to train and guard our sensitive natures until they are strong and resistant to the incident forces of an unfavorable environment. The preservation of psychopathic individuals accounts for the apparent increase of neurotics in civilized communities.

It may be well to add that, although the occasions for sudden, intense, overwhelming shocks are not so prevalent in organized societies as they are in primitive savage communities, the worries, the anxieties, the

Introduction in

various forms of slow, grinding fears of a vague, marginal, subconscious character, present in commercial and industrial nations, are even more effective in the production of psychopathic states than are the isolated occasions of intense terrors occurring in the life of the primitive man of the paleolithic or neolithic periods.

In my works I lay special stress on the fact that the psychopathic individual has a predisposition to dissociative states. Early experiences and training in childhood enter largely into the formation of such a predisposition. Still, there is no doubt that a sensitive nervous system is required, — a brain susceptible to special stimuli of the external environment. This, of course, does not mean that the individual must suffer from stigmata of degeneration. On the contrary, it is quite possible, and in many patients we actually find it to be so, that the psychopathic individual may be even of a superior organization. It is the sensitivity and the delicacy of nervous organization that make the system susceptible to injurious stimulations, to which a lower form of organization could be subjected with impunity. An ordinary clock can be handled roughly without disturbance of its internal workings, but the delicate and complicated mechanism of a chronometer requires careful handling and special, favorable conditions for its normal functioning. Unfavorable conditions are more apt to affect a highly complex mechanism than a roughly made instrument. It is quite probable that it is the superior minds and more highly complex mental and nervous organizations that are subject to psychopathic states or to states of dissociation. Of course, unstable minds are also subject to dissociative states, but we must never forget the fact that highly organized brains, on account of their very complexity, are apt to become unstable under iv Introduction

unfavorable conditions. A predisposition to dissociation may occur either in degenerative minds or in minds superior to the average. Functional psychosis requires a long history of dissociated, subconscious shocks, given to a highly or lowly organized nervous system, dating back to early childhood.

As Mosso puts it: "The vivid impression of a strong emotion may produce the- same effects as a blow on the head or some physical shock." We may, however, say that no functional psychosis, whether somopsychosis or psychoneurosis, can ever be produced simply by physical shocks. In all junctional psychoses there must be a mental background, and it is the mental background alone that -produces the psychosis and determines the character of the psychopathic state.

The basis of functional nervous or psychopathic maladies is essentially a pathological process involving the nervous system in as definite a way as the invasion and infection of the organism by various species of bacteria, bacilli, and other micro-organisms which attack the individual during his lifetime.

Like infectious diseases, psychopathic deviations, abnormalities, and excesses are acquired by the individual in the course of his relations with the external environment, and are as real as syphilis, smallpox, diphtheria, cholera, and the bubonic plague. To regard them as imaginary, or to relegate them to the action of Providence or to heredity is theoretically a misconception, and practically a great danger to humanity.

There is nowadays a veritable craze for heredity and eugenics. Biology is misconceived, misinterpreted, and misapplied to social problems, and to individual needs and ailments. Everything is ascribed to heredity, from folly and crime to scratches and sneezes. The

Introduction v

goddess Heredity is invoked at each flea-bite — in morsu pulicis Deum invocare. Even war is supposed to be due to the omnipotent deity of Heredity. Superior races by their patriotism and loyalty destroy the weak and the helpless, and relentlessly exterminate all peaceful tribes. Such warlike stock comes of superior clay. The dominant races have some miraculous germ-plasm (chromatin) with wonderful dominant "units" (chromosomes) which, like a precious heritage, these races transmit, unsullied and untarnished, to their descendants. Wars, carnage, butcheries make for progress, culture, and evolution. Our boasted civilization with its "scientific" business thoroughness and its ideal of "efficiency" attempts to carry into effect this quasievolutionary doctrine — this apotheosis of brute force under the aegis of science. The eugenic belief is really a recrudescence of the ancient savage superstition of the magic virtues of noble blood and of divine kingly stock.

