to the easily verifiable observation that these external causes can bring about an attack only in persons who are subject to the malady, and that on the other hand the most scrupulous avoidance of all these alleged "causes" will not prevent attacks with those in whom the predisposition is sufficiently pronounced. It is probable that most of the causes that have been given by various writers in this connection may play some slight part in the manner we have indicated, though I am convinced that the significance of them has in the past been enormously exaggerated. For instance, that a heavy repast is apt to be followed by an accession of erotic desire is an observation acted on by every roué; that it, like alcohol, tends to dull the activity of the conscious inhibitions of the waking state and so release suppressed mental trends is so well known as to make it comprehensible that it may occasionally play some part in the evocation of Nightmare. A full stomach may also act by arousing the sensation of a heavy weight lying in, and therefore on, the abdomen. The relation of diet in general to erotic dreams is fully pointed out by Spitta.' Thus the observations made in this connection by the older writers almost always contain a certain modicum of truth, although the explanations of them offered have been wide of the mark in attributing to physical factors ninety-nine per cent of importance in the production of Nightmare, whereas in reality less than one per cent should be so attributed.

168

We have last to say a little about the clinical significance of Nightmare. I shall say nothing about the occurrence of Nightmare in children, for the subject has such special features, and the psycho-sexual life of children is so enshrouded in obscurity, as to demand treatment in an article devoted to it alone. I shall further take the definition of Nightmare in its strict sense, as a distressing dream necessarily showing, amongst other features, the three cardinal ones that were described above. A large variety of distressing dreams, equalling in intensity the classical Nightmare attack but not having the sense of direct physical oppression characteristic of this, will thus be excluded.

It is impossible to reach even an approximate estimate of the

169

Spitta. Die Schlaf- und Traumzustände der menschlichen Seele, 1882, S. 252.

170

171

frequency of the malady. Waller's 10 statement that there are few affections more universal among all classes of society is certainly untrue if the above definition is adhered to, for true Nightmare is beyond doubt much rarer than the more complex forms of Angst dreams. Waller 1 and Macnish both state that men are more subject to it than women, and of these unmarried women more than the married. In judging from my own experience I would say that the second statement is true; as to the first, I have no decisive evidence, though I would agree with Cubasch" when he says that the manifestations of Nightmare are generally more stormy and vehement among men and the agony correspondingly greater. Waller and Macnish " also state that sailors are of all men most subject to Nightmare, the former attributing this to their coarse unwholesome food; there is, however, a clue to another explanation in Macnish's remark, made in the days when long voyages were common, that the attacks more often occurred at sea than on shore. Bond quaintly observes that "Melancholy persons, profound Mathematicians, and fond pining Lovers, are most subject to this affection," and Bell, a still earlier writer,TM says that it affects those who "are Melancholly, of few and gross Spirits and abounding with Phlegm."

173

175

174

In subjects who pass as being mentally normal, Nightmares rarely occur as isolated morbid phenomena; on investigation it will always be found that other manifestations of Angst neurosis are present, with or without evidences of hysteria. In short, Nightmare may in such a subject be regarded as a symptom of this affection, and should be treated accordingly. This fact was partly realized nearly a century ago by Waller when he wrote that "Nightmare may be considered only as a symptom of great nervous derangement or hypochondriasis." I might add that in my

experience "repression" of the feminine or masochistic component of the sex instinct rather than of the masculine is apt to engender the typical Nightmare, a fact which probably explains why the malady is usually more severe, and possibly even more frequent, in men, with whom this component is more constantly and more intensely repressed than with women.

178

In subjects who deviate still more from the normal, more alarming evidences of a lack of harmonious control of the psycho-sexual activities may be present, such as satyriasis or nymphomania, as in a case recorded by Ribes." This however is decidedly uncomAlso, as was previously mentioned, the affection is frequently met with in various forms of mental alienation, particularly manic-depressive insanity and dementia præcox, and especially during the early stages of the disease.

We may summarize the conclusions reached in the statement that Nightmare is a form of Angst attack, that it is essentially due to an intense mental conflict centering around some repressed component of the psycho-sexual instinct, and that it may be evoked by any peripheral stimuli that serve to arouse this body of repressed feeling; the importance however of such peripheral stimuli in this connection has in the past been greatly over-estimated as a factor in the production of the affection.T

178 Ribes. Observation d'un cauchemar causé par la nymphomanie. Mém et observ. d'anat., de phys., etc., 1845, T. III, p. 127.

179 It is intended that this part be followed by two others, one detailing a number of cases of Nightmare studied by the psycho-analytic method, the other dealing with the role played by the Nightmare in history and in mythology.

SYPHILIS AND INSANITY.

A STUDY OF THE BLOOD AND CEREBRO-SPINAL FLUID.

BY A. J. ROSANOFF, M. D.,

Second Assistant Physician,

AND

JOHN I. WISEMAN, M. D.,

Medical Interne, Kings Park State Hospital, Kings Park, N. Y.

Since the introduction of the Wassermann reaction it has become possible to detect syphilis in cases in which it exists in a latent form. This reaction, besides being an aid in diagnosis, affords important therapeutic indications and constitutes, furthermore, a means of investigation of the relationship between syphilis and various pathological conditions of obscure etiology.

In the work, the results of which are embodied in this contribution, we have made use of the Wassermann reaction, applied to the blood and to the cerebro-spinal fluid, for the purpose of gaining some acute knowledge of the role played by syphilis in the pathogenesis of insanity.

With the same object in view we have also made use of the butyric acid reaction for syphilis recently suggested by Noguchi' and have subjected our findings to control by means of cytological examinations of the cerebro-spinal fluid.

§1. METHODS OF INVESTIGATION.

2

The original technique of the Wassermann reaction has given in the hands of different investigators widely differing, almost contradictory results. To take a few striking instances, Plaut examined the blood serum from 159 cases of general paresis and found a positive reaction in 100 per cent; Edel' obtained similar

1

1 Proceedings of the Soc. for Experimental Biol. and Med., 1909, Vol. VI, pp. 51-54.