Insomnia; and Other Disorders of Sleep

by Henry M. Lyman

“One of the most remarkable of his exploits occurred several years after the incident just given. I think it was in 1860 or 1861.... In the rounds of his practice he had a patient, about whom he was very anxious. It was in the coldest winter weather, and the residence of the patient was about two miles distant. Visiting him early in the evening, he found him in a state so unsatisfactory, that he informed the family that if he did not find him better the next visit, he should change the medicine entirely. On rising the next morning, he went to the barn to put his horse to the cutter for an early start. He was a little puzzled at finding things somewhat misplaced, but supposed some person had been at the stable in search of a missing article. On visiting the patient, he was gratified to find a marked improvement. He inquired when the improvement commenced, and was answered, ‘Immediately after taking the powders which he had given in the night.’ The truth flashed upon him at once, but concealing his emotion, he inquired, with as careless an air as he could assume, ‘About what time was it when I was here?’ They replied, ‘Between two and three o’clock.’ This proved to have been the case, as he was afterwards told by the family where he boarded. He had been giving the patient some fluid medicine, which he ordered discontinued, and then put up several powders, such as he had concluded upon the night previous, combining them as usual, and administering the first one himself.”

The foregoing examples illustrate the fact that ordinary vision is not necessary to guide the movements of the somnambulist. Sometimes the patient walks about with open eyes; on other occasions they are firmly closed. It is generally admitted that the tactile and muscular senses are greatly exalted, so that they furnish guiding sensations which are sufficient to direct the most complicated movements. The history of the medical student observed by Dr. Allen shows how preternaturally sensitive the organs of vision may become—actually seeing the clock in the dark during the somnambulic paroxysm. When one considers the remarkably hyperæsthetic condition of the senses in certain other forms of nervous disorder, it is not surprising that sensory impressions which would be wholly neglected in a healthy waking state, may become sufficient to excite perceptions and to guide the movements which they have aroused. It is undoubtedly true that in certain cases the somnambulist does derive some information through the medium of the eyes—does really see; but it is also a fact that he only sees, hears, tastes and feels the objects which are immediately related with the action of his dream. It appears also that an impression derived from any organ of sense may suffice to arouse any other or all of the internal organs of perception, so that the patient seems to see, to hear, and even to taste objects which he knows only through the sense of touch. Sometimes the image thus externalized coincides with the actual reality; but often this is not the case, as, in the experience of the young clergyman, the somnambulist seemed to see the paper which he only perceived through contact with his fingers. The image thus created corresponded exactly with the external fact; but when a similar contact with a pile of bed-clothes excited the illusion of a drowning child in his grasp, the internal image did not in the least correspond with the external object, and he probably derived no information through the sense of sight in either case. In another instance, however, as we shall learn upon another page, the subject is so far dependent upon the sense of sight that its obstruction is sufficient to arrest his movements, as certainly as if he were awake.

Ordinarily the memory is not impressed by the events of the somnambulic dream, but we have already learned that it is sometimes affected precisely as in common dreaming. One of my little acquaintances could not find her night-dress when she went to bed one night. She was therefore obliged to wear a gown that was old and ragged. Later in the evening her sister discovered the missing garment, and laid it over a chair in the bed-room. In the morning the night-dresses had changed place, and the ragged one occupied the chair. This occasioned considerable surprise, until the child remembered that during the night she had dreamed that two of her playmates had come to sleep with her, and that she felt so mortified at being seen in a ragged dress that she got out of bed and changed her night-gown. Sometimes the events of a somnambulic paroxysm are remembered during a subsequent attack, though they are forgotten during the interval, as in a case, reported by Macario, of a young girl who had been violated during somnambulic sleep. On awaking she had no idea of anything that had occurred, but during a subsequent paroxysm she told her mother all that had happened.[81] In certain cases a dim recollection of some particular incident may be retained, as in the case of my patient who was for eight weeks in the somnambulic state. On recovery, the only thing that she could remember was a momentary glimpse of some one who was holding up his fingers before her eyes. Meeting the physician, subsequently to her recovery, who had thus attempted to arouse her attention, she recognized in his countenance the features which had momentarily impressed her consciousness during the period of somnambulic life.

