This form of lethargy is characterized by the complete unconsciousness which persists during its course. Its duration is variable, sometimes continuing for a few minutes only; sometimes lasting through many days and weeks. Dr. W. T. Gairdner, Professor of Medicine in the University of Glasgow,[76] reports the case of a woman who remained for over one hundred and sixty days in a condition of lethargic stupor. “The patient was the mother of a family, and had lived a strictly domestic and (up to a short time before her seizure) healthy and regular life. There were no peculiar moral and religious problems to perplex the situation. There was no history of inveterate hysteria, or of long continued rapt contemplation; nor has there been the slightest evidence of any craving after notoriety, either before the attack or since its termination. The moral atmosphere, in short, surrounding the phenomena, is altogether unfavorable to exaggeration and imposture, for which, indeed, no reasonable motive can be assigned. Nevertheless, under these very commonplace conditions, concurring with some degree of melancholy or mental despondency after delivery, but during a convalescence otherwise normal, Mrs. McI—— presents to our notice a condition of suspended consciousness and disordered innervation in no degree less extreme than the ‘trances’ or cataleptic attacks which have been recorded as the result of the most aggravated hysteria, or as the miracles of religious ecstasy and profound mental emotion. She becomes for the long period of over one hundred and sixty days continuously an almost mindless automaton, connected with the external world only through a few insignificant reflexes and through the organic functions. She is fed, almost without resistance, through the stomach-tube; she defecates and urinates (during much the greater part of the time) unconsciously; she is absolutely passive as regards everything that demands spontaneous movement, and betrays almost no sign of sensation, general or special, when subjected to the severest tests that can be applied short of physical injury. But while her senses were thus shut, and her volitions in suspense to an extent much beyond ordinary sleep, there was, nevertheless, a sleep within the sleep. The periodicity of day and night was maintained by some change in the condition of the innervation, of which snoring was the sole indication. She was not convulsed, nor paralyzed, nor delirious; the singing, laughing, weeping, adoring ecstasies of hysteria and of religious excitement were wholly wanting; nor were there during many months such intervals of normal consciousness as are observed in almost all the recorded cases of hysterical coma and of catalepsy. The statue-like pose, moreover, and the flexibilitas cerea of typical catalepsy, are absent in this case. The return to consciousness was followed or accompanied by a return of all the normal functions of mind and body; there is now no incoherence, nor even distorted perceptions, as of a dream-life occupying the somnolent imagination for months, and therefore all the more hard to reconcile with realities. She is self-possessed, but unobtrusive, easily managed, and betraying only natural emotion; she persists in maintaining that the whole period of the apparent unconsciousness is a complete blank to her recollection. She is grateful for her recovery, but manifests no craving for sympathy, and no tendency, as yet, to revert to any morbid condition of despondency, such as was described at the commencement of the attack. In connection with this last point, although there is no evidence of her having been personally insane, it is not to be denied that her family history contains strong presumptions of a hereditary predisposition bearing in that direction.”
These cases must not be confounded with the examples of lucid lethargy, to which allusion has been made in a previous chapter. Somnambulic lethargy is a condition in which the cerebrum is wholly inert. In lucid lethargy, although there is complete loss of general sensibility and of the power of voluntary motion, the field of consciousness is continually enlightened by perceptions derived from one or more of the special senses, so that the subject is conscious of much that transpires in his immediate neighborhood. These two forms of lethargy sometimes alternate in the experience of the same individual, constituting a portion of the indefinitely varied manifestations of hystero-epilepsy. Grasset relates the case[77] of a little girl, ten years old, who suffered with various forms of hysteria, which were finally replaced by attacks of stupor, lasting several hours. After a time these crises of “nervous sleep” were transformed into more ordinary attacks of somnambulism, in which, “although the child’s eyes are shut, she sees and hears everything during the crises, knows who comes into the room by their step and walk. If anything unpleasant is said to her, or if they threaten to wet her, or make her smell something, she gets angry, and pushes everything violently away that is offered to her. She replies by signs to all questions, and if she wants anything, asks for it by gesture: if she wants to drink, she puts her finger to her lips as if in the act of sucking, and if not understood, becomes irritated, gets up, and leads the father or mother to the sideboard or cupboard, where the things she wants are, and always with the eyes shut. She is able to go through the whole house, I do not say quite alone, because they do not allow her to walk alone, but with help, and she directs the way wherever she wishes to go. During the crises she even sometimes amuses herself with a little dog, which she makes jump over a stick resting on the cross-bars of two chairs opposite each other; and according as she wishes the dog to jump higher or lower, she moves the stick to the lower or higher bars of the chairs, and that with eyes always shut spasmodically. During the whole attack she cannot talk; but towards the end she speaks, although not yet recovered from her state of somnambulism. When the crisis is over, the child remembers nothing of what she has said or done in her sleep, and is much surprised at everything told her.”