All nervous, mental, neuropathic, and psychopathic maladies are supposed to be a matter of heredity. If people are poor, ignorant, superstitious, stupid, degraded, brutal, and sick, the eugenists unhesitatingly put it all up to poor stock. The eugenic remedy is as simple as it is believed to be efficacious: Introduce by legislation "efficient" laws favoring "eugenic" marriage, sterilize all the "unfit," and teach the masses control of births. The select and chosen stock alone should multiply — the millennium is then bound to come. Such is the doctrine of our medico-biological sages.

"Scientific" farmers and breeders of vegetables, fruits, and cattle are regarded as competent judges of human "breeders." Agriculturists and horticulturists set themselves up as advisers in "the business of raising good crops of efficient children." Bachelors, spinsters, and the childless generally, are specially versed in vi Introduction

eugenic wisdom and pedagogics. All social ills and individual complaints are referred to one main source — heredity. With the introduction of eugenic legislation, with the extermination of the socially unfit, among whom the greatest men and women may be included, with the philanthropic sterilization of the "defectives," with the breeding of good "orthodox, common stock," and with the eugenic Malthusian control of births, all evil and disease on earth will cease, while the Philistine "superman" will reign supreme for evermore.

In the Middle Ages all diseases and epidemics, all wars, all social and private misfortunes were considered as visitations of Divine wrath. In modern times our would-be eugenic science refers all ills of the flesh and woes of the mind to an outraged Heredity. The dark ages had resort to prayers, fasts, and penitence, while our age childishly pins its faith to the miraculous virtues and rejuvenating, regenerative powers of legislative, eugenic measures, sterilization, seclusion, restriction of marriage, and to the eugenic Malthusian control of births.

Our scientists in eugenics gather hosts of facts, showing by elaborate statistical figures that the family history of neurotics reveals stigmata of degeneration in the various members of the family. "The Jukes" and their ilk are trumpeted about as great discoveries of eugenic research work. Any group of individuals of various "breeds" and "families," living under the action of the same conditions, social, economical, and educational will have the same impress. Anthropology has found this out in the case of so-called "nations" and "races." The eugenic inquirers do not stop for a moment to think over the fact that the same sort of evidence can be easily brought in the case of most people. In fact, the eugenists themselves, when inquiring into the pedigree of talent and genius, invari-

Introduction vii

My find somewhere in the family some form of disease or degeneration. This sort of "scientific" evidence leads some eugenic speculators, without their noticing the reductio ad absurdum, to the curious conclusion or generalization that degeneration is present in the family history of the best and the worst representatives of the human race.

The so-called scientific method of the eugenists is radically faulty, in spite of the rich display of long pedigrees and family histories, of colored plates, stained tables, glittering biological speculations, brilliant mathematical formulae, and complicated statistical calculations. The eugenists pile Ossa on Pelion of facts by the simple method of enumeration which Bacon and the thinkers coming after him have long ago condemned as puerile and futile. From the savage's belief in sympathetic, imitative magic with its consequent superstitions, omens, and taboos down to the articles of faith and dogmas of the eugenists we find the same faulty, primitive thought, guided by the puerile method of simple enumeration, and controlled by the wisdom of the logical post hoc, ergo propter hoc.

What should we say of the medical man who should claim that measles, mumps, cholera, typhoid fever, yellow fever, malaria, tetanus, and various other infectious diseases are hereditary by quoting learnedly long tables of statistics to the effect that for several generations members of the same family suffered from the same infectious diseases? What should we say of the medical advice, forbidding marriage to individuals whose family history reveals the presence of exanthemata? We stamp out epidemics not by eugenic measures, but by the cleansing of infectious filth and by the extermination of pathogenic micro-organisms.

