ON 
MORBID DROWSINESS AND 
SOMNOLENCE 
A CONTRIBUTION TO THE PATHOLOGY OF SLEEP 
BY 
C. L. DANA, M.D. 
NEW YORK 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE POST-GRADUATE MEDICAL SCHOOL 
[Reprinted from the Journal of Nervous and Mental Disease, Vol. xi/., 
No. 2, April, 1884] ON MORBID DROWSINESS AND SOMNOLENCE. 
A CONTRIBUTION TO THE PATHOLOGY OF SLEEP. 
By C. L. DANA, M.D., New York. 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE POST-GRADUATE MEDICAL SCHOOL. 
I WISH to call attention to certain forms of abnormal 
drowsiness and somnolence, which I believe many 
physicians have had some experience with, but concerning 
which little has, of late years, at least, been systematically 
written. I do not mean the somnolence of indolence, obe- 
sity, bad air, or organic disease, but I refer to certain pecul- 
iar forms of morbid sleepiness which are dependent upon 
some constitutional, and generally neurotic, taint. 
The first writer upon this subject was a physician of the 
first century, Aretseus, who left two books upon “ The 
Lethargies.” Galen, his contemporary, also made many 
references to abnormal somnolence and lethargy. On the 
other hand, as Mr. More Madden well says, at the present 
day we find that in the five large volumes on nervous dis- 
eases in Ziemssen’s Cyclopjedia there is barely a reference 
to this subject. Perhaps we are more wide-awake than 
we were seventeen centuries ago. 
I have been able to find reports of only about fifty cases 
of-morbidly prolonged somnolence. Nearly all of those re- 
ported previous to 1878, are cases of what have been termed 
trance-sleep, or lethargy. Since the above date, when 
Gelineau called attention to a disease which he called nar- 
Reprinted from the Journal of Nervous and Mental Disease, Vol. xi, 
No. 2, April, 1884. 2 
C. L. DANA. 
colepsy, other and more peculiar forms of somnolence 
have been placed on record. 
In my own experience, I have seen five cases which come 
under the head of morbid somnolence, and to these I can 
add two cases, the notes of which were kindly furnished me 
by Dr. L. Putzel, of this city. 
A study of these cases which I have collected shows 
some curious perversions of sleep. 
A married woman in good health, active, but somewhat 
advanced in years, was subject to continual attacks of 
drowsiness and sleep, so that she had to have an attendant 
with her whenever she went out to call or to walk. This 
condition lasted for years. 
A girl, says Lesegue, while sitting in church, felt an irre- 
sistible desire to go to sleep. Such sensations have been 
felt by others, but not manifested in this same way. She 
went home and decently retired to bed, where she fell 
asleep, and did not wake up for three days. She subse- 
quently often had similar attacks. It was certainly a 
unique illustration of the persistent hypnotic effect of 
Biblical exegesis. A married man of forty, while out in a 
field hunting, in the midst of the excited expectation of the 
prospective game, sat down and slept for three hours. He 
could only be aroused by the de-mesmerizing process of his 
wife, who, it was subsequently found, could send him to 
sleep and wake him up at her own sweet conjugal will. He 
lived for many years under this morphic sway of his too- 
soothing consort. 
A young officer in the British army, says Madden, slept 
so long every day, that he was forced to resign his commis- 
sion. This was not due to laziness, but was explained in 
politer terms as an idiosyncrasy. 
A patient of my own, a healthy young salesman, was 
subject to periodical attacks of somnolence. He would go to ON MORBID DROWSINESS AND SOMNOLENCE. 
3 
bed at the usual hour feeling well, and could not be roused 
until 12 M. or 6 o’clock P. M. the next day. These attacks 
would last for a week or ten days. During them his mind 
appeared to be disturbed. 
A prominent clergyman in New York City used to be 
constantly overcome with sleep while writing his sermons, 
or engaged in any other mental work. 
Gelineau tells of a man who was subject to frequent and 
annoying attacks of drowsiness or sleep. Whenever he was 
in a most expectant or interested condition, when about to 
dine, when going to the theatre, when walking in the street, 
he would fall sleep, and had to be pinched and drubbed 
till he awoke again. 
A patient of mine, an active business man, while suffering 
from a train of neurasthenic symptoms, became the victim 
of an unconquerable and persistent drowsiness, which 
obliged him finally to leave his work. 
These are some of the illustrations of the perversities of 
sleep. The cases which I have collected include those of 
trance lethargy—the sleeping men and girls, as they are 
called. They include also some of the cases of hysterical and 
mesmeric sleep. Moreau, Briquet, Bourneville, and Richer 
have reported altogether a good many cases of this latter 
kind, which I have not tried to quote. And they show 
that this form of morbid somnolence, though more common 
than other forms, is still comparatively rare. Briquet, 
among over 400 cases of hysteria, met three cases of pro- 
longed somnolence and eight of lethargy. He makes a 
distinction between these terms, as do others, and very 
properly. In lethargy the condition of unconsciousness is 
generally more profound, the reflexes are abolished, and 
the patient cannot be roused. As a case reported by 
Gairdner shows, a patient may even have periods of sleep 
within the lethargy. Nevertheless, the two states are very 4 
C. L. DANA. 
closely allied clinically and pathologically. And in some 
instances the patient is part of the time simply in deep 
sleep, at other times in complete lethargy. I have thought 
best, therefore, to consider the two states together under 
the common title of prolonged or morbid somnolence. 
I have already said that the various forms of morbid 
drowsiness and somnolence to which I call your attention, 
do not include the common and simple cases, such as occur 
in every-day practice. Many persons are too drowsy after 
meals, and perhaps too sleepy on cold mornings or after 
midnight indiscretions, to be in a perfectly healthy state. 
There are many forms of drowsiness due to old age, to 
organic disease, to obesity, to diabetes, and to cerebral 
vascular disease. 
I enumerate these causes here, and exclude them as the 
chief pathological factors in my cases. These latter I con- 
sider to be in the main expressions of some neuropathic 
state; to be, in fine, neuroses. 
The causes of ordinary forms of drowsiness and som- 
nolence are: 
1. Old age, when there is a weakened heart or diseased 
arteries, with cerebral mal-nutrition. 
2. The diseased vascular conditions which precede cere- 
bral hemorrhage. 
3. The cerebral mal-nutrition or inflammations occurring 
before or during certain forms of insanity. 
4. Various toxaemiae, e. g., malarial, uraemic, cholaemic, 
syphilitic. 
