Spontaneous somnambulism may occur without sleep in certain subjects as the result of a strong emotion which may cause a profound psychic disturbance lessening the activity of the attention and so modifying the consciousness as to induce the symptoms of somnambulism. Religious ecstacy at times is responsible for an hallucinatory somnambulism in which visual and auditory hallucinations play a part. Hysteria, especially, induces somnambulism either during the convulsive crises, subsequent to them or even in their absence, when the somnambulistic state seems to replace the crisis.

The cause of the somnambulism is often unknown. Out of the innumerable ideas passing through the mind one alone may in an impressionable individual be retained by the brain and be responsible for an active auto-suggestion. A dream, for example, forgotten in the waking state, may by some association of ideas give rise to a more or less lasting suggestion which will absorb and direct the physical and psychic activity of the subject.

Before leaving the subject which I have elaborated further elsewhere, I would add a word on the transformation of the personality manifested in that form of somnambulism in which the subject, controlled by a certain sequence of ideas, may lose the feeling of his own identity and believing himself another personality act in consequence. Other subjects without losing their identity, without active hallucinations change only as to their character or habits for a variable time and upon their return to the normal consciousness have forgotten that they have passed through an abnormal state. Such a state may be repeated periodically and constitute the so-called double personality or consciousness of which many examples have been cited in the literature. At first glance, cases of this type seem strange and mysterious, contrasting so strongly as they appear to with our physiological psychology, yet, reflection shows that they have their analogues in normal states so common that we pay no attention to them. Under the influence of certain emotions or impressions there may be an entire change in character; a person becomes angry, for example, and does things which are entirely at variance with his accustomed mental attitude. After a time his good nature returns and sometimes he has no clear recollection of what he did during the period of transformation. Certain women at

the time of the menstruation pass through such experiences. These phenomena are not extraordinary and do not impress us nor appear pathological unless they are followed by amnesia when we believe that the subject has two lives, two personalities of which the one is ignorant that the other exists.

But however remarkable this amnesia may be it does not

imply any fundamental peculiarity of the period of modified consciousness; it is not constant, it is not always complete. We have seen that in the second state certain subjects preserve a memory of the first condition, retain their sense of identity. The experiences of experimental somnambulism are sometimes, as with dreams, more or less clearly realized on the resumption of the normal state and one can always, by suggestion, recall them. Is it the same with the spontaneous double personality? The reawakening of the memory is more difficult in the natural than in the experimental somnambulism because in the latter we ourselves, by suggestion, have placed the mind in a state of concentration which has created the images and it is easy to reduplicate that state. But when the somnambulism is the result of special emotions provoked by hysteria, illness or certain physical or moral shocks it is not always easy, by suggestion, to reproduce an analogous state of consciousness which shall recall the same images, for the conditions responsible for the phenomena must be reproduced, and that mere verbal suggestion cannot always do. This same amnesia, more or less well marked, is common as the result of emotional shocks, accidental or pathological, which profoundly modify the consciousness. Following typhoid fever the patient has sometimes forgotten what happened in the early days of his illness or even before its onset, when the consciousness was active and the intelligence clear. Certain criminals who have perpetrated a crime, even with premeditation, but with a brain over excited by their horrible conception, preserve only a confused recollection of the drama in which they have played a part, or else appear to have forgotten it entirely.

Hence, amnesia must be considered as a phenomenon, sometimes but not always, added to all serious psychological disturbances. But whether amnesia is present or not, the modification of consciousness which we term somnambulism is the same, just as the dream is the same whether or not it be followed by amnesia. Between absolute amnesia and perfect recollection all stages may occur, and this fact does not change the psychic nature of the phenomenon. To show that the psychology of somnambulism and the double personality, however singular and abnormal it may appear, has its analogue in normal psychology, and to separate from these phenomena the taint of the mysterious and marvelous has been the constant aim of my studies.

CONCLUSIONS.

I. Profound sleep is characterized by complete suppression of the psychic function of the brain occurring spontaneously as a periodical, psychological process.

2. Dreams are the result of the automatic activity of the imagination uncontrolled by the faculty of judgment.

3. The dream presupposes that the brain is awake to some degree, greater in the case of the active dream than of the passive. 4. Profound sleep produced by suggestion is accompanied by unconsciousness with purely reflex reactions.

5. The so-called hypnotic phenomena, catalepsy, induced contractures, analgesia, hallucinability and suggestibility demand a reasoning activity implying the awakening of the mental faculties.

6. Active suggestion expressing itself by acts, thoughts or hallucinations constitutes somnambulism which may be induced in certain subjects either in the sleeping or waking states, and in both states it may occur spontaneously as the result of emotional shocks of hysterical or epileptic crises or of injuries.

7. The acts of somnambulism like all serious disturbances of consciousness may be followed by a total or partial amnesia. In the induced form of somnambulism the memory can always be reawakened.

8. Somnambulism lasting for a considerable period of time with or without hallucinosis constitutes a somnambulistic life which if repeated often in the same subject alternating with fair regularity with a period of normal life constitutes the so-called phenomenon of double consciousness or double personality. Such states without amnesia are natural to many individuals.

9. These different phenomena, dreams, somnambulism or the double personality are not due to unconscious cerebral activity but rather to a cerebral activity modified dynamically by suggestions or auto-suggestions which control the acts, thoughts and feelings, indeed all the active mental life of the subject.

VIII

PURULENT STREPTOCOCCIC CEREBRO-SPINAL MENINGITIS

FROM MIDDLE EAR DISEASE:

(PLATES XXVII-XXIX)

BY RUTH B. COLES, M.D., AND SOLOMON C. FULLER, M.D.

The opportunity to follow clinically the development, course and termination of even an isolated case of purulent cerebro-spinal meningitis, of streptococcic origin, and to compare with these the autopsy findings, is not sufficiently common to detract from the interest of the following case:

W. S. H. (Dr. Coles) No. 9291, a woman thirty-six years of age, was admitted to Westborough State Hospital, Dec. 3, 1910.

Family History.-The family history reveals a neurotic taint, if not a direct heredity for mental disease. The mother of patient was of a nervous temperament and suffered from heart disease. Two near relatives (brother and paternal grandfather) died from tuberculosis, one distant relative (paternal) was insane following an accident when twenty. Otherwise the family history as elicited is unimportant.

Previous History.-The patient herself was never rugged as a child, although she had no serious illnesses. She showed a normal mental development, and was a graduate of Wellesley College. She was naturally a student and hard worker; normally social and of attractive personality. She was married at the age of twentysix and had borne one child, now eight years old. There were no complications noted with the labor, but during the lying-in period the nurse reported that the patient appeared "queer" at times. To everyone else she had seemed normal until two years ago, when the mental trouble developed rapidly. She was, at first, excessively "nervous" and worried over unimportant things. She did not sleep or eat well, and complained of her head feeling badly. Hallucinations of hearing soon developed with ideas of suspicion against those about her; she was fretful and despondent, though this last was not profound. She was later untidy, even filthy, but not violent or especially resistive.

Here. The patient was well nourished physically on admission to Westborough, but the following abnormal conditions were noted: heart's action arythmical and accompanied with mitral and aortic murmurs; tongue coated, bowels sluggish; the left pupil larger than right, both reacting sluggishly to accommodation but normally to light; hearing normal in right ear, markedly dull in left. No other physical disturbances were detected.