Every human being has a predisposition to smallpox, cholera, tetanus, bubonic plague, typhus fever, viii Introduction

malaria, and to like infectious diseases, but there is no inherent necessity for everyone to fall a victim to the action of pathogenic organisms, if the preventive and sanitary conditions are good and proper. No one is immune against the action of bullets, cannon balls, shells, and torpedoes, or to the action of various poisons, organic and inorganic, but one is not doomed to be killed by them, if one does not expose oneself to their deadly action. Every living organism is by the very nature of its cellular tissues predisposed to the wounding by sharp instruments, or to the burning action of fire, but this does not mean an inherent organic weakness to which the organism must necessarily submit and perish. We are all of us predisposed to get injured and possibly killed, when we fall down from a high place, or when we are run over by an automobile or by a locomotive, but there is no fatalistic necessity about such accidents, if care is taken that they should not occur.

We may be predisposed to neurosis by the very nature of complexity, delicacy, and sensitivity inherent in the structure of a highly organized nervous system, and still we may remain healthy and strong all our life long, provided we know how to keep away from noxious agencies. The creed of the inevitable fatality of neurosis is as much of a superstition as the Oriental belief in the fatalism of infectious diseases, plagues, and accidents of all kinds. Such fatalistic superstitions are dangerous, fatal, because they distract the attention from the actual causes and from the requisite prophylactic measures.

We go far afield in search for the remote source of our troubles, when the cause is close at hand. We need only open our eyes to see the filth of our towns, the foul, loathsome slums of our cities, the miserable training, the wretched education given to our children, in

Introduction ix

order to realize at a glance the source of our ills and ailments. We should lay the guilt at the door of our social order. We starve our young. We starve our children physically and mentally.

We piously sacrifice our tender children and the flower of our youth to the greedy, industrial Moloch of a military, despotic, rapacious plutocracy. Witness semi-civilized Europe with its lauded culture brutally shedding the blood of its youth and manhood on the altar of commercial patriotism. It is not heredity, it is the vicious conditions of life that stunt the physical, nervous, and mental growth of our young generation. When we are confronted with the miserable, degraded, crippled forms of our life, we fall back cheerfully on some remote grandparent and credulously take refuge in the magic panacea of eugenics.

The practical aspect is clear. Psychopathic neurosis in its two varieties, Somatopsychosis (Somopsychosis) and Psychoneurosis, is not hereditary, but acquired. We should not shift the blame on former generations and have resort to eugenics, we must look to the improvement of mental hygienic conditions of early childhood, and to the proper education of the individual.

It is easy to put the blame on grandparents, — they are dead and cannot defend themselves. Could they arise from their graves, they could tell some bitter truths to their 'degenerate' descendants who are ready to shift responsibility to other people's shoulders. It is about time to face the truth fairly and squarely, a truth which is brought out by recent investigations in psychopathology, that the formation of psychopathic neurosis with all its characteristic protean symptoms, is not hereditary, but acquired. Neurosis arises within the life cycle of the individual, — it is due to faulty training and harmful experience of early child life.

x Introduction

Future medicine will be largely prophylactic, preventive, sanitary, hygienic, dietetic. What holds true of medicine in general holds true of that particular branch of it that deals with neurosis. The treatment will become largely prophylactic, preventive, educational, or pedagogic. It is time that the medical and teaching professions should realize that functional neurosis is not congenital, not inborn, not hereditary, but is essentially the result of a defective education in early child life.

Boris Sidis.

Sidis Institute,

Portsmouth, New Hampshire, 1915.

Table Of Contents

CHAPTER PAGE

Introduction i

I. Psychopathic Reflexes 21

Chapter I Psychopathic Reflexes

THE profound influence of the central nervous system, more especially of the cortex with its mental processes, on bodily activities, on glandular, circulatory, and visceral functions, is now firmly established by psychophysiological and psychopathological research work. As Darwin puts it: "The manner in which the secretions of the alimentary canal and of certain glands, as the liver, kidneys, or mammae are affected by strong emotions, is an excellent instance of the direct action of the sensorium on these organs." The heart is extremely sensitive to sensory and ideosensory stimulations. Claude Bernard has shown how the least excitement of sensory nerves reacts through the pneumogastric nerve on the heart. The vasomotor system is directly acted on by the sensorium.