5. Dyspepsia. 
6. Diabetes. 
7. Obesity. 
8. Insolation. 
9. Cerebral anaemia and hyperaemia. 
10. Cerebral tumors and cranial injuries. ON MORBID DROWSINESS AND SOMNOLENCE. 
5 
11. Exhausting diseases. 
12. The sleeping sickness of Africa. 
Of course, I cannot deny that in some cases of the hyp- 
notic neurosis certain of the above factors enter. But I 
look upon them as secondary. 
In studying the symptoms in the various cases which I 
have collected, I find that the somnolence shows itself in 
very different ways : 
I. Sometimes the patient suffers from simply a great pro- 
longation of natural sleep. He sleeps fourteen or eighteen 
hours out of the twenty-four. When awake he is not 
drowsy. His attacks may daily succeed each other (periodi- 
cal prolonged somnolence). This may be continued for 
some time. 
II. Sometimes the patient suffers from a constant per- 
sistent drowsiness, which he is often obliged to yield to. 
(Persistent drowsy and somnolent condition, with some re- 
missions.) 
III. Again, the patient may be subject to frequent brief 
or comparatively brief attacks of somnolence, not being 
drowsy in the intermissions. 
IV. In some cases there are single or repeated prolonged 
lethargic attacks. These are the cases which often become 
notorious, as sleeping or fasting girls. But it also includes 
others of a less marked type. 
V. Finally, some patients—and they include the largest 
number—suffer from periodical attacks of profound som- 
nolence or lethargy, which last for days, weeks, or months. 
If they continue for months they are generally interrupted 
by very brief and incomplete remissions. 
In these different conditions, the accompanying symp- 
toms necessarily vary much. As a rule, the health of the 
patient finally suffers. Morbid somnolence may be much 
more serious than insomnia. Sometimes the consciousness 6 
C. L. DANA. 
during the attacks is not entirely abolished. In the epilep- 
toid and hysteroid sleep, and in the lethargic states, the 
pupils are generally dilated instead of contracted, as in 
normal sleep. In deep lethargy the reflexes are abolished. 
The diseased condition is generally a chronic one, lasting 
for years. It may end in insanity, suicide, or in death from 
mal-nutrition or starvation. In certain forms of somnolence, 
however,—especially those of a hysterical nature,—the 
patient’s health does seem to suffer. 
I do not find that a clinical classification is alone a suffi- 
ciently useful one. Morbid somnolence is, of course, a 
symptom, and, in the cases which I am considering, a symp- 
tom of some neuropathic condition. I have tried, there- 
fore, to classify the cases in accordance with the pathological 
state which we may assume to be at the bottom of the 
trouble. 
One very soon sees that most cases of functional morbid 
somnolence are closely related to the epileptic or hysterical 
diathesis. 
We have, therefore : 
I. The epileptoid sleeping states, some of which seem to 
correspond to petit mat,—some to haut mal. 
II. We have also the hysteroid sleeping states. These 
include the lethargies and the sleeping-girls, but also indi- 
viduals who are subject to short attacks of sleep and even 
persistent drowsiness. They should include, also, the vic- 
tims of spontaneous or provoked mesmeric sleep. 
III. Finally, there is a class of cases of a puzzling na- 
ture. We find no history or evidence of epilepsy or hysteria 
in them ; and though we may call them epileptoid or hys- 
teroid, it is certainly but a make-shift to do so. The pa- 
tients seem to be the victims of a special morbid hypnosis. 
Possibly they have a cerebral hyperaemia or anseuria. 
Some of them simply feel a morbid necessity for sleep, and ON MORBID DRO WSINESS AND SOMNOLENCE. 
7 
do sleep twelve hours or more out of the twenty-four. Or 
they are oppressed by a continual drowsiness or by frequent 
attacks of somnolence, or even by attacks of long and pro- 
found lethargy. 
The predisposing causes in these forms of somnolence are 
chiefly a neuropathic constitution, which is in some cases ac- 
quired, in some cases inherited,—sometimes the disease itself 
seems to be directly inherited. The epileptic and hysteric 
diatheses, are found with especial frequency. As regards 
sex, it is only in those cases where the morbid sleep is ap- 
parently a pure hypnostis that the males are more suscep- 
tible. In the other forms the ratio of females to males is 
about as four to one, which is considerably less than the 
ratio in hysteria. The age at which the trouble appears 
varies between eleven and forty-seven. Most cases occur 
between the ages of twenty and forty. The hysteroid cases 
are materially younger. 
This may be shown by the accompanying table: 
Total No. 
Age. 
Sex. 
Epileptoid. Sleeping States. 
ii 
15-30=6. 
30-40=65. 
Male 4. 
Female 7. 
Hvsteroid. Sleeping States. ■ 
26 
16-32. 
Male 5. 
Female 21. 
Other Forms. 
12 
12-40. 
Male 9. 
Female 3. 
Male 18. 
Total. 
49 
Female 31. 
The exciting causes are difficult to determine. Violent 
emotions, fright, injury, great exhaustion, over-work, ex- 
cesses, appear to bring on the attacks in many instances. 
Habits of indolence may finally end in producing a degree 
of drowsiness, which is certainly morbid. 
Treatment.—“ Lethargies,” says Aretaeus, “ are to be laid 
in the light and exposed to the rays of the sun (for the dis- 
ease is gloom) ; and in a rather warm place, for the cause 
is congelation of the innate heat.” C. L. DANA. 
Noises to arouse the patient, cupping, blisters, and rube- 
facients, sternutatories, of castor, emetics, and purges are 
recommended, by that author and by Galen. 
Modern therapeutics has not advanced greatly beyond 
Aretaeus in the treatment of lethargies. In the other and 
slighter forms of the disease, however, we can do much more. 
We can, for example, remove cerebral anaemia, or hyperae- 
mia, improve the general nutrition, reduce obesity, correct 
the diabetic troubles, and greatly relieve the epileptic or hys- 
terical taint. 
We can and should exclude such factors as malaria, 
uraemia, cholaemia, dyspepsia, or syphilis. If there is anae- 
mia, we should use iron, arsenic, nitrite of amyl, glonoin, 
digitalis, hydrotherapy, electricity, and general hygienic 
measures and tonics. Change of occupation or travel and 
a course of mineral waters at some resort have proved suc- 
cessful. 
As symptomatic remedies we can recommend coffee, 
caffein, coca, belladonna, nitrite of amyl, and sternutatories. 
Laycock’s sternutatory, composed of powdered cinchona and 
white hellebore, is an excellent one. The ancient authorities, 
like Galen and Aretaeus, recommend castor. 
In hysterical cases, tartar emetic has been very success- 
fully used. 
Systematic and persistent attempts should be made to 
break up the special somnolent attacks. Some cases need 
to be fed with the stomach-tube. 
