业 lation and giving a supply of bad blood to the brain, fairly represent a large number of writers on the subject. In this brief review of the different hypotheses we thus see that they fall fairly distinctly into two groups. On the one hand sources of peripheral irritation, which consist almost exclusively of various indigestible foods, are made to play the chief part in the production of the malady; on the other various mechanical sources of embarrassment to the circulation and respiration, principally a distended stomach and a constrained posture, are asserted to be the efficient agents and to act by bringing about a supply to the brain of non-aerated blood. 130 129 So far as I am aware, the first writer to point out the insufficiencies of these physical factors was Moreau 1 of Tours. He laid such stress on the psychological side of the problem as to call forth from Rousset the shocked protest: "Il admet bien une excitation comme point de départ des troubles psychiques, mais avec tant de réserve, qu'on se demande si, réellement, il fait intervenir le système circulatoire dans la production des désordres cérébraux." The heresy of Moreau was, however, soon surpassed by that of Splittgerber, who not only expressed dissatisfaction with the adequacy of the physical explanations but went on to trace the origin of the mental distress in Nightmare to hidden tendencies in the mind and the agonies of an evil conscience, thus lightly foreshadowing the modern psychological view of the malady. Before discussing these matters he says in reference to the physical explanations: "Es führen uns aber gerade diese letzten Bemerkungen von selbst darauf, dass wir nun auch noch den eigentlichen und tiefsten Grund aller Verwirrung des Seelenlebens im Traum aufdecken; denn alle turbirende Einwirkung auf die in sich selbst zurückgezogene Seele von aussen her, sei es dass sie von der weiteren Aussenwelt oder von dem sei enger umschliessenden körperlichen Organismus herrührt, reicht doch nicht hin, un die Turba des Traumlebens überhaupt nach ihrer ganzen Tiefe und Ausdehnung zu erklären. Oder woher kommt es denn, dass in den phantastischen Gebilden des Traums gerade so wie in unserm wirk lichen Leben mehr Aengstlichkeit als Heiterkeit des Gemüths, mehr Unfriede als Friede des Gewissens, mehr Unreinheit als Keuschheit des Herzens, mehr Sorge als kindliches Gottvertrauen heimisch sind?" This penetrating querry of Splittgerber's well reveals the momentous gap that stands between the agents operative according to the physical explanations and the predominating features actually observed in the attack. In reality, to regard the discovery of any conceivable modification of the quantity or quality of the cere bral circulation as a satisfactory and final explanation of such a phenomenon as a sudden and mortal dread of some assaulting monster displays a divergence from the canons of scientific thinking of a kind that leaves no common ground on which the subject can be discussed. We need not further consider, however, a priori probabilities, for on the purely observational side we find that what at once strikes anyone who begins to study the malady uninfluenced by previous views is the singular lack of correlation between the alleged causes and the actual attacks. In other words, the most damaging criticism of all the hypotheses above mentioned is the straightforward observation of the frequency with which on the one hand the alleged factors occur without being followed by Nightmare, and with which on the other hand given attacks of Nightmare occur without having been preceded by any of the alleged factors. Let us take any one of them as an example, for instance gastric disorders. As a plain fact it may be observed that only a minority of individuals who suffer with Nightmare also suffer from gastric troubles, while on the other hand the percentage patients with gastric ulcer, carcinoma ventriculi, or any other form of gastric disorder-except possibly the so-called nervous dyspepsia that is found in patients suffering from Angst neurosiswho are subject to Nightmare is correspondingly small. Take again the question of posture; is there the slightest reason to believe either that the sufferers from Nightmare are peculiarly apt to sleep in constrained attitudes in comparison with other people, or that their cerebral circulation is especially liable to be disorganized by the adoption of a supine posture? As to the over-full stomach hypothesis, how many patients who dread the Nightmare, or for the matter of that, how many other people, so distend their of stomachs just before retiring to rest as to set up an embarrassment of the heart and lungs enough to cause acute poisoning with the carbon dioxide of non-aerated blood? On the other hand healthy individuals who are in reality thus poisoned or who are suffocated in any kind of way, from immersion under water, from the chokedamp of colliery explosions or from the leak of a gas stove, may pass through various interesting experiences and may suffer from many mental symptoms, but they hardly ever undergo an attack even distantly resembling that of Nightmare. Any sceptical inquiry, therefore, immediately reveals two facts. First, that all the alleged causes of Nightmare often occur, both alone and in combination, in persons who never show any symptom of Nightmare; a patient whose stomach is half destroyed with cancer may commit all sorts of dietary indiscretions, including even indulgence in cucumber-the article of food that is most looked askance at in relation to Nightmare,-he may even sleep on his back, and still will defy medical orthodoxy in not suffering from any trace of Nightmare. Secondly, that a habitual sufferer from Nightmare may be scrupulously rigorous in regard to both the quality and quantity of all that he eats, may in fact develop a maladie de