It is seldom observed that somnambulism is attended with dangerous tendencies, yet they are sometimes present. One of my patients once took by mistake ninety grains of chloral at a single dose. While under its effects she got out of bed, walked into her sister’s room, shook her fist in her face, and swore furiously at her. On awaking, next morning, she was greatly shocked by the account of this dreadful behavior, so utterly at variance with her usual temper and character. Another somnambulic patient one night rushed into her mother’s room, violently accusing her of stealing her pocket-book, and threatening vengeance if it were not returned. Such patients sometimes mislay the articles with which they occupy themselves during a paroxysm, and on waking they erroneously infer that they have been robbed. Sometimes, as in the celebrated case related by Mesnet, the natural propensities of the individual seem to be released from all restraint, and brutal instincts guide the actions of the somnambulist, who then steals, or eats and drinks with the voracity of a savage. Ball and Chambard (loc. cit.) have collected a number of examples in which impulses to suicide or other forms of violence were manifested under such circumstances. Obviously, where the moral sense is asleep, and where the affection is the result of causes beyond the control of the patient, he cannot be held morally responsible for the consequences of such actions. His condition closely resembles that of the victim of epileptic mania who delivers himself during a paroxysm to all degrees of furious and homicidal violence, without retaining the slightest recollection of the fact after its conclusion. The closeness of the parallel between these two disorders is rendered further apparent by the circumstance that although all memory of the events of epileptic mania is usually abolished, it does sometimes persist after the termination of the attack. Thus, one of my epileptic patients for a time manifested symptoms of insanity after every fit. During one of these paroxysms he imagined that the sparrows on the housetop were all singing a particular tune which had attracted his attention shortly before the convulsion. Then it seemed to him that the breathing of his sleeping child whispered the same tune. Placing his hand upon the bosom of his wife, her breathing assumed the same musical character. Calling upon his family to listen to the wonderful music, they all asserted that they too could hear it. It was a considerable time after his recovery before he could be convinced that this vividly remembered experience was a pure illusion. The members of his family had been cautioned against contradicting their father during his paroxysms; consequently, when he asked if they could hear the melody which delighted him, they answered affirmatively, and thus confirmed him in his delusion. To the ordinary form of epileptic mania such paroxysms sustain a relation similar to that subsisting between ordinary dreams and the somnambulic experience.

In like manner as it is often remarked that certain dreams betray a condition of unusual cerebral excitement, so do certain cases of somnambulism manifest a delirious exaltation of the faculties in action. This characteristic often belongs to the night-terrors of children. It is a condition in which the brain is occupied by the scenery of a vivid and highly dramatic vision which dominates the actions of the subject. This was most conspicuously shown in the following case, from J. P. Frank,[82] and in certain periods of the paroxysms observed by Mesnet (p. 198). Frank’s patient was a healthy and well nurtured young German girl, who during the wars of 1812 had been terribly alarmed by a party of French soldiers who had broken into the house and threatened to kill her father. The next day at the same hour she passed into a somnambulic state, which lasted till sunset. After a brief introductory period of agitation, she uttered a deep sigh, which was rather a sob than a sigh, and fell into a profound sleep. Presently she smiled, her countenance seemed lighted with inspiration, her right arm was raised in the air, and the left was directed towards the earth. In this cataleptic attitude she remained for about a minute. She then seemed to have decided what to do; from an imaginary cartridge-box behind her back she pulled out a cartridge, bit off the end, poured out the powder upon her fist as if she were priming a musket. She then went through the motions of loading a gun, ramming down the wad with an imaginary ramrod, and cried out in French, a language which she had never heard before: “Marche! Ou est le baron? Sacré nom de Dieu!” Repeating the violent ejaculations and threats addressed by the soldiers to her father, she exhibited the utmost terror; her body was covered with a cold sweat, and she seemed ready to faint away. At this moment she woke up, called impatiently for her handkerchief, with which she wiped the perspiration from her face, and resumed her ordinary avocations as if nothing had happened.

Still more remarkable was the case reported by Dr. Mesnet.[83] From the excellent translation prepared by T. J. Huse, M. D.,[84] the following sketch has been outlined:

The patient, aet. 27 years, received in one of the battles near Sedan, during the Franco-Prussian war, a bullet wound which fractured the left parietal bone. His right arm was almost immediately paralyzed; after a few minutes the paralysis involved the right leg, and he lost consciousness. It was only after the lapse of three weeks that he recovered his senses. He was finally taken to Paris, where the paralysis gradually disappeared. From a period some three or four months after the reception of the injury, he began to manifest periodical attacks of somnambulism, at intervals of fifteen to thirty days with an average duration of fifteen to thirty hours. During the whole of this time his life presented two essentially distinct phases—the one normal, the other pathological. In the normal condition he was able to gain a livelihood. He had been a clerk in several houses, a singer in a café, and while in the hospital had made himself useful and agreeable. The somnambulic attacks which he experienced were characterized by an instantaneous onset, resulting in the abolition of all his senses except the tactile sense. Sight was perhaps partially persistent, for on many occasions he seemed to be impressed by brilliant objects, but he was obliged to employ the sense of touch in order to understand their form, volume, etc. During all these crises his gait was easy, his attitude calm, his countenance peaceful; his eyes were widely open, with dilated pupils; the forehead and brows were contracted; there was an incessant nystagmus, indicating a disordered state in the brain; he was continually mumbling or muttering. When walking in a familiar locality he moved with perfect freedom; but if in a strange place, or if obstacles were placed in his way, he examined the obstructions by feeling of them with his hands, and turned easily aside. If any attempt was made to change his direction, or to quicken or retard his pace, he allowed himself to be directed like a mere automaton, continuing to walk in any way thus chosen for him. He would also eat, drink, smoke, dress himself, walk out, and retire to bed as usual. These processes seemed to be effected as a result of previous habit, without any actual consciousness or feeling. He ate voraciously without discernment, and drank in the same manner ordinary wine, wine of quinine, water, assafœtida, without exhibiting any evidence of sensation whatever.