Having reviewed the general features of the mor- 
bidly somnolent states, I now present the history of a few 
cases which came under my own experience. Two of 
them I have briefly alluded to. None of them, I believe, 
come under the head of epileptoid sleeping-states. Two 
occurred in persons who presented the symptom-complex 
known as neurasthenia. One was a case in which the som- ON MORBID DRO WSINESS AND SOMNOLENCE. 
9 
nolent attacks alternated with attacks of cataleptic petit 
mal, while the fourth is a case which I can only classify as 
being a separate morbid neurosis. 
The history of this last case, which was the most in- 
teresting as well as perplexing to me, is as follows: 
Case i.—The patient is a young man, twenty-eight years old, un- 
married. There is a history of phthisis in the family but no nerv- 
ous trouble of any kind, except that a younger brother had when 
about ten years of age several general convulsive attacks, 
probably epileptic, which later disappeared entirely. The patient 
himself when a boy had eczema, and when about twenty years 
old suffered from a loose cartilage in the knee-joint and dropsy of 
the same articulation. From this he entirely recovered in a 
year or two. Aside from these things he has always been well. 
He had always been a late sleeper but when awake was 
bright, active, intelligent, and of excellent business capacity. 
There was not the slightest evidence of hysteria about him, though 
he has some unobtrusive mental peculiarities. About eight 
years ago his family began to have serious trouble in getting him 
up in time for his work in the store where he was a salesman. He 
would be easily roused mornings but would go to sleep again and 
would not get out of bed, despite all arguments and urging, until 
ten, eleven, or twelve o’clock in the morning. 
The trouble seemed to grow upon him until finally he would 
stay in bed all day, getting up at about five or six o’clock in the 
evening. 
The severer attacks of somnolence came on periodically. He 
would get up at a tolerably good hour for two or three weeks. He 
would then, after going to bed at the usual hour, about eleven 
or twelve o’clock, stay in bed till noon or evening of the next day. 
He would repeat this for several days and would then get up 
at the ordinary hour. The frequency and severity of the attacks 
have of late been increasing. When awake and up he seemed 
as bright as ever and apparently felt well. He states that he goes 
to bed feeling as usual and expecting to get up to his work. The 
next morning, however, he is unable to do so. I saw him several 
mornings when in this lethargic state. He could easily be roused 
to a certain extent, and could be made to sit up in bed, but his 
mind seemed to be in an abnormal state. If urged to get up he 
would only say : “ Yes, yes, I ’ll get right up.” If pulled out of bed C. L. DANA. 
and made to begin dressing himself he would perhaps do it slowly 
and mechanically. If urged harshly he would whimper like a 
child, and when possible he would get out of the room and lie 
down elsewhere. If closely followed up and watched until 
dressed and gotten down-stairs he would finally get into a normal 
state of mind. When examined by me some months ago he 
seemed in perfect physical health, except for a slight dyspepsia. 
He had no headaches or vertigo. His heart, lungs, and kidneys 
were normal. His pupils are even and not large. He did not 
have sugar in the urine, nor is he at all fleshy or obese, rather 
the contrary. He drinks and smokes very moderately. Has 
emissions only about once a fortnight. 
The attacks naturally suggested the possibility of nocturnal epi- 
lepsy, drinking, or masturbation. The most careful inquiries and 
investigations enable me to exclude these. 
I am forced to believe that his condition is an idiosyncrasy 
which habit has developed into a morbid neurosis. 
Case 2.—The patient in this case was a gentleman who 
came under my observation eight years after his attacks of 
somnolence. He was a business man, of a healthy family history, 
who had himself been tolerably well up to about ten years before. 
At that time he had a train of nervous symptoms which would be 
called neurasthenic. While still suffering from them he became 
the victim of an intolerable and persistent drowsiness. It inter- 
fered with his business, and he finally went away for a few months. 
Rest and life in the country restored him. 
He came to me about nine years later with neurasthenic symp- 
toms, which interfered greatly with his comfort and capacity to 
work. He was a spare man, quiet in manner, yet evidently of a 
nervous temperament. He stated that at the time when he suf- 
fered from somnolence, he had no hepatic or renal or any organic 
trouble so far as he knew. Somnolence was not one of his symp- 
toms when I saw him. 
Whether this attack was due to cerebral anaemia, or hypersemia, 
or to any disturbances of the abdominal viscera, or whether it was 
simply a symptom of his nervous asthenia, I cannot say. When 
I was treating him he used to pass very large quantities of limpid 
urine, after exacerbations of his symptoms, but it contained no 
sugar. 
Case 3.—This patient also came under my treatment a few 
months after the severer symptoms of her somnolence appeared. ON MORBID DROWSINESS AND SOMNOLENCE. 
11 
She was a married woman, aged forty-five, who had always 
been healthy, and was the mother of several healthy children. 
Of late she had had much domestic trouble and worry. About six 
months before I saw her she had suffered a great deal from “ner- 
vousness,” weakness, and various vaso-motor disturbances, the 
most prominent being profuse sweating. She at this time began 
to be very drowsy at times. She would go to bed early and sleep 
till late in the morning. She would also sleep several times during 
the day, and at any time could sit down and fall instantly asleep. 
When I saw her in January, 1883, she still slept more than the 
ordinary length of time, but did not suffer so much from drowsi- 
ness in the daytime. 
She was a well-nourished woman, not especially anaemic. She 
complained of extreme nervousness and weakness and a constant 
sweating, also of some digestive troubles. 
She had no discoverable organic disease ; the urine was normal 
and the bowels regular. She had more markedly the symptoms 
of general nervous asthenia than of hysteria ; that is to say, she 
had no globus, no spasmodic troubles, no great emotional dis- 
turbances. I could find no toxaemia or organic trouble which 
would account for her somnolence, although in this case the hy- 
pothesis of a cerebral anaemia might be brought in. 
Case 4.—F. S., age fifteen, came to me in January, 1882, suffer- 
ing from paralysis of the left arm. She was a fleshy, robust-looking 
girl with ruddy complexion. Her parents were healthy, and she 
herself had always been well until a few months previously. She 
then began to have attacks of unconsciousness, lasting from a few 
minutes to half an hour. These were preceded by clonic spasms 
of the left hand ; when she came out of her attacks this hand was 
tightly clenched. The arm grew gradually weaker, and when she 
came to me it was nearly helpless, although she could move her 
fingers; the attacks referred to had ceased. Examination of the 
affected arm showed slight anaesthesia and vaso-motor disturb- 
ance. The electrical reactions were normal. Under treatment 
the paralysis gradually disappeared. During the time of treat- 
ment, and for some months subsequently, she complained of per- 
sistent drowsiness. She slept twelve hours at night, and in the 
daytime took frequent naps ; she could lie down and sleep at any 
time. There was no uraemia or other toxaemia, and the bowels 
were regular. The somnolent tendency left her very nearly with 
the paralysis. 12 
C. L. DANA. 
In conclusion I present a case illustrating a condition of 
“ cataleptic petit mal,” as Richer calls it, and mesmeric som- 
nolence. The girl was one whom I could undoubtedly have 
mesmerized if I had thought it wise. The case illustrates 
the close relation between hysterical attacks of sleep and 
of catalepsy. 
