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"NARCOLEPSY1"

BY C. WORSTER-DROUGHT.

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As the name implies (Gk. νάρκη = stupor λαμβάνειν = to seize), narcolepsy is a condition which is characterised by recurrent states of sudden and profound sleep.

The condition appears first to have been described by Gélineau (9) in 1881, under the name of 'la narcolepsie'; he considered it a rare neurosis in which the outstanding feature was a sudden and irresistible desire to sleep, the period of slumber being usually of short duration. Gowers (10) considered the term best applied to a condition in which the patient showed recurrent attacks of apparent sleep, varying in duration from a few minutes to a few hours, and from which he or she could be roused with comparatively little effort; on the other hand, he distinguished 'trance' and 'lethargy' from narcolepsy in that the sleep of the former states was more prolonged and the patient could be roused only imperfectly and with extreme difficulty, while 'catalepsy' was accompanied by that plastic state of the limbs known as 'flexibilitas cerea' or katatonia. The distinctions between these closely allied conditions, and especially between narcolepsy and lethargy or trance, is somewhat artificial, as in many cases which otherwise fulfil the definition of narcolepsy, the patient cannot be roused during the attack; similarly many examples of so-called trance have a recurrent tendency. Later authors-Ballet (3), Féré (7), Lamarcq (16), Achard (2), and others have employed the term narcolepsy to include all states of paroxysmal sleep, and it is in this sense that I am using it in the present communication.

Symptoms. The characteristic feature of narcolepsy is the occurrence of paroxysms of diurnal sleep in the midst of whatever occupation the patient may be engaged. The attack may occur suddenly under any conditions, seizing the patient while walking or eating, while actively engaged in mental work, conducting business, or playing at a game. One of Robin's cases-a medical man-often used to fall asleep when walking, while in the daily press of March 22nd, 1921, there was reported an inquest on a man aet. 60, held at Newport, Mon., at which the evidence 1 A paper read before the Medical Section of the British Psychological Society on May 23rd, 1923.

Med. Psych. III

18

showed that he used to fall asleep when walking or eating. He worked in a farmyard and had frequently been seen to fall asleep in the midst of his meal, the cows eating the remainder of the food out of his hand. He had apparently fallen asleep in the roadway when he was run over by a cart and died as the result of his injuries. Féré (7) records an instance of the patient falling asleep while standing as soon as she leaned against a piece of furniture, and P. Stewart (19) that of a man who would fall asleep while playing the piano or at a game of cards, during the latter especially if he held a losing hand. Oppenheim (18) mentioned the case of a schoolmaster who was obliged continually to prick himself during his teaching in order to prevent himself from falling asleep. Carlill (5) records the case of a young man, who, for as long as he could remember, was liable to fall asleep at any time of the day without feeling tired and had never been free from the attacks for longer than a week at a time. He had fallen asleep on the tail-board of a cart and had been thrown off, and also on the top of a van when he was caught by an archway and swept off. He had been found asleep while scrubbing the floor, with his arm immersed in the pail of water, and had also been observed asleep while walking about.

Various influences may induce the actual attack; thus, conversation on any unpleasant subject (Weir Mitchell's case) or, as in a case described by Gowers (10) -that of a man who suffered from a nasal fistula; whenever a probe was passed down this fistula the patient promptly fell asleep. The attacks are seldom associated with any feeling of fatigue although they show an increased liability to occur during phases of mental depression. In most of those cases which are not associated with organic disease, the attack-as we shall endeavour to show later-is initiated by a complex of psychical origin.

In the majority of cases the attack occurs quite suddenly without premonitory signs, although headache is an occasional prodromal symptom. As a rule the patient suddenly feels drowsy, the eyelids droop and he is soundly asleep in a few moments. A few cases actually sink to the ground should the attack occur when standing or walking, but usually the attack takes place when sitting down. Only a minority of cases—as we shall see later-have any recollection of what occurs during the sleep, and generally the patient remains quiet. Dreams occasionally occur for instance, in one of Gowers' cases the patient experienced vivid dreams during the attack but was unable to recollect the actual details. Also, in a case recorded by L. Guthrie (11), that of a boy aged 12, a form of 'night-terror' occurred. The boy would fall asleep in the midst

of a meal or while dressing or undressing. At first the sleep appeared natural, but later was disturbed by mutterings and screaming, and finally by violent struggling.

Occasionally the sleep can be induced voluntarily-by auto-suggestion -as in a case mentioned by Gowers (10); in one attack so induced the patient died. Voluntary induction is common in the so-called 'trance' of spiritualistic mediums and in devotees in the East.

In some cases the patient can be readily awakened at any time, but in others he can be aroused only with extreme difficulty or not at all. The duration of the attack varies from a few minutes to several hours, the patient awakening spontaneously at the end of this period. Marduel records the case of a soldier who slept 70-80 hours on six occasions in two years. In most of the cases which I have encountered, the sleep lasted from 10-20 minutes. The actual frequency of the attacks varies from four to five a day (Gowers' case) to one or two a year. In some cases the attacks are more frequent and of longer duration after deficient sleep, and the leading of an active life, or the fact of being on holiday, tends to lesson their intensity and frequency. In one type of case the patient may keep off an attack with a strong voluntary effort, but feels uncomfortable and will stretch and yawn continually.

Clinical forms. Cases of narcolepsy may be divided into two main

groups:

(1) Those in which the attack is symptomatic of definite organic disease.

(2) Those in which no evidence of organic disease can be discovered.

I. CASES IN WHICH THE NARCOLEPSY IS SYMPTOMATIC
OF DEFINITE ORGANIC DISEASE.

In dealing with any particular case of narcolepsy, we have first to exclude all possibility of organic disease. The attacks may depend upon any of the following morbid conditions:

(1) Cerebral tumour, particularly of the frontal lobes and region of the third ventricle and sylvian aqueduct (mesencephalon). For instance, Stewart (19) has recorded a case of cystic growth involving the floor of the third ventricle in which the chief symptoms were paroxysms of overpowering sleep. In a case recently under my care, that of a clerk aged 40, the complaint of his employer was that he continually found the patient asleep at his work, leaning over his typewriter or across his desk; he could always be aroused without difficulty. At the time there were no definite signs of organic disease, but gradually he developed

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