Insomnia; and Other Disorders of Sleep

receive at once the benefit of sl

cbe

nquiry that the subject is nevertheless connected by near relationship with a neurotic stock. In a third class of patients the neuropathic diathesis is not congenital, but is the acquired result of particular injuries or diseases of the head. It is also observed sometimes as a consequence of transitory functional disturbances of the brain connected with the period of convalescence from diseases that profoundly affect the nutrition of the nervous system. In all cases, however, it is probable that a special nervous temperament exists as a predisposing cause of the phenomena, for the majority of people can sustain injuries of the head, or of the peripheral nervous system, and can pass through all kinds of illness without exhibiting any tendency to somnambulism. As the nervous te

the elements of dreams are arranged. Consequently, though the elements of the somnambulic process may be far more numerous and various than the elements of a dream, they may be less capable of rising into the realm of consciousness. Such a process may differ from the phenomena of ordinary life only in the fact of unconsciousness; and, when concluded, it leaves no traces in the memory of the waking state. In other instances, on the contrary, so many nervous functions may be suppressed, and so great may be the intensity of the remaining cerebral processes, that the resulting phenomena scarcely differ from an ordinary dream in which consciousness is aroused, and the waking memory is durably impressed. Between these extremes lie opportunities for an indefinite number of combinations; consequently the forms and degrees of somnambulism present a very great variety of manifestation. Maury[74] reduces these to five principal forms: First, simple movement of the limbs in connection with t

further suppression of the co?rdinative faculties. The third stage is marked by the loss of memory and imagination. In the most profound and perfect sleep the functions of organic life alone remain. The process of awaking consists in the revival of the faculties in the inverse order of their extinction. Dreams occur during the period in which motion, sensation, and the co?rdinative faculties are in abeyance; but somnambulism may accompany each of the stages of sleep. Its simplest form is perhaps the rarest; corresponding to Maury's fifth variety. In this form the functions of organic life are intact; motion and sensibility s

ased in great measure from the control of the higher intellectual faculties, and excited by such vestiges of sensation as still persist, create a species of delirium in which mutilated sens

m which the cerebral hemispheres have been removed. He is little better than a living automaton, guided only by impressions received from without. In this

c life remain. The patient merely lives, he neither thinks nor acts. This constitutes the state of somnambulic lethargy, a condition which differs from deep sleep o

somnambulism are reached. But it must be remembered that between these pronounced and definite forms exist a great number of intermediate degrees. Partial revivals and temporary resurrections of the higher faculties of the mind may intrude themselves among the activities which depend upon lower functions; as,

of disease or of congenital defect of cerebral organization. What the particular structural difference may be, it must be impossible to decide, until it shall become possible to state the reason why one brain shall behave only in a normal manner, while another presents all the vagaries of hysteria, somnambulism,-perhaps even of insanity. That the affection is

will be found interesting to consider a few illustrative examples of

to a somnambulic state corresponding to the somnambulic life of the preceding table. This continued about five weeks, when she became completely lethargic, and was transferred to my care. In this condition she remained unconscious, almost perfectly insensible, with pupils somewhat contracted and sluggish before the light, with a feeble and slightly accelerated pulse, a moderately elevated temperature, bowels and bladder insensible to their contents, mouth and throat filled with an offensive mucous secretion. By great urgency

usness 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 re

nally 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

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 rela

enerally 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 express

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 dis

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,

kenness has been applied. Its connection with morbid disturbance of the brain is usually very evident. Obviously, the moral resp

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. O

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 t

e 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

lt a portion of the coverlid gathered in a heap on one corner of the bed. He believed this to be the child; grasped it in one hand, and with the other went through the motions of swimming back to the bank of the supposed river. There he laid down his burden, and came out, shivering and chattering his teeth as if he were really getting out of an icy river. To the bystanders he said that he was freezing, and would die of cold, that his blood was all turned to ice; he must have a glass

dams Allen.[80] The subject of the observation was a medical student who resided

d in the small hours by the inevitable tuning up prelude, mingled with slipping of the old keys, and quiet objurgations upon his part. Sometimes the bridge would fall down when the keys slipped, and sometimes a string would snap or escape from the keys, nevertheless he would persevere, repair damages, tune up, and then execute all varieties of music of which the machine was capable, not unfrequently accompanying it with his voice. All this would be done in total darkness. When any one entered the room with a light, he took not the l

voice of the purest tone and very considerable compass, in fact of rare sweetness. I am enabled to say from a multitude of observations, that he played with a precision and skill while asleep that he could not approximate while awake. Besides this, he would execute music which he had hea

his somnambulism, I have time only

he figures on pp. 596 and 597 of Carpenter's Principles, in the edition of 1853.... These drawings are now in the series used for illustration in Rush Medical College. Although we had a light in the room while watching him, he went on with his work entirely regardless of it. Before completing the work, he went to bed and slept until the usual hour in the morning, when at the breakfast he asked if he had been up in the night, as he had dreamed that he had. This was the only time he ever remembered even dreaming about being up or occupied in anything. He had by this time become so fully aware of his habits, that nothing of the sort astonished him. Shortly after this he went to spend the night with a fellow student, but a little after midnight he rose, dressed himself, and went out, followed by the other gentleman, walked down to the Exchange Hotel, where there were a number of his acquaintances and others waiting for a train of cars due at that time. Some one rallied him on his being out so late, but being cautioned by h

ands, and everything we could do to attract his attention. He dealt the cards in his turn, correctly, and played 'according to Hoyle.' In one hand, spades were trumps, and he held the jack of clubs. Clubs being l

ime, by throwing water in his face-the only method, by the way, in which we could awake him without great

g from a severe shock. The influence upon the pulse and nervous system was al

gestion, or after watching with the sick, or fatigue, he would be

ne 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, b

pressions 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 wi

til 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

ho 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

ly 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

t.[83] From the excellent translation prepared by T. J.