Case 5.—Miss Fanny H., age seventeen. Family healthy. 
When a child had severe attacks of syncope, or “fainting spells,” 
as she called them. Otherwise, was healthy though somewhat 
delicate. Is well-developed ; menses regular, but has suffered from 
dysmenorrhoea, for which she was successfully treated. 
In March, 1883, while with her companions at recess, she sud- 
denly felt her left hand being spasmodically twitched ; she then 
appeared to lose consciousness, sat down, closed her eyes as 
though in sleep. In about ten minutes she roused spontaneously, 
and declared that she had been conscious of every thing, but was 
helpless. For some hours after this she felt weak and tired. A 
few days later a similar attack occurred. 
The attacks then began to recur very often ; sometimes she 
would have them once or twice daily, sometimes only once or 
twice a week. They occurred generally when she was at school 
and while engaged in study. Her left hand would begin to shake, 
constituting a kind of motor aura. If the hand were seized and 
held by her companion, she could often keep the attack off. If 
the attack came on the face would get paler ; the eyes generally, 
she says, remained open. 
As a rule, she continued sitting upright in her seat. Sometimes, 
however, her head went forward upon the desk, and her teacher 
would think she had fallen asleep.. 
She came under my treatment in April, 1883. She was then a 
somewhat delicate-looking girl, intelligent, studious, and not 
markedly nervous or hysterical in manner. She was found to 
be perfectly healthy as regards the thoracic, abdominal, and pel- 
vic viscera. 
While visiting me she had one of her attacks. The left hand 
shook, the eyes then closed, the body relaxed, and she seemed to 
be in a kind of stupor or sleep. She could not be aroused by any 
ordinary stimuli, although the reflexes were not abolished. In 
about fifteen minutes she returned to a normal condition, and 
then asserted that she had been conscious of every thing. I ON MORBID DROWSINESS AND SOMNOLENCE. 
13 
treated her with tonics, bromides, electricity, spinal douche, etc. 
She improved somewhat, and, being finally through her school 
work, the attacks stopped. 
The next fall she started to begin study again, when she had 
another attack, and then gave up study. Since then she has been 
perfectly well. 
This patient had attacks, some of which appeared to observers 
to be attacks of sleep ; in other cases they were more of a cata- 
leptic nature. The initiatory movement of the hand suggests a 
petit mal. or aborted epilepsy, but the preservation of conscious- 
ness and other points in the history, such as her prompt recovery, 
are against this. 
The attacks were evidently of a hysterical nature, sometimes 
resembling those of morbid somnolence ; of.tener those of cata- 
lepsy. 
The case resembles in some points that reported by Gelineau 
as a case of “ narcolepsy,” and furnishes a kind of connecting 
link between some of the narcolepsies and catalepsies. 
In addition to the cases thus related, I present two, of 
which the notes were kindly furnished me by Dr. L. Putzel, 
of New York City. 
Case x.—The patient was about twenty years old, and had 
been subjected for a couple of years to attacks of falling asleep for 
a few minutes in any position, often while standing, and when not 
tired. There did not appear to be any thing pathological about 
them except their occurrence when the patient was not tired. She 
married at about the age of twenty-two or twenty-three years, and 
then began to suffer from infrequent, well-marked epileptic at- 
tacks. Her brother subsequently came to me, also suffering from 
epilepsy. The patient herself appeared to be entirely healthy in 
all other respects. 
This case clearly illustrates the epileptoid sleeping-state, 
and is similar to those reported by Westphal, Fischer, Por- 
ter, and others. 
Case 2.—The second case was that of a patient married, about 
thirty years old, who suffered from all the evidences of general 
anaemia. In addition, she was always excessively drowsy, and at 
times would fall asleep standing up. Dr. Putzel regarded this as 
evidence of cerebral anaemia, and the patient recovered under the 
use of iron and nitrite of amyl. 14 
C. L. DANA. 
To my own and Dr. Putzel’s cases, I add a brief resume 
of the others which I have found. Some exception may 
be taken to the classification which I have made of them, 
yet I believe that in the main it is correct. 
I first present those which illustrate the epileptoid sleep- 
ing-states. 
I.— The Epileptoid Sleeping-States. 
Case i.—A young woman, aged twenty-six, had had epileptic 
attacks three years before. These had ceased and her health ap- 
peared good. She was seized with attacks of somnolence with 
dilated pupils ; normal temperature ; quiet breathing. She could 
not be awakened, but awoke spontaneously after 12, 16, 18, or 24 
hours. Once she slept for twelve days. Lately she had slept two 
thirds of each day. (Rahlman: Beilin. Klinish. Wochensch., Brit. 
Med. 'Jour., April 2, 1881, p. 527.) 
Case 2.—A young woman, aged twenty-two. Sister had the same 
trouble for a time but it disappeared spontaneously. Well until 
six years ago, when her voice became weak and hoarse. After 
this, there supervened attacks of somnolence—two to six daily, 
lasting five to sixty minutes. They would attack her at ar.y time. 
They were most frequent at her menstrual period. Consciousness 
was sometimes partially, sometimes entirely, lost. When the at- 
tacks first began she had some slight preliminary muscular twitch- 
ings ; later, she had peculiar feelings like an auraa. General 
health good. Case attributed to fright. (Reported by F. Fischer, 
Jr.: Arch.f. Psychiatrie, Bd. viii., p. 200. 
Case 3.—Sister of case 2. See above. 
[Fischer considers this case epileptoid, but it might well 
be of a hysteroid or cataleptoid nature.] 
Case 4.—The patient was a man aged thirty-seven, who had 
had syphilis. He had an attack of mania ; was taken to hospital. 
Recovered, but showed much mental weakness. He was then 
attacked with somnolent seizures. He would suddenly fall into a 
sleep lasting ten to thirty minutes. This occurred every day, or 
only once a week. He was apparently in ordinary sleep, but was 
anaesthetic ; reflexes lost. The attacks were accompanied by 
vaso-motor disturbances, especially those showing irritation of 
right cervical sympathetic. The attacks ended in sweating. 
(E. Mendel: Deui. med. Wochensch., 1880, p. 226.) ON MORBID DROWSINESS AND SOMNOLENCE. 
