the eyes, by feeble and monotonous excitation of the senses, and by
various other methods of an analogous character. This forms the most
common variety of the hypnotic condition. It may very easily supervene
during either the lethargic or the cataleptic state as a consequence
of pressure or gentle friction upon the top of the head. Thus,
Heidenhain caused muscular paralysis by rubbing the scalp. Unilateral
friction of the same surface produced paralysis of the opposite side
of the body without notable affection of consciousness. The eye and
the eyelids behave as in the lethargic state. The patient seems
asleep, but there is less muscular relaxation than in hypnotic
lethargy. There is no exaggeration of the tendinous reflexes, and
muscular hyperexcitability is absent. But by lightly touching or
breathing upon the surface of a limb its muscles may be thrown into a
condition of rigidity which differs from the contracture of the
lethargic state in the fact that it does not yield to excitation of
the antagonistic muscles, though yielding readily to a sudden
repetition of the same form of excitement by which it was originally
produced. From the immobility of the cataleptic state it also differs
by a greater degree of resistance to passive motion. Though analgesia
may be perfectly developed in this state, there is generally an
exalted condition of certain forms of cutaneous sensibility and of the
muscular sense. Strange perversions of other special senses are
sometimes remarked. Cohn[20] discovered that a patient who was
naturally color-blind “when unilaterally hypnotized was able to
distinguish colors which were otherwise undistinguishable.”
Conversely, when the cataleptic state is induced the eye becomes
incapable of discerning colors. Spasm of accommodation is also
present, and is one of the earliest demonstrable symptoms of the
hypnotic condition.
[Footnote 20: _Brain_, vol. iii. p. 394.]
These remarkable exaggerations and perversions of special sensibility
have been the cause of much scepticism on the one hand regarding the
verity of the phenomena of hypnotism, and of much credulity on the
other, extending even to a belief in the existence of supernatural and
miraculous gifts. But when the fact is once comprehended that in this
capacity for uncommon feats of vision, hearing, touch, etc. we observe
merely the exaggeration of a process which occurs in every act of
attention, the miraculous semblance of the phenomena disappears.
Attention implies an increase of activity in certain portions of the
brain, with {377} diminution of the function in the remainder of the
organ. In the wild excitement of a cavalry charge the soldier feels
not the sabre cut which will fill his consciousness with pain so soon
as his attention is released from the fetters imposed by the more
engrossing events of the combat. So in the somnambulic sleep those
parts of the brain which remain awake perform their functions with a
vigor that is enhanced by a concentration of cerebral energy in
certain restricted portions of an organ that, by reason of its
naturally excessive instability, had been previously fitted for the
liberation of an inordinate amount of molecular motion. Hence the
slightest suggestion of sense may suffice for the most extraordinary
perception. Such persons see through their eyelids and hear at a
surprising distance. The memory of past events, the recollection of
long-forgotten words and thoughts, supplies in this state an abundance
of materials out of which an exalted imagination may construct the
most astonishing scenes. By this method of combination are produced
those remarkable oratorical utterances which by the ignorant have been
so widely attributed to the supervision of guiding spirits from
another world. In this condition the essential characteristics of the
mind of the so-called medium become the real guides of his mental
processes. Hence the infinite variety and contrariety of the
utterances of such declaimers.
Among other consequences of this exalted susceptibility of the waking
portions of the brain may be noticed the effect of suggestions by
others upon the mind of the somnambulist. Numerous examples scattered
through the literature of the subject[21] illustrate the manner in
which the course of our ordinary dreams may be thus directed. The
hypnotic dream is far more easily modified.[22] The simplest
manifestations of such influence are exhibited in movements in
obedience to the command of the hypnotizer. Next in rank are those
more complicated actions that are effected by excitement of the
imitative faculties of the subject. Every suggested movement that can
be in any way perceived by the patient will be at once reproduced.
