German authors, respiration may even cease (hysterical suspended animation). In a case of Pfendler's quoted by Binswanger, no sign of life could be detected for 48 hours and everything was prepared for the interment. There is usually complete anaesthesia to all stimuli and the superficial reflexes-including the corneal are abolished. The deep reflexes are usually retained. The attacks in duration may be very prolonged; Achard (2) mentions the case of a woman aet. 25, who lived in a little village on the Aisne, in whom an attack persisted for several years. Some writers have regarded this cataleptic form as closely allied to stuporose states. (e) Lastly, we have a form which is comparable only with true epilepsy, and indeed, as Westphal and others have considered, may occur as the 'equivalent' of an epileptic attack. We thus reach a physiological level in our scale of gradations. Although these latter narcoleptic attacks may alternate with ordinary epileptic seizures, they are in no sense attacks only of 'petit mal.' They differ from this form of minor epilepsy in that there is no pallor, they are of longer duration, and there is a perfect resemblance to normal sleep both in their onset and character. I have met with one example:

L. F. B. aet. 25, was first seen in May, 1920. There was a history of 'fits' in childhood but they ceased at the age of 10, and no further attack occurred until August, 1913; at this time he was serving in the Army. About four weeks after the above attack he fell asleep whilst cleaning his buttons and could not be roused for several hours. Since this time he has had 24 such attacks; they have occurred at any time, under all conditions, and often in perilous situations. In duration they have varied from two hours to two days. He states that he sleeps quite soundly at night, even though he may have had an attack during the day. Three fits -description suggesting true epilepsy-have occurred since 1913. In January, 1919, he was seen towards the end of a narcoleptic attack. The face was normal in colour, pulse and respiration slowed, the corneal reflex feebly present, the eyes rotated upwards with slight lateral nystagmus, the optic discs pale, the right abdominal reflex absent, and the left sluggish, the left plantar reflex extensor and the right indefinite, and the deep reflexes sluggish. He could not be roused even by forcible stimulation, or by pressure on hyperaesthetic zones, although the latter gave rise to slight defensive movements.

The time has now passed when we were content merely to have diagnosed a condition as hysterical; we now have to learn something further regarding the mechanism of the patient's so-called hysteria, for purposes of both accurate diagnosis and treatment. Even a superficial

analysis will often reveal that a particular attack served a purpose in enabling the patient to escape from a painful idea or responsibility— to avoid some necessity for adaptation. Some painful experience or unpleasant idea is repressed, and the emotion, which appertains to the dissociated complexes and to which there has been no reaction, manifests itself in the attack of sleep, and in this way the affect of the dissociated complex is weakened. The complex is robbed of its affect, which is the real object of the conversion, and hence its value to the individual. This mechanism can best be illustrated by reference to a case which recently came under my observation.

L. L. aet. 27, a schoolmaster, complained that from time to time he had 'attacks of sleep' of several (4-6) hours' duration. They invariably occurred in term time (never during the holidays) and always developed soon after he woke up in the morning and before he got out of bed; he would then sleep until 4 or 5 o'clock, all attempts to rouse him being futile. He had no recollection of what occurred during his sleep, nor of any of the efforts to awaken him, but would often swallow food if placed in his mouth. He insisted that he was very keen on his work, and desired no other form of occupation. A psychological investigation, however, soon revealed that this was not the case, there being an unconscious resistance to teaching, and that the mechanism in his case was as follows:

L. L., having repressed his distaste for teaching, finds on waking up that he has to go to school; the work is irksome, consequently his necessity for escaping reality and seeking pleasure are in conflict and results in his falling asleep. He does not go to school, therefore, his own desire is gained, and at the same time his herd instinct (or employment demand) is satisfied by the attack of sleep, which is an acceptable excuse, and the painful recognition of his own selfishness is converted into sleep.

In other cases the occurrence of the narcoleptic attacks depends upon a tendency to the revival by association of certain painful experiences that have been repressed from consciousness.

The actual starting-point of an attack is usually by an associationcomplex which probably acts upon the sleep-controlling centre in the manner already described. In some cases there is a tendency to fix the gaze on some small object immediately prior to the attack.

Treatment. It is beyond the scope of the present communication to deal with the treatment of the organic forms of narcolepsy, for the relief of which therapeutic measures must be directed towards the cause. As regards the psychogenic forms we have the following methods of treatment at our disposal:

1. Simple explanation and encouragement.

2. Hypnotic and post-hypnotic suggestion.

3. Preliminary psychological investigation with the revival in a hypnoidal condition of the emotional experience on which the attacks depend.

4. Complete psycho-analysis.

It is very rarely that simple explanation has the slightest effect, and in my experience hypnosis and post-hypnotic suggestion is equally unsatisfactory. Although this method may abolish the attacks, such relief is, as a rule, only temporary. In this connection Myers (17) points out that it is a well-established fact of experimental psychology that one process does not destroy but can at most merely inhibit an antagonistic process, and that other things being equal the older process tends to outlast the later acquired activity.

The forms of gross suggestion that have been employed in the attempt to relieve narcoleptic attacks (e.g. false operations, trephining (as in Carlill's (5) case), without impugning the purity of motive of the physicians concerned, cannot be too strongly condemned.

I believe the most satisfactory of the shorter methods of treatment to be (1) a preliminary modified 'psychoanalysis' with a detailed investigation into the history of the onset of the attacks, and of the individual, followed by (2) reconstruction of the origin of the narcolepsy, or of the emotional experience giving rise to the condition, under light hypnosis. It is well known that a light degree of hypnosis is most effective for the process of reassociation, and its value, for the elicitation of memories which one is unable to revive in a waking state, is undoubted. The following is an example of a case of narcolepsy which responded favourably to this form of treatment.