15 
[The syphilis might have been at the bottom of this.] 
Case 5.—The patient was a man, a book-binder, aged forty. 
(Westphal : Arch. f. Psych., Bd. vii., p. 656) Mother has attacks 
similar to the son’s. After a powerful excitement, he had an at- 
tack in which he lost speech, with great trembling and weakness. 
After this he suffered from two classes of attacks. In one he 
would suddenly reel like a drunken man, then fall, his jaw twitch- 
ing, eyes half open, respiration hastened. At the end he would 
have a movement from the bowels. He said he was conscious 
all the time. 
In the other attacks he would suddenly be seized with drowsi- 
ness, alone or in company, or when on the street. He would 
sleep until wakened accidentally or otherwise. 
Case 6.—Mother had similar attacks as son. (See above case 
5. Westphal.) 
Case 7.—A woman aged forty. Mother and sister epileptic. 
Had suffered many years from attacks of neuralgia. Finally she 
had a very severe attack of neuralgia with insomnia. After this 
passed away, she suffered from attacks of somnolence alternating 
with vertigo. On one day she would suffer from the somnolence, 
on the other from vertigo. These attacks of somnolence occurred 
six or seven times daily, but lasted only two to five minutes. 
After several days of alternating somnolence and vertigo, she 
would remain free from any symptoms for a week or more. (R. 
H. Porter, Medical Record, Nov. 27, 1880, p. 610.) 
Case 8.—A girl aged eighteen, of neurotic family, well-nour- 
ished, inclined to corpulence. No symptoms of hysteria and no 
convulsions. Subject to severe headaches for several years. 
About a year ago became subject to attacks of somnolence, at 
first rare, later every few days. She would have a headache, and 
then pass into a sleep lasting several hours. At other times, while 
suffering from headache, she would have several short attacks of 
sleep lasting a few minutes. 
At other times, instead of going to sleep, she would pass into a 
kind of somnambulent state (epileptic cerebral automatism), and 
would do her routine work unconsciously and automatically. 
Her cousin was a sleep-walker. (R. H. Porter, vide loc. cit.) 
Case 9.—The patient was a man aged thirty-eight. Family 
and early personal history good. No syphilis. Married, and had 
two children. Moderate drinker. Had had acute articular rheu. C. L. DAtVA. 
matism. Three years ago had a fight and a fall. Two years ago 
his symptoms began. He would fall asleep whenever he under- 
took to eat, walk, go to theatre. Any thing particularly exciting 
his attention would throw him into a sleep. He would sleep a 
little, then wake. He had one or two attacks daily, accompanied 
by dizziness. He often had attacks of dizziness. Intelligence, 
memory, and consciousness were not lost during the attacks. 
(Gelineau : Gazette des hdp., July 8, 1880.) 
[This was the case originally published by Gelineau as 
one of narcolepsy. He does not consider it as epileptoid, 
but as a distinct neurosis. I place it here as being clinically 
most like other epileptoid cases.] 
Case 10.—A woman aged thirty-five, healthy in other respects, 
had short attacks of somnolence daily. They lasted about ten 
minutes. (G. Ballet: Revue de mtdecene, Nov., 1882.) 
[This case, too, which I do not report in full, cannot be 
certainly considered as epileptic.] 
Case ii.—Putzel’s. (See ante.) 
II.—Cases Ilhistrating the Morbid Somnolent Neurosis. 
Case i.—My own. (See ante. Case 1.) 
Case 2.—A young officer could not possibly get along without 
fourteen hours of sleep. He slept until noon every day and lost 
his commission in consequence. (Quoted by T. More Madden : 
Dublin Journal of Medical Sciences.) 
Case 3.—The patient was a woman aged fifty-two. Her grand- 
father was trte dormeur, otherwise her family and personal history 
were good. For several years she has had an unconquerable 
tendency to sleep. At night she sleeps like others ; in the day- 
time she has from three to six attacks of somnolence. These are 
more frequent at the menstrual epoch. (G. Ballet : Revue de 
mddecine, Nov., 1882, p. 945.) 
[This case is clinically somewhat like some of the epilep- 
toid cases, yet there is no evidence furnished that there is 
any epileptic taint.] 
Case 4.—A wine merchant, aged twenty-eight. Family history 
good. Always had a tendency to sleep in the daytime. When ON MORBID DROWSINESS AND SOMNOLENCE. 
three years old had typhoid fever, which was followed by seven- 
teen days of lethargy. Suffered from headaches. In the last 
two or three years the attacks of somnolence and drowsiness have 
been increased. Has difficulty in keeping awake during work, or 
even while waltzing. Sleeps very heavily and long at night, and is 
hard to waken. No albumen or sugar in the urine. Improved 
somewhat under hydrotherapy. (G. Ballet vide loe. cit.) 
Case 5.—The patient was a man aged forty-seven, married. 
Family and personal history good ; a clerk ; sober. For a year he 
was subject to attacks of somnolence, and had to give up his em- 
ployment. He was large and corpulent. He was of fair intelli- 
gence but slow. 
Under treatment he improved, then relapsed. Later he seems 
to have become insane, or to have had a chronic meningitis. 
(Caffe : Journ. des connaissances medical pratique, Aug. 20, 1862.) 
[Caffe considered this at the time a case of passive cere- 
bral congestion with serous effusion. Gelineau thinks it 
was a distinct neurosis. The termination of the case, 
though occurring years later, rather points to some organic 
trouble.] 
Case 6.—J. M., a man aged thirty-nine, good constitution and 
family and personal history ; plethoric ; a farmer. Twelve years 
before was exposed to rain and wet, with the result of getting se- 
vere pains (rheumatic ?). Under treatment these all disappeared 
except at base of skull and back of neck. After the general pains 
or neuralgise had disappeared, he observed that, especially after 
eating, an irresistible tendency to sleep set in, accompanied by 
heaviness of the head and general dulness of disposition. During 
the second year of his illness the attacks of somnolence occurred 
frequently—twenty or more times a day—always preceded, how- 
ever, by an aggravation of pain at the base of the cranium and 
cervical region. A peculiarity about these neuralgic pains was 
that they lasted for a very short time, and left him with the sleepi- 
ness only, which deprived him of a great deal of valuable time. 
Toward convalescence these neuralgic and sleepy attacks dimin- 
ished in frequency, being limited to five or six spells a day. (E. 
Paz : Cronica Medico-Quirurg., Havana, 1876, p. 328. Quoted by 
Dr. Matas.) 
[The case might have been syphilitic.] 18 
C. L. DANA. 
Case 7.—Jose, a young Mexican herdsman living near Mata- 
moras, Mexico. He had been a bright, active, healthy fellow. 