Early investigators (Bidder, Schmidt, Richet) observed the fact that the sight of food causes the secretion of gastric juice. Pavloff in his experiments has shown that the central nervous system acts on the secretions of the stomach through the vagi nerves that innervate its glandular activity. Pavloff made a gastric fistula in the dog, then exposed the esophagus, opened it, and sewed the cut end to the edges of the wound. Food taken by the mouth fell out through the opening, but an abundant secretion of gastric juice was observed. There are two moments in the process of secretion: (i) The psychic moment, the perception of food and, (2) the chemical moment. According to Pavloff, the psychic moment is the more important.

By the term "unconditional reflex" PavlofI means to indicate the response which the animal with a fistula in the secretory glands reacts by secretion to a normal stimulus, such as bread, meat, and other food. By "conditional reflex" PavlofT indicates the reaction made by the operated animal to a stimulus artificially associated with the unconditional reflex. Thus during the time the animal is fed, a light is flashed or a whistle is sounded or various figures are shown to the animal, as Doctor Orbeli has done. After a series of repetition, twenty, thirty, or a hundred, the animal reacts with secretion to that artificially associated stimulus. When another stimulus is in its turn associated with that of the conditional reflex, the result is not an increase, but a total inhibition of the conditional reflex.

Savadsky modified the conclusions of the previous investigators, but he affirms the fact that an intense stimulus completely annihilates the secretion of the conditional reflex, such as is due to scratch stimulus, for instance, while a weak stimulus produces a lesser effect. He finds that the external stimulus inhibits the condition of the nerve centres. In summarizing the work of previous investigators in PavlofPs laboratory, Orbeli says: "Vasiliev and Mishtovt have shown that any phenomenon indifferent in itself may not only become a source of a new conditional reflex, but may become a special inhibitory agent in relation to the existing conditional reflexes. This quality of the nervous system to work out special cases of inhibition makes the conditional reflexes a delicate index of reactions of the organism to its external environment. "

On the strength of experiments performed on the

Psychopathic Reflexes 23

visual reactions of the dog, Orbeli comes to the same conclusion with Vasiliev, Mishtovt, Babkin, and Savadsky.

Similarly in the experiments carried on in my laboratory on the galvanic reflex, I find that the results coincide with PavlofFs experiments on inhibition. In a letter to me Pavloff writes that he is at work on the higher activities of the brain of the dog, studying mental reactions by the methods of conditional reflexes. According to Pavloff, mental life, however complex, can be studied successfully by the reactions of glandular secretions.

An intimate relation exists between the functions of the central nervous system on the one hand and the sensory, motor, glandular, and visceral functions on the other. This vital relation, though unobtrusive to the casual observer, stands out clear and distinct in the domain of certain nervous and mental disturbances, such as hysteria, hystero-epilepsy, larval epilepsy, neurasthenia, psychasthenia. All such conditions are mental disturbances, conscious or subconscious, and are termed by me psychopathies, or recurrent mental states. Recurrence of the symptom complex is pathognomonic of psychopathies, or briefly, of neurosis. This essential trait of recurrence, found in neurosis, is a reversion to a low type of mental life. I refer all those who are interested in the subject to my work on the moment consciousness, studied from a psychobiological standpoint in my recent volume, The Foundations of Normal and Abnormal Psychology,

In psychopathic affections the disturbance consists in the formation of non-adaptive associations of central neuron-systems with receptors which normally do not have as their terminal response the particular motor and glandular reactions.

In PavlofFs experiments the flow of saliva or of gastric juice in the dog with the fistula could be brought about by association with blue light, with the sound of a whistle, by a tickle, a scratch, or by various diagrams, squares, circles, as in the experiments of Orbeli. What holds true in the case of conditional reflexes in regard to saliva and gastric juice, also holds true of other conditional reflexes formed by psychopathies. The mechanism in psychopathies is the same which Pavloff and bis disciples employ in the formation of various conditional reflexes in the case of the dogs. All kinds of abnormal reactions of a morbid character may thus be formed in response to ordinary stimuli of life.