Somnambulic Dreams.—The preceding cases illustrate the variable character of the manifestations of somnambulism, and may also serve as an introduction to the more common form of the affection, in which the patient experiences a dream, probably excited by the same causes that produce ordinary dreams, and also acts out his dream. The differences between an ordinary dream and a somnambulic dream lie in the fact that the one produces an often vivid impression upon consciousness and memory, while the other is entirely expended upon the organs of external expression. Starting probably from the same portion of the brain, the physiological dream sets in motion the cortical structures which are in immediate relation with conscious memory; the impulses of the somnambulic dream, on the contrary, are directed towards the lower portions of the nervous system, where they serve to excite the organs of locomotion and expression, which are destitute of every form of mnemonic register. Consequently, the somnambulist retains no recollection of the incidents of his dream.
The simplest form of this affection is presented by the restless child who talks, cries out, and brandishes its fists in sleep. In the majority of instances these manifestations create little more disturbance than the half uttered yelping of a dog that barks in its sleep. But in some cases the outbreak assumes a distressing, if not an alarming character, constituting the affection known by the name of night terrors. The disorder is usually observed in young children of a highly nervous temperament, before the conclusion of their second dentition. The little patients are generally of neurotic lineage. Insanity, hysteria, neurasthenia, epilepsy, chorea, and nervous dyspepsia, are often discovered among their near relatives. Not unfrequently they have been, or will become, choreic. The attack is often preceded by symptoms of indigestion and constipation; but the exciting cause may be usually traced in the commotion of a brain that has been wearied by the exertions of the previous day. The child starts up out of an apparently sound sleep, crying with seeming alarm, calling for his mother, and staring wildly around, with every possible expression of terror. Sometimes he jumps from his couch, and runs headlong into a corner, or seeks concealment under the bed, as if escaping from some frightful object. The eyes are open, tears flow, perspiration covers the skin, there is the greatest excitement, and the little one, clinging convulsively to its parent, will not be quieted. Only after a number of minutes does the child seem to recover the power of recognizing his friends. Presently, however, he lies down, and falls immediately asleep, waking in the morning without the slightest remembrance of the unpleasant event.
Such paroxysms occur during the early part of the night, one or two hours after bedtime, when sleep is passing from its maximum intensity to an inferior degree of depth. This, moreover, is the time when the controlling power of the sensory apparatus over other portions of the nervous system has already reached its minimum. The spinal centres and those intra-cranial ganglia which do not share in the full measure of this repose are therefore in a condition of relative exaltation. Disturbances of internal origin, consequently, produce inordinate excitement of these waking portions of the nervous apparatus. The abnormal quality of this excitement is attested both by the history of the patient, and by the fact that it does not pervade the whole brain. The distribution of motion through the cerebrum is hindered, so that certain portions of the organ remain asleep while other regions are thrown into a state of tumultuous uproar. Such disconnection of the different organs of the nervous system, by withdrawing particular ganglia from the inhibitory influence of the other centres, gives opportunity for violent explosions of nervous force.
Somewhat similar in their origin are those acts of unconscious violence which sometimes occur during the process of sudden awakening out of sound sleep. The patient is usually a deep but uneasy sleeper, who is only aroused imperfectly and with difficulty when the attempt to awaken him is made. Under such circumstances the disturbance to which he is subjected serves as the exciting cause of a dream which, like the ordinary somnambulist, he puts into action before he is fully waked. On recovering complete consciousness, he may retain no recollection of the events of his dream, and may also experience as great a degree of astonishment at the results of his violence as if he had taken no part in its display. A gentleman of my acquaintance, who had suffered considerable uneasiness regarding burglars, was, one night, startled by a noise in his room. Jumping up suddenly, he grasped a pistol and fired it in the direction of a figure dimly perceived near the bed. On waking fully out of sleep, he found that he had inflicted a wound upon the hand of his wife whose movements had disturbed him. Another unfortunate, who was once under my observation for undoubted insanity, was in like manner aroused out of sleep by a supposed noise, probably heard in a dream. With a pistol in each hand, he commenced firing wildly in every direction, fatally wounding his wife who was in bed at his side. When completely awakened he had no recollection of what had occurred, and was overwhelmed by the event.