After a long ride on a hot, sunny road, one and a half months 
previous, he began to show a disposition to somnolence. He 
slept late in the morning, again in the afternoon. Finally he slept 
twenty-four to forty-eight hours, with brief periods of wakeful- 
ness. Had no headache or fever ; pulse and respiration and skin 
appeared normal in the attacks. No evidence of renal disease. 
He could be aroused, but would fall asleep again. Sleep seemed 
natural and calm. (Dr. Rudolph Matas : New Orleans Med. and 
Surg. jfour., Jan., 1884.) 
[While this was probably a neurosis, we cannot positively 
exclude diabetes, uraemia, or the effects of insolation.] 
Case 8.—A boy aged twelve, much overgrown ; weight, one 
hundred and fifty pounds ; height, five feet six inches. An aunt 
is epileptic, and his mother a sufferer from neuralgia. 
Nine months before he was seen by Dr. Porter he began to suffer 
from attacks of somnolence. They began at 9 a.m., and continued 
forty-eight hours. He could be roused, but would fall asleep 
again. Would take no nourishment. After they had passed off 
he felt tolerably well. They came on monthly at first, then be- 
came more frequent. He showed symptoms of neurasthenia. For 
these he was treated, and gradually recovered. (Robert H. 
Porter, M.D. : Med. Record, Nov. 27, 1880, p. 610.) 
[Dr. Porter considers this a case of epileptoid somnolence ; 
but this is hardly satisfactory, not being clinically like most 
of such cases. It was more likely a nutrition disturbance.] 
Case 9.—Farmer, age forty-three ; for nineteen years was sub- 
ject to attacks of somnolence, coming on without appreciable 
cause. He was a healthy man otherwise, and intelligent. No 
hysteria. His attacks last two to five days, averaging two days. 
The disorder came on in 1842, lasted a year ; again in 1848, lasted 
one and a half years ; again in i860. During sleep he is pale, 
feet and hands cold, pulse slow and feeble. Awakes refreshed. 
In 1878 had trismus after the attacks. Since last attack has be- 
come weaker. Dr. Cousins reported in 1865 that his patient was 
still suffering from the abnormal attacks, and was weaker and less 
interested in business, otherwise well. (Dr. J. W. Cousins : Med. 
Times and Gazette, April 18, 1863, and July 27, 1865.) ON MORBID DROWSINESS AND SOMNOLENCE. 
19 
[This case resembles those of hysterical trance lethargy, 
but there is no reason for calling it “ hysterical ” except the 
symptom morbid somnolence.] 
Hysteroid Morbid Somnolence. 
The cases of morbid somnolence and lethargy occurring 
in hysterical persons and in hystero-epileptics are, com- 
paratively speaking, quite numerous. This is especially the 
case if we include under this head the various instances of 
trance lethargy which have been related. Yet for all this, 
morbid somnolence is not absolutely a frequent phenome- 
non, as has been already stated. 
In looking over the history of the cases of prolonged 
sleep in persons of a hysterical diathesis, we find that the 
disease shows itself in several markedly different ways. 
Thus there is a set of cases of trance lethargy so-called, 
in which the patients are plunged into a deep and prolonged 
unconsciousness, lasting from one day to several years. 
These are “ sleeping girls,” and fasting girls. 
Another class includes those who apparently are the 
victims of a too ready susceptibility to hypnotism or mes- 
merism. 
A third class includes the patients who suffer from 
somnolence or drowsiness in other irregular forms. These 
patients are evidently hysterical, but their somnolent symp- 
toms appear in peculiar ways. 
I have collected and give below brief references to the 
cases of trance sleep or remissive lethargy which have ap- 
peared in medical literature in the past years. 
I do not include those cases which are cataleptic in their 
nature, although there is undoubtedly a close relation be- 
tween the cataleptic and ordinary forms of lethargy. 
Case i.—A woman, aged twenty-four, large, well formed. At 
the age of eighteen ; she fell into a trance sleep lasting forty 
days ; at age of twenty another attack lasting fifty days. All the 20 
C. L. DANA. 
latter time she was insensible, could not be roused, and had to be 
fed. When twenty-eight years old she fell into another lethargy, 
which lasted several months. The respiration was very shallow, 
pulse slow, organic life at a low ebb. (M. Blondet: Ga. hebdom- 
adaire, October 28, 1864, p. 726. 
Case 2.—Young lady, aged nineteen, apparently well ; suddenly 
attacked with lethargic sleep, resembling syncope ; was occasionally 
aroused for a time. After nine days suddenly awoke. (T. More 
Madden : Dublin Medical Journal, vol. 71, 1881, p. 297.) 
Case 3.—A young woman, aged eighteen, slept forty days, 
could not be roused, was fed. At age of twenty, slept fifty days. 
At age of twenty-four, slept twelve months, being fed. Pulse slow 
and weak. Respiration almost inappreciable. (Blondet : Med. 
Times and Gaz., Nov. 12, 1884, p. 519.) 
Case 4.—R., a soldier, age twenty-five. Two years before, in 
July, 1870, after a struggle with a comrade, fell into a sleep for 
seventy-four hours. He then had attacks as follows : November, 
three days ; March, 1871, five days. In subsequent year he had 
three attacks for two or three days each. 
In the attacks, the pulse was 84 ; resp., regular. He had a 
peculiar hyperaesthesia ; stimuli would provoke spasmodic move- 
ments. (M. Mendel : Lyon medical, Oct. 27, 1872.) 
Case 5.—“ A young woman in perfect health suddenly experi- 
enced such an irresistible desire to sleep that she sought refuge 
in a solitary and unfreqented place to realize her inexplicable de- 
sire unmolested ; her sleep lasted eight consecutive days, when 
she was awakened by the great stir and noise produced by a 
number of persons who surrounded her. She was very much 
weakened by this prolonged fast, and death would have been 
certain if the sleep had not been interrupted.” (Fournier : Dic- 
tion. des sciences mid. Cas rares. Quoted by Matas.) 
Case 6.—A young lady, aged seventeen, while in church was 
suddenly seized with a desire to sleep. She went home, went to 
bed, and slept three days. No catalepsy. She awoke, was well 
for a month ; then went into a sleep again. (Lasegue : Gaz. des 
hdp., Jan. 3, 1882.) 
CAse 7.—A girl went into a room by herself, and was found 
shortly after in a state of trance sleep, which lasted thirty-eight 
hours. (W. R. Gowers : Quain's Diction. Medecine.) 
Case 8.—A woman of twenty-seven, of small stature and weak 
mentally, was admitted to London Hospital for heart trouble. ON MORBID DROWSINESS AND SOMNOLENCE. 