Emotions are specially subject to associations of a morbid or psychopathological character. The physiological effects of emotions may be linked by associative processes with ideas, percepts, and sensations which are ordinarily either indifferent or give rise to reactions and physiological effects of a type opposite to that of the normal. Milk may excite nausea, a rose induce disgust, red paint produce fainting, while the croak of a crow, Limburger cheese, overripened game, the smell of garlic and asafcetida may be enjoyed with delight.

The reactions of muscle and gland are like so many electric bells which by various connections and combinations may be made to ring from any sensory button or receptor, as Sherrington would put it. An object, however harmless, may become associated with reactions of anguish and distress. This holds true, not only of man, but also of the life of the lower animals.

Associations and reactions, motor, circulatory, glandular, however abnormal, formed by young animals, persist through life. This holds specially true in the case of the higher and more sensitive animal organisms, such as the mammals. All training and formation of peculiar reactions, such as various tricks, habits,

Psychopathic Reflexes 25

scare-habits, scare-pain reflexes depend entirely on this plasticity of the nervous system to form new associations, or as Pavloff and his school put it, to form conditional reflexes and inhibitions in regard to glandular secretions as well as to other psychophysiological reactions.

Psychopathies are essentially pathological affections of associative life. Psychopathic maladies are the formation of abnormal, morbid "conditional reflexes" and of inhibitions of reactions of associative normal life activity.

chapter; ii

MAIN CLINICAL FORMS OF NEUROSES AND PSYCHO- PATHIES

A brief outline of the classification of nervous and mental diseases, made by me in my various works, is of importance to a clear understanding of the etiology and differential diagnosis of the neurotic affections under discussion.

The different forms of nervous and mental diseases may be classified into organic and. functional.

By organic affections we mean to indicate all pathological modifications of the neuron and its processes taking place in the very structure, probably in the cytoreticulum, of the nerve cell. Under this category come such maladies as general paralysis, dementia praecox, and mental and nervous affections of an involutionary and degenerative nature. Such diseases are termed by me Organopathies or Necropathies.

By functional affections we mean to indicate all neuron changes in which the neuron functions and their reactions to external and internal stimulations are involved in the pathological process without, however, affecting the anatomical structure of the nerve cell. The pathological changes are not permanent, recovery of normal function is possible.

Functional nervous and mental diseases may in their turn be subdivided into Neuropathies and Psychopathies.

Functional neuropathic diseases are disturbances of functioning activity of the neuron, due to defective metabolism in cellular nutrition, brought about by external, and especially by internal stimuli-secretions,

Clinical Forms of Neuroses and Psychopathies 27

hormones, and other agencies. The pathological process in functional nervous and mental diseases produces few, if any, anatomical, structural changes in the neuron. The pathology of functional neuropathic diseases {probably of the cytoplasm) is essentially chemico-physiological in character.

Neuropathic diseases include maladies in which the neuron undergoes degenerative changes which at first may bring about an apparent increase, then an inhibition, and finally a complete suspension of neuron function, not terminating in the destruction of the neuron.

This follows the general physiological law that all causes which tend to destroy the vital functions of cell activity begin at first to work as stimulants and afterwards become depressants, finally ending in the total destruction of the cell or of the neuron in the case of the nervous system. Thus in many cases small doses of opium or of morphine, chloral or other toxic and autotoxic products bring about an excitement. In such cases we should increase the dose or repeat it, if we wish to obtain depressant effects. In ether and chloroform anesthesia before the deep state of anesthesia sets in there is a stage of excitement. This law holds true in the case of the process of degeneration of the nervous system in the various forms of nervous and mental diseases as in the process of the downward course of cellular disintegration.

In neuropathic disturbances neuron restitution is possible. Neuropathic affections are produced by poisons, organic or inorganic, by autotoxic products, by hyposecretion or hypersecretion, or total absence of glandular secretion or hormones in the economy of the organism. Here belong all the temporary, or recurrent maniacal, melancholic, and delusional states, puerperal mania, epileptic insanity, the mental aberrations of adolescent and climacteric periods, periodic insanity, alternating insanities, and in general all the mental affections at present known under the description of manic-depressive insanity.