F. L. T. aet. 21, was first seen on March 22nd, 1920, the diagnosis being one of traumatic minor epilepsy.

History. No illness of any importance prior to war service; no previous fits or nervous disorders. His mother suffers from Graves' disease; family history otherwise negative.

He enlisted in the R.A.F. in March, 1917, was commissioned in December, 1917, and proceeded to France in April, 1918. Having made several successful observations and bombing flights soon after arrival, he was acting as observer on one occasion during May, 1918, when his aeroplane came under the fire of enemy anti-aircraft guns at fairly close range; one shell exploded underneath the machine, whereupon his pilot lost control and a crash resulted. F. L. T. was apparently thrown upon

his head and lost consciousness; he 'came round' about an hour later in a dressing station, and while he was still an inmate there was bombed by enemy aircraft. He felt very nervous but immediately fell asleep; these attacks of sleep recurred almost daily even after he was evacuated to England. After a few months the attacks averaged three per week. Finally, he was discharged from the Army in much the same condition in February, 1919.

Condition on admission. He states that all attacks are diurnal and are preceded by no warning whatever. He was unable to assign any causes to individual attacks. Following the attacks, he occasionally became emotional and also suffered from intense headache. He was depressed, somewhat irritable, and stated that he was too nervous to go to sleep at night; dreams were few and far between and were not of a startling character. He had a definite fear that he would become insane. At this time, owing to erroneous diagnosis of epilepsy, he was taking 30 grains of potassium bromide a day, and two drachms of paraldehyde at night, and was not allowed to go about alone.

The physical examination did not reveal any evidence of organic nervous disease; he appeared very apprehensive, and exhibited slight general tremors. He said the last attack of sleep had occurred on the previous day, quite suddenly while he was talking to a nurse; he recollected sinking down but remembered nothing further until he found himself in bed with an intense headache. He related the history of the crash and the development of the nervous disorder quite clearly and without any sign of increased emotion.

Progress, etc. Following a detailed investigation of his case history, the first step was to bring about the omission of the paraldehyde and a rapid reduction in the amount of bromide he was taking. As a result there was no appreciable increase in the frequency or severity of the sleeping attacks, and after three weeks bromide was stopped entirely. A further discussion of the experiences of the crash, and an endeavour to revive in the waking state the emotions associated with it, did not meet with any success. In the meantime he was encouraged to go about alone. At his next visit, he was lightly hypnotised and the 'crash' experience again revived. After a few preliminary suggestions that he was in the air, over the enemy lines, and was apprehensive of crashing, he went through the whole experience without any further exhortation, and exhibited all the emotion that one would associate with such an experience. He trembled, sweated, and clung to imaginary stays, and finally finished by shouting, "We are going to have a hell of a crash."

Incidentally I ascertained that a thought of a crash or similar accident had immediately preceded his attacks of sleep. From that time, which was in June, 1920, he has had no more attacks, has quite lost his fear of insanity, and has worked continuously as an election agent, passing through the stress of a general election.

C. S. Myers (17) has also recorded a case which was much relieved by the revival under hypnosis of a repressed incident in which the patient was face to face with an orang-utang and had to shoot the animal. In this case there was no emotional abreaction during the return of the lost memories, and from this case and others Myers concludes that for a successful result an emotional 'abreaction' during the revival of the dissociated memories is not essential. He believed that it is not the emotional component of the experience that is primarily repressed, but the 'unpleasant' component (cognitive experience) and that the resistance against revival expresses the inability to admit the unpleasant, not the inability to face the emotion. Of the veracity of this latter view I am not entirely convinced, as I have seldom been fortunate enough to obtain a satisfactory result in any form of neurosis by a mere revival of a repressed experience in the absence of an emotional component.

REFERENCES.

(1) ABRAHAMSON. Journal of Nervous and Mental Diseases, LII. 193. (New York.) 1920.

(2) ACHARD. Paris Med. 209. Sept. 18th (38th year). 1920.

(3) BALLET, G. Rev. de Med. 925. 1882.

(4) CAMUS and Roussy. Bull. et Mem. Soc. Med. des Hôp. de Paris, XLVI. 1238. 1922.

(5) CARLILL, H. Lancet, 1128. Dec. 20, 1919.

(6) ECONOMO. 35th "Congress of Internal Medicine." Vienna, 1923.

(7) FÉRÉ. Semaine Medicale. 1893.

(8) FRIEDMAN. Zeit. Für. Neurolog. XXX.

(9) GÉLINEAU. De la Narcolepsie. Paris, 1881; Gaz. des Hôp. de Paris. 1880.

(10) GOWERS, W. Diseases of the Nervous System, 1. 953. 1888.

(11) GUTHRIE. Allbutt and Rolleston's System, VIII. 814. 1910.

(12) HALL, A. J. Lancet, 739. April 14th, 1923.

(13) JANET. Major Symptoms of Hysteria. Paris.

(14) JELLIFFE and WHITE. Diseases of the Nervous System. 1919.

(15) KÜLPE, O. Outlines of Psychology. 1909.

(16) LAMARCQ. Rev. de Med. 1897.

(17) MYERS, C. S. Lancet, 491. Feb. 28th, 1920.

(18) OPPENHEIM. Diseases of Nervous System, II. 1117. 1911.

(19) STEWART, PURVES. Diagnosis of Nervous Disorders. 1911. (20) STODDART. Mind and its Disorders. 1921.

(21) THOMSON, J. Brit. Journ. of Children's Diseases, xx. 1923.