While under treatment in the Saint Antoine Hospital, this patient was carefully studied by Dr. Mesnet and by Alfred Maury, the celebrated author. They found that by means of impressions upon his tactile sensibility it was possible during any one of his paroxysms to suggest certain modes of action which were reproduced whenever he was again placed in the same conditions. Thus, “he was promenading in the garden, under a grove of trees, when some one put back into his hand the cane which he had let fall a few moments previously. He felt of it, turned his hand several times around the curved handle of the cane, became attentive, seemed to listen, and suddenly cried out, ‘hurry!’ then, ‘there they are! there are at least twenty of them, to the two of us! we shall get the better of them!’ and then, carrying his hand behind his back, as if to get a cartridge, he went through the movements of loading his musket, crouched at full length in the grass, concealing his head behind a tree, in the posture of a sharp-shooter, and following with his gun at his shoulder all the movements of the enemy whom he seemed to see close at hand. This scene often repeated in detail during the course of the observations, has seemed to each of us the most complete expression of an hallucination called up by an illusion of touch, which, giving to a cane the properties of a gun, awakened in this person remembrances of his last campaign, and reproduced the struggle in which he was so grievously wounded.”

On another occasion the patient was at the end of a corridor, near a door that was locked; he “passed his hands over this door, found the knob, grasped it, and attempted to open it; failing to accomplish this, he sought for the keyhole, then for the key, which, however, was not there; then, passing his fingers over the screws which secured the lock, he endeavored to seize them and turn them for the purpose of detaching the lock. This entire series of actions bears witness to an effort of his mind connected with the object before him. He was on the point of leaving the door and turning towards another room, when I held up before his eyes a bunch of seven or eight keys; he did not see them; I jingled them loudly at his ear; he did not notice them; placing them in his hand, he immediately took hold of them, and tried them one by one in the keyhole, without finding the single one which could fit; he then left the place, and went into one of the wards, taking in his passage various articles with which he filled his pockets; at length he came to a little table used for the records of the wards. He then passed his hands over the table, but it was empty; in feeling of it, however, he came across the handle of a drawer; opening it, he took up a pen, and all at once this pen suggested to him the idea of writing; for at that moment he began to ransack the drawer, taking out and placing on the table several sheets of paper, and also an inkstand. He then sat down and commenced a letter, in which he recommended himself to his commanding officer for his good conduct and bravery, and made application for the military medal. This letter was written with many mistakes in it, but these were identical as regards expression and orthography with all that we have seen him make in his healthy state. While the patient was writing, he aided us in an experiment that encouraged to immediately examine in what degree the sense of sight assisted in the performance of this action. The facility with which he traced his letters, and followed the lines upon the paper, left no doubt concerning the exercise of vision upon the writing; but, in order to make the proof satisfactory, we have several times interposed a thick plate of sheet-iron between his hands and his eyes when he was writing; and, although all the visual rays were intercepted, he did not immediately break off the line he had begun; he still continued to trace a few words written in an almost illegible manner with the letters entangled in each other; then finally he stopped without manifesting either discontent or impatience. The obstacle removed, he finished the uncompleted line, and began another. The sense of sight was therefore in full activity, and essential to the written expression of the patient.” Other observations showed that the sense of sight was only roused at the instance of touch, and that its exercise remained limited to those objects alone with which it was actually connected by the touch.

On another occasion he passed through a long ward of patients, “taking indiscriminately every article that came within his reach, and concealing them afterwards under the quilt, under a mattress, under a chair-cover, and under a pile of sheets. Arrived in the garden, he took from his pocket a book of cigarette papers, opened it, and detached a leaf from it; then took out his tobacco and rolled a cigarette with the dexterity of one who is accustomed to this proceeding. He searched for his match-box, lighted his cigarette with a match, which falling still burning on the ground, he extinguished by placing his foot upon it; then smoked his cigarette while strolling back and forth to the entire extent of the garden, without any of these actions presenting the slightest deviation in their manner from the ordinary method. Everything that he did was the faithful reproduction of his ordinary round of life.