scrupule in this direction, that he may martyr himself with elaborate precautions to avoid these and other "causes" of the malady, and by means of a contrivance of spikes ensure against ever lying-let alone sleeping-on his back, but despite all his endeavors he will have to endure as many and as severe attacks as before. Thus, apart from any theoretical considerations, purely empiric observation compels the conclusion that any part played by the factors we have mentioned above must of logical necessity be an exceedingly subordinate one, and that what we have called the predisposition of the individual must be a factor of overwhelming importance. My own experience has convinced me that in individuals healthy in a certain respect presently to be defined it is impossible by any known physical or mental agent to evoke any state at all resembling that of Nightmare, while in other individuals unhealthy in this respect nothing will prevent the recurrence from time to time of Nightmare attacks, and further that these can be elicted in them by the most insignificant of morbid occurrences. This is the reason why all attempts to base on experimental evi dence the physical hypotheses concerning Nightmare have had to be carried out on persons who habitually suffered from the malady; such are for example the oft-quoted experiments of Boerner," who succeeded in evoking Nightmares by covering the nasal pas sages and otherwise obstructing the breathing of sleeping individ uals, and of Radcliffe, Hoffmann, Macnish and Waller," all of whom employed various ill-digestible articles of diet. Such methods notoriously fail when applied to individuals who are not already subject to Nightmare. 133 134 135 It is therefore quite obvious that some entirely different standpoint is needed from which the problem, and especially the ques tion of predisposition, can be attacked anew. This, it seems to me, is best obtained by considering the phenomena themselves in a more direct and less theorizing way than before. Looked at quite simply, the prominent manifestations of Nightmare are seen to be an overmastering dread and terror of some external oppression against which all the energies of the mind appear vainly to be fighting. They are thus pre-eminently mental manifestations, the central one being a morbibly acute feeling of Angst. It therefore behooves us to make some enquiry into the nature and origin of this emotion in general. It may at once be said that Angst, when developed to anything approaching the morbid extent present in Nightmare, is altogether a pathological phenomenon, and in fact forms the cardinal feature of the well-defined malady known as Angst neurosis. It is interesting to note in this connection that many years ago Sauvages 17 and Sagar 1 pointed out the kinship of Nightmare and what was then called panophobia (an important clinical type of Angst neurosis). Long prior even to this, Burton, in his dis 18 Boerner. Op. cit. 138 150 183 Radcliffe. Cited by Spitta. Die Schlaf- und Traumstände der menschlichen Seele, 1882, S. 237. 184 Hoffmann. Cited by Spitta. Die Schlaf- und Traumstände der menschlichen Seele, 1882, S. 238. 135 Macnish. Op. cit., p. 133. 190 Waller. Op. cit., pp. 105, 106, 109. 17 Sauvages. Nosolog. Method. 1763. Vol. III, p. 337. 138 Sagar. Systema morbor. sympt., Vol. II, p. 520. 130 Burton. The Anatomy of Melancholy, 1826 ed., Vol. I, Pt. I, Sec. 3, Mem. 2, Subsect. IV, p. 302. 2 cursion of Symptomes of Maids, Nuns, and Widows' Melancholy, had given an excellent description of Angst neurosis and had remarked " from hence proceed . . . . terrible dreams in the night." He further pointed out that the symptoms were cured by marriage, an observation which in a modified sense contains a considerable nucleus of truth. 140 142 141 140 Many hypotheses have at different times been framed concerning the nature of Angst; thus Arndt 100 attributed it to an abnormal functioning of the heart, Wille 1" to irritation of the brain centers, Roller 140 to irritation of the medulla oblongata, Krafft-Ebing to cramp of the cardiac arteries, and Meynert to impoverishment of the cortex induced by the vessel contraction following on stimulation of the cortical vasomotor centers. The subject however remained in total obscurity until Freud "" published his now classical papers on Angst neurosis, in which he established the nosological independence of the affection and stated his conclusions as to its ætiology and nature. In these papers he pointed out how important a part is played in the generation of this malady by various abnormalities in the functioning of the sexual activities of the individual. The association in general between the sex instinct and the emotions of fear and dread is a very distant one; it is however impossible here to enter into a discussion of the exact relationships of the two, the more so as it is proposed later to deal with the subject in another paper. Suffice it to say that the type of emotion designated as Angst is in general closely connected with sexual feeling, and in particular with pathological "repression" of it or with unsatisfactory functioning of what may broadly be called the psycho-sexual system of activities. Since Freud's writings it has gradually become recognized how important is this 140 Arndt, Wille, Roller, Krafft-Ebing. Cited by Puschmann. Handb. der Geschichte der Medizin., Bd. III, 1905, S. 717. 14 Meynert. Psychiatrie. Klinik der Erkrankungen des Vorderhirns, 1884. 142 Freud. Ueber die Berechtigung, von der Neurastherie einen bestimmten Symptomenkomplex als "Angstneurose" abzutrennen. Neurolog. Centralbl., 1895, S. 50. Zur Kritik der "Angstneurose." Wiener klinische Rundschau, 1895. Both papers are reprinted in the Sammlung kleiner Schriften zur Neurosenlehre, 1906, and in Brill's recent translation of Freud's "Selected Papers on Hysteria." |