Wharton and Stillé[78] have collected a number of similar examples of this disorder, to which the term somnolentia or sleep-drunkenness has been applied. Its connection with morbid disturbance of the brain is usually very evident. Obviously, the moral responsibility of the agent in such cases is identical with that of the ordinary somnambulist, or of the subject of epileptic mania.
Ordinarily, however, the somnambulic dream is less agitated. The patient merely continues the movements with which he was occupied at the moment of falling asleep, as in the case of Galen, who, though long an unbeliever of the tales regarding sleepy soldiers who had unconsciously continued to march with their comrades, at last found himself in a similar manner walking a considerable distance after he had been overtaken by sleep while journeying on foot. In other cases the phenomena though intimately connected with the daily occupations of the subject, present themselves in a form somewhat detached from the waking life. Such are the common experiences of children who get out of bed, and walk around the house, seeking their playthings, or pulling their clothes out of the drawers in which they have been laid. Sometimes the events of the day have evidently suggested the deeds of the night. One of my little acquaintances will leave her bed, walk into another room, seat herself by her mother’s work-basket, thread a needle, and proceed to sew up the imaginary holes in her dress. One of my early playmates, in like manner, after puzzling over a difficult sum in arithmetic, before retiring, arose in his sleep, took paper and a pencil from his mother’s desk, and proceeded before her eyes to work out the correct answer. Another, tempted probably by a vision of ripe grapes upon the trellis, climbed out of his window upon the roof of a shed. Unfortunately, the certainty with which somnambulists usually direct their movements seemed to fail him. He fell heavily to the ground, where he awoke to find himself seriously injured.
An excellent example of a still more complicated series of actions during somnambulism is quoted by P. Max Simon.[79] It illustrates a majority of the facts which have been already brought forward, and will well reward careful consideration. “A young clergyman was in the habit of getting up in his sleep, taking paper, composing and writing sermons. When he had finished a page, he would read it over, if an action performed without the assistance of sight can be called reading. If dissatisfied with anything, he would blot it out, and then write the corrections with great accuracy in their appropriate place above the line. In one of these sermons he made a correction which was quite remarkable. Having in one place written the words ce divin enfant, on revising the page he decided to substitute the word adorable instead of the word divin. He therefore blotted out this last word and placed the other immediately over it; then, perceiving the word ce, which was proper enough before the word divin, lacked the terminal letter t that was needed before a vowel, he very adroitly added the necessary letter, so that the amended sentence correctly read cet adorable enfant. In order to ascertain whether the somnambulist made any use of his eyes, a cardboard was placed under his chin in such a way as to completely obstruct the view of the paper upon the table; but he continued to write without paying any attention to the obstacle. In order to ascertain whether he was aware of the presence of the objects which were before his eyes, the paper upon which he was writing was taken away, and a number of other sheets were successively slipped into its place; but he always noticed the substitution, because they differed in size. When an exactly similar piece was substituted, he accepted it as his own, and wrote down the corrections at the points which corresponded exactly with the writing upon the page which had been removed. It was by means of this ingenious stratagem that some of his nocturnal compositions were preserved.
“The most astonishing thing of all,” continues the author of this article, “was the exact composition of music. A cane served him as a ruler. With it he ruled at equal distances the five necessary lines, putting in their proper place the clef, the flats and the sharps. Finally, he inscribed the notes, at first all in outline, but, when he had finished, he blackened those which should be dark. The words of the song were written below. On one occasion he happened to write them with too large a hand, so that they were not placed directly under their corresponding notes. He soon perceived this defect, and, in order to amend it, he blotted out what he had done by drawing his hand over it, and then rewrote the line of music lower down the page with all the precision imaginable.