n 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 mumb

et 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 th

icles 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 fa

igarette 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 plac

his eyes, yet he still did not perceive it; even when I shook it just in front of his nose, he did not notice it. But when I placed it in contact with his hand, he seized it and completed his cigarette directly. Just as he was about to light his cigarette with one of his matches, I blew it out and offered him instead a lighted match which I held in my own hand; he did not perceive it; I brought it so close to his eyes as

k his cane, and traversed the ward with a slow step, well contented. When stopped on his way, for the purpose of taking off the coat he was wearing (which had been foisted on him by one of the observers), he permitted it without offering any resistance.... At this moment the sun lit up with a bright ray a glass window that closed the lodge on the side towards the court.... This ray must have given him the impression of a footlight, for he at once placed himself before it, readjusted his toilet, opened the roll of paper which he carried in his hand, and softly hummed an air, running his eyes over the pages as he slowly t

emarkable history have been sufficiently expre

s awakens some instinctive excitation which surrenders the individual without any defence, and destitute of rational discernment, to the most deplorable impulses. He acts with the semblance of a freedom which he do

uestion of the moral responsibility of the

sensations from without, so that their movements may be directed by the will of another. We have seen how the course of an ordinary dream may be modified by such suggestions. The history of the patient just related, illustrates the manner in which the actions of a somnambulic dreamer may be controlled by the will of a spectator. The ordinary phenomena

t state; as soon as the connection is shifted, the mind takes cognizance of the events that are recorded upon the other portion of the register, but, for want of physical continuity between the different portions of the record, the mind cannot at once receive a continuously connected report from the entire organ of recollection. From this results a mode of life essentially similar to the life of certain epileptics who are ushered by each seizure into a state of apparently conscious activity of which they have no recollection after recovery. Thus, one of my epileptic patients, who was subject to seizures, both of the convulsive and the non-convulsive form of the disease, on one occasion left home, after a fit, and traveled a considerable distance into the country, putting up for the night at taverns and farm houses, and apparently behaving like any other respectable citizen. It was three weeks before he came to himself. On recovering his normal consciousness, the period of his wanderings was a perfect blank in his memory. Such attacks are usually of shorter duration, and are more frequently associated with hysteria; bearing to the hysterical paroxysm the same relation which they share with the epileptic fit. When the predisposing temperament exists, a great variety

cises she made considerable proficiency. But, after a few months, another fit of somnolency supervened. On rousing from it, she found herself restored to the state she was in before the first paroxysm; but was wholly ignorant of every event and occurrence that had befallen her afterward. During four years and upwards she has passed periodically from one state to the other, always after a long and sound sleep.... The former condition of her existence she now calls the Old State, and the latter the New State; and she is as unconscious of her double character as two distinct persons are of their respective natures. For example, in her o

g about ten minutes. She would then open her eyes, apparently awake, and would remain in the condition of somnambulic life for an hour or two, when the languor and sleepiness would reappear for a few minutes, after which she would awaken in her normal state. At first these paroxysms were renewed every five or six hours; but, as she grew older, they occurred less frequently, and were greatly prolonged, until, finally, the periods of somnambulic life considerably exceeded the duration of normal life. During normal life she was hypochondriacal, hysterical, and a

of the German language until he was restored by rest and food, indicate that such defects of memory depend upon a deficient nutrition of the brain substance-a condition which is undoubtedly associated with an enfeebled cerebral circulation. We may, therefore, suppose that in Dr. Azam's case the paroxysms of somnambulic life were induced by periodical discharges of force within the brain, causing an improvement in the circulation of blood, and a corresponding gain in health and general vivacity. Such exaltation of the faculties would be pe

sible removed from all connection with the mental actions which arise directly from the operation of the senses. By reason of such isolation the ordinary association of ideas affords no help to the memory, and the dream remains in oblivion. Alfred Maury expresses the opinion[90] that the principal cause of forgetfulness of the events of somnambulism consists in the exhaustion of the cerebral elements through the intensity of the excitement to which they have been subjected during the paroxysm. Doubtless this, in certain cases, may contribute to the loss of memory, but it should be remembered that the excitement may be relative rather than absolute. Certain elements wake while others are asleep; and these waking cells may be aroused to a degree far in excess of what is usual during the sleep of the brain without attaining to the level of their diurnal activity. The mind, undisturbed by external impressions, gives its attention to the operation of these waking organs, and a dream with all its consequences, somnambulic or otherwise, is the result. In other words, the plane of consciousness, so to speak, is lowered in sleep to the level of these molecular vibrations. But when the entire brain has been completely reawakened, the residual vibrations of those elements which yielded the physical basis of the dream, and which, had they originally occurred during the waking state, might have persisted with energy sufficient to furnish a groundwork for recollection of the ideas which they had first suggested, are no longer sufficiently forcible to be felt in consciousness. Recollection of mental states thus generated must necessarily be impossible under such conditions. Sometimes, however, the somnambulist who