Where the disease depends not so much on the neuron itself, but on the interrelation of neurons in a complex system, on association of systems of neurons, the condition is psychopathic in nature. In psychopathic troubles the neuron itself may remain unaffected, may be perfectly normal and healthy. The disorder is due to associations with systems of neurons which are usually not called into action by the function of that particular neuron or neuron system.

Briefly stated:

Organopathies or Necropathies include a group of psychophysiological symptoms accompanied by structural, necrotic changes of the neuron, terminating in the ultimate death of the neuron systems involved in the pathological process.

Neuropathies include a group of psychophysiological manifestations due to pathological functional neuron modifications, capable of restitution through a more perfect, more normal metabolism.

Psychopathies are pathological phenomena of psycho-physiological dissociation and disaggregation of neuron systems and the resultant disturbances of aggregate functions, the neuron itself, remaining undamaged and untouched.

The Psychopathies may be classified into: Somatopsychoses or Somopsychoses and Psychoneuroses.

This classification may be represented by the following diagram (Fig. i):

The psychopathies may present chiefly somatic symptoms, such as paralysis, contractures, convulsions, or anesthesia, hypoesthesia, hyperesthesia of the various organs, glands, and tissues. Such mental diseases

Clinical Forms of Neuroses and Psychopathies 29

Nervous and Mental Diseases

Organic

Organopathies

Neuropathies

Somatopsychoses Somo psycho sea

Functional

Psychoneuroses Neuropsychoses

Fig. 1

may be termed somatic psychoses, somatopsychoses. The somatic psychoses or neuroses would comprise the various manifestations of what is at present described as hysteria and neurasthenia as well as the milder forms of hypochondriasis. In all such diseases the psychical symptoms form the prominent elements of the mental malady. The patient remains unaware of the underlying mental grounds. So much is this the case that the patient is offended, if his trouble is regarded as purely mental In character. The mental side of the diseases is then said to be submerged subconsciously. In the psychoneuroses or neuropsychoses the physical symptoms are, on the contrary, few or none at all, while the predominating symptoms are entirely of a mental character. The patient ignores his physical condition, even if any exists, and his whole mind is occupied with mental troubles. Such conditions are to be found in all obsessions, fixed ideas, imperative impulses, and other allied morbid mental states. Thus one patient is in agony over the unrighteousness of his conduct, another is obsessed by a terror of some mysterious agency, or by religious and moral scruples.

The two clinical forms of psychopathies are in strong contrast. In the somatic psychopathies or somatopsychoses, the patient brings before the physician physical symptoms — stomach derangements, intestinal pains, contractures of limbs, menstrual disturbances, affections of the sexual organs and their functions, paresis, paralysis, anesthesia, headaches, and similar bodily troubles. It is for the physician to discover the underlying mental states. In the mental forms, the psychoneuroses, the patient omits reference to his physical condition. He usually states that he has always been physically well, and some patients assert that they are sure that they will always be physically well, that the whole trouble is purely mental. "I have no physical trouble," he tells the physician, "all my troubles are mental. If you could cure me of my mental suffering, I should be perfectly happy."

The psychosomatic patient lays stress on his physical symptoms and is offended when they are declared to be mental; the psychoneurotic, on the contrary, insists on his mental symptoms, and becomes impatient when the physician pays attention to physical symptoms or to bodily functions. The psychosomatic patient believes he is afflicted with some awful, incurable, physical malady, such as cardiac trouble, tuberculosis, or some other fatal bodily, disease. The psychoneurotic, on the contrary, ignores all physical troubles, but he thinks he is on the verge of insanity. The psychosomatic seeks to be assured that he is not an incurable invalid. The psychoneurotic wants to be certain that he is not crazy. The psychosomatic wishes to know whether or no he is really and truly free from some malignant disease, some horrible infection, or some fatal physical