21 
She passed into a lethargic trance. There was no rigidity or cat- 
alepsy. Could be aroused somewhat. Had to be fed with tube. 
Pulse normal, pupils large, lungs normal, no reflex action. (Dr. 
L. Doure : Brit. Med. Jour., May 3, 1879, p. 827.) 
Case 9.—Mrs. M., aged thirty-two, mother of six children, 
of good family and personal history. Had had no symptoms of 
hysteria. Six weeks after confinement she suddenly fell into a 
trance sleep, which lasted for several months. Reflexes were not 
quite abolished at first, and could then swallow food. Later she 
had to be fed. She slept within her trance, i. e., at night she 
would snore. No cataleptic or other rigidity. She had some 
color. (W. T. Gairdner : Lancet, Dec. 22, ’83 ; Jan. 5 and 12, 
1884. 
Case 10.—A young lady, age twenty, previously healthy, was 
found one morning in a state of profound sleep, from which she 
could only be aroused by bleeding ; next morning the same. 
After several mornings left alone, slept thirty hours ; awoke 
refreshed. Later often sleeping thirty to sixty hours. Finally 
became insane. (Cooke’s “ Treatise, on Nervous Diseases,” vol. 
i-> P- 372-) 
Case ii.—The sleeping girl of Trouville. At the age of eleven 
she fell into a sleep or lethargy which continued for ten years. 
She could be roused enough to swallow food. (Mr. Haymen: 
Lancet, June, 1881.) 
Case 12.—A girl who had been for some time in a lethargy 
was sent to London Hospital, and treated there with tartar 
emetic, by which she was speedily cured. (John Gay : Lancet, 
July 3, 1880, p. 31.) 
Case 13.—A similar case to that of Gay’s is reported by Gaird- 
ner, of a girl who had attacks of lethargy alternating with violent 
choreic movements. The whole turned out to be a case of hysteri- 
cal malingering. (British Med. Journ., May 4, 1878.) 
Case 14.—The patient was a single woman, known generally as 
“ Sleeping Effie.” She used to wander about for miles, then go 
home, and fall into a sleep lasting one to five weeks. Attacks 
continued for fifteen years. She finally died of exhaustion after 
sleeping three weeks. (Dr. James Edwards : La7icet, vol. i., 1848, 
p. 309.) 
To the above cases we must cite three more briefly- 
referred to by Mason Good {vide op. cit.) as cases of “ ab- 22 
C. L. DANA. 
solute lethargy.” In one case the patient slept forty days ; 
in another, forty-nine days; in the third, three days, then six 
weeks, then three days. The last patient finally committed 
suicide, and probably was then insane. 
Cases of lethargy are also reported by Wyatt {Med. Times 
and Gazette, vol, i., 1865, p. 111) and by Gimson {British 
Med. Journal, July 13, 1863). 
Mesmeric or Hypnotic Somnolence. 
We now come to a class of hysterical cases in which the 
sleep is more plainly of the mesmeric character. Sometimes 
it is provoked, at other times it comes on spontaneously. 
Richer and Bourneville have shown how susceptible 
hystero-epileptics are to provoked attacks of somnolence, 
and I simply refer to the former’s work on hystero-epilepsy 
without attempting to cite cases. 
It is certain, however, that spontaneous mesmeric sleep 
occurs in those who are not hystero-epileptics. This opin- 
ion is confirmed by the fact that a young girl who had been 
a few times hypnotized by Hansen became the subject of 
attacks of auto-mesmeric sleep, and applied to Finkelnburg 
for treatment. {Berlin klinisch. Woch., No. 3, 1884.) 
Lesegue cites the following three cases : 
Case i.—A rich farmer, aged thirty, married, went hunting one 
day, and fell down in a field and slept for seven hours. Next day 
did the same, and continued to have attacks for a long time. 
Lesegue was called in, and saw it was a hypnotic sleep. His wife 
found out that she could put him in or out of sleep, and amused 
herself by doing so. 
Case 2.—A young lady used to fall asleep at 8 p.m. precisely 
no matter what she did or how much she slept. 
Case 3.—A Belgian countess, daily, for two years, fell asleep at 
9 p.m., no matter what she was doing. 
Case 4.—An educated young woman, previously healthy, had 
attacks of somnolency lasting several hours, followed by loss of ON MORBID DROWSINESS AND SOMNOLENCE. 
23 
all her previous knowledge, and return of same on the alternate 
attacks. This alternation continued for four years. In one in- 
terval she retained her original knowledge ; in another, only what 
she had previously learned. (Major Elder, of West Point. Good’s 
“ Study of Med.,” vol. ii., p. 218.) 
Case 5.—The patient was a man aged forty-five, large, robust. 
The family and personal history were good. Had a large fistula. 
Any emotion or excitement would send him into a sleep, during 
which he was sometimes conscious—e. g., when a probe was passed 
into his fistula. (G. Camuset : Gaz. des hop., July 20, 1880.) 
Case 6.—Woman aged thirty-five. Healthy in other respects. 
Had attacks of sleep—ten minutes. Several daily. No epileptic 
history. (G. Ballet : Rev. de mkdecine, Nov., 1882.) 
Case 7.—Josephine F., aged sixteen. Family and personal 
history good. At the age of fourteen she experienced a great ex- 
citement and emotion. This was followed by hysterical contrac- 
ture and deaf-mutism. 
She became relieved of these symptoms, but on receiving a 
fright one day, they returned. Taken to a hospital she had 
attacks of sleep lasting twenty-four hours, alternating with con- 
tractions. (Ballet : vid. loc. cit.) 
Case 8.—A young lady of delicate constitution, aged eighteen, 
had been subject to great anxiety. She had attacks of somnolence 
lasting two or three hours and coming on two or three times a 
week. She recovered suddenly. (Good’s “ Study of Medicine,” 
vol. ii., page 384.) 
Case 9.—See my own case, No. 5. 
Case 10.—Finkelnburg’s ; vide above. 
Case ii.—A case is briefly described in The Lancet, vol. i., 
1867, p. 532, of a spare, abstemious man, otherwise in apparent 
good health, who suffered from a continual drowsiness. 
The writer inquired for a remedy and was advised by another 
correspondent to use belladonna. 
Case 12.—This case is referred to by Handheld Jones (“ Func- 
tional Nervous Diseases,” p. 405). A man, aged twenty-two, was 
ill for a year, suffering from continual drowsiness. His face was 
flushed, and there appeared to be a paresis of the cerebral 
vessels. 
A few interesting cases illustrating somnolence from C. L. DANA. 
organic brain disease, from great exhaustion, or from 
diabetes, may be briefly referred to. 
Case i.—Ballet cites a case (loc. cit.) of a diabetic who suffered 
from persistent drowsiness and prolonged attacks of sleep. 
Case 2.—Matas cites a case (loc. cit.) of somnolence from 
syphilis probably. 
Cases 3-4.—Buzzard (Lancet, June 7, 1879). cites two cases of 
this kind. 
In these three cases there was persistent drowsiness. 
Case 5.—Matas also cites a case of persistent drowsiness and 
somnolence from a brain tumor. (Loc. cit.) 
Case 6.—Laycock cites a case of morbid somnolence from an 
injury to the head. There was no paralysis. He was cured by a 
sternutatory. Dying later, no lesion of the brain was found. 
(Medical Times & Gaz., May 13, 1865, p. 489). 
A. Weber cites a case of somnolence in a girl who suffered 
from hemiplegia and epilepsy. She had convulsive attacks fol- 
lowed by lethargic attacks, lasting for hours or days, and finally 
ending in hemiplegia. (Brit. Med. your., Oct. 22, 1870.) 
Case 7.—Madden (loc. cit.) cites the case of a boy who passed 
into a soporose state, lasting forty-seven days, after an attack of 
typhoid fever. 
Case 8.—Also the case of a woman who, after confinement 
and typhoid fever, passed into a similar state, lasting twenty- 
seven days. APPENDIX. 
Since reading my paper, several new cases have been reported, 
and I present notes of them now. 
At the meeting of the New York Neurological Society, March 4th, 
Dr. R. B. Prescott of this city related the following history : 
Case T.—The patient was a farmer, unmarried, forty years of age 
or more, living in a small village in Massachusetts, who, some ten 
years ago, began, without any apparent cause, to be troubled with ex- 
cessive drowsiness. It manifested itself first in a disposition to sleep 
unseasonably long in the morning. He would remain in bed until 
long after the breakfast hour, and complain at intervals during the 
day of still feeling sleepy. Gradually he came to neglect the work of 
his farm, and remained about the house dozing away a considerable 
portion of the time. His social nature, too, underwent a decided 
change. He became reserved and silent. He shunned all inter- 
course with friends and acquaintances, was with difficulty made even 
to answer ordinary questions, and was easily moved to tears. On 
one occasion I was told that he fell asleep on his wagon while taking 
a load of produce to the nearest market town, and slept soundly for 
many hours, his horse having of his own will taken an unfrequented 
road, and finally stopped at the place where he was discovered, the 
driver still fast asleep. 
His condition at present is that of a gradually deepening mental 
lethargy. He passes a large portion of his time in bed, and takes lit- 
tle interest in what takes place around him, though at times he par- 
tially arouses, and will read the newspapers or carry on a brief conver- 
sation, mainly in monosyllabic replies to questions. His bodily 
functions are all normal, and there is no evidence of any physical dis- 
ease. His general health w'as good up to the time of the appearance 
of this morbid somnolency, and he is not the subject of any hereditary 
taint, so far as known. He is now regarded by those who know him 
as mildly insane, and his recovery is not expected. 
At a meeting of the same Society in May, Dr. William J. Morton 26 
APPENDIX. 
reported a case of morbid somnolence, in which the persistent drow- 
siness was apparently a symptom of cerebral asthenia, or some nutri- 
tion defect of the nervous system : 
Case II.—The case was that of a physician in this city, who had 
suffered from this condition for fifteen years. He was habitually over- 
come by an uncontrollable desire to sleep during the day time, no 
matter how malapropos the time or place ; this desire he would fight 
against with all his power of control, but would finally yield to sopor. 
Even in the dentist’s chair, while a sensitive tooth was being “scraped,” 
he had fallen asleep. Often in. the rounds of daily practice he would 
feel this lethargy creeping over him at critical moments, as, for in- 
stance, when his services were most needed at confinements, and 
would be forced to yield to it and sleep. It was impossible, for the 
same reason, for him to read for but a short time, and he had been 
obliged to abandon study and mental work entirely. He had other 
symptoms of brain exhaustion, such as forgetfulness, frontal headache, 
etc. 
Ur. D. E. Sibert of South Hill, Ala., sent me a description of the 
following interesting cases in his practice : 
Case III.—Mother, age 28, good health, family history good, re- 
duced and anaemic from suckling ; and babe, year old, just well of 
remittent fever. The woman has suffered with the trouble since her 
first confinement, about six years since. The somnolence is manifest- 
ed only during the night, and only as a profound slumber, from which 
it is exceedingly difficult, even by the roughest handling and the in- 
fliction of pain, to arouse her. I failed to get any history of vascular, 
digestive, or cerebral disorder. Her general health has been, and is, 
good. I have thought that the condition may be due to cerebral 
anaemia, induced by protracted nursing. Lacteal secretion is abun- 
dant. It is proper to state, however, that the difficulty is not worse 
during lactation than it is observed to be during the intervals. She 
has improved, since weaning child, under the blood and nerve tonics, 
medicinal and hygienic ; but the difficulty is not removed, and the 
improvement is not satisfactory to either patient or physician. Now, 
from these meagre notes, can you suggest the cause of the difficulty, 
and also a line of treatment that will relieve it ? 
Case IV.—The babe is a lively little fellow, usually. Its spells 
of somnolency come on at any time of day or night, in irregular par- APPENDIX. 
27 
oxysms. Usually they are preceded by a sort of seizure that resembles 
the eclamptic spasm, in which the head and body are thrown back- 
ward and the eyes turned" upward, and in this position it remains in a 
somnolent condition for an indefinite time. There is no evidence of 
pain, no loss of consciousness beyond the stupefaction, the face is 
never blanched or flushed, there is no rise of temperature, no excite- 
ment of pulse, no appearance of convulsion, tonic or clonic (the back- 
ward movement of head and body seems to be voluntary). Since its 
recovery from the fever there has existed a slight paraplegia, evidenced 
by the child’s failure to bear any weight upon his feet, and the relax- 
ation of the muscles of the extremities. I can discover no spinal ten- 
derness. No loss of power over bladder or sphincter ani. The nu- 
trition of affected limbs seems undisturbed—limbs are plump, but of 
course soft and flabby. Now, what are these seizures ? Are they in 
their nature eclamptic, or are they voluntary, and excited by some dis- 
turbance in the system ? What is the cause of the stupor which ac- 
companies, and, for a varying period, follows the seizures ? And 
finally, what is the remedy ? I have this case under observation, but 
as yet have prescribed no treatment. I had thought I would try 
phosphorus and strychnia, with frictions and massage. G. P. Putnam’s Sons, Printers 
27 and 29 West 23d Street 
New York