Various emotions and passions may thus be aroused by simply placing
the sleeper in the appropriately suggestive attitudes. Under the
influence of a pregnant idea intruded upon the mind of the patient the
subsequent association of ideas will suffice for the evolution of a
complicated series of hallucinations, as in the case of a young woman,
who on being directed to put out her tongue immediately began to feel
sensations of uneasiness in her stomach, followed by nausea and
attempts at vomiting, accompanied by the impression of being on
shipboard. In the lowest grades of the hypnotic state consciousness
may remain, and the subsequent recollection of the events of the
paroxysm may be quite persistent. In such cases illusions that were
produced by suggestions from other minds generally survive in memory
and become the causes of serious delusion. Witness the manner in which
susceptible individuals, partially hypnotized in a so-called spiritual
circle, believe in the reality of the illusions which have occupied
their senses during a séance.
[Footnote 21: Carpenter's _Physiology_, 8th ed., p. 765; _Le Sommeil
et les Rêves_, par L.-F. Alfred Maury, 4th ed., p. 153 _et seq._]
[Footnote 22: _Loc. cit._, p. 357.]
A higher degree of insensibility to ordinary impressions is necessary
to the production of the phenomena of passive obedience and of
automatic {378} imitation. It is probable that the degree of sensory
hyperæsthesia which enables certain hypnotic patients to read the
thoughts of others belongs rather to the first than to the last of
these classes. This capacity is usually associated with preservation
of consciousness and memory, and is, essentially, a mere exaggeration
of that power which all possess in greater or less degree. Numerous
well-authenticated examples of a surprising manifestation of this
faculty have been recorded, so that the possibility of its existence
no longer admits of doubt.[23] In all cases it has been remarked that
the hypnotic mediums can only respond correctly to questions for which
the true answer is present in the mind of the questioner. For all
other interrogations the replies are delivered purely under the
influence of random suggestion. In certain of these cases the pathway
of communication lies through actual physical contact, as in ordinary
mind-reading, where the insensible molecular oscillations of the
muscular elements of one individual serve to guide the movements of
another. But more frequently the transmission of ideas is effected
through the eyes. With these organs the table-rapper or the
planchette-writer reads the unspoken words of the questioner in a
manner very like, yet vastly more deliberate than, that by which
deaf-mutes now learn to interpret the movements of the lips of persons
with whom they converse. This fact is well illustrated by the
experience of Maury[24] in an interview with a celebrated
table-rapper, who without the slightest hesitation made known to him
the age, name, and date of death of a brother whom he had lost. She
also gave the same information regarding his father, and related the
names of other persons upon whom he had fixed his attention. But if he
turned away his face or concealed his eyes, so that the woman could no
longer watch their expression, her responses ceased to be of any
value.
[Footnote 23: Luther V. Bell, _Two Dissertations on what are termed
the Spiritual Phenomena_, read at the meetings of the Association of
Medical Superintendents of American Insane Hospitals at Washington and
Boston in 1854 and 1855.]
[Footnote 24: _Le Sommeil et les Rêves_, 4th ed., p. 361.]
In these partial developments of the hypnotic state it is worthy of
note that the phenomena of sleep are so few and so comparatively
insignificant that they are usually overlooked. Hence the veil of
mystery which has so often obscured the interpretation of such cases.
Careful observation, however, will always detect some characteristic
departure from the normal standard—some loss of balance between the
different parts of the nervous system—by means of which the true
relations of each example may be determined.
TREATMENT.—A large proportion of the phenomena of somnambulism and
hypnotism depend rather upon an originally irritable organization than
upon a specially diseased condition of the nervous system. Their
treatment, therefore, frequently resolves itself into the management
of hysteria or of cerebrasthenia. But if the manifestations of
somnambulism develop for the first time in a person advanced in years,
who has previously enjoyed good health and a sound mind, it should be
regarded as an omen of grave import, signifying the imminence of
organic cerebral disease. Though the meaning of such incidents is less
sinister in early life, they reveal an ill-balanced state of the
nervous system and an imperfect process of nutrition in the growing
body. Such children are the {379} frequent victims of night-terrors,
the form of disorder most commonly evolved by their somnambulistic
proclivities. The treatment of night-terrors should therefore be
chiefly directed to the invigoration of the general health of the
patient. Indigestion and malnutrition are among the most prominent
antecedents, and they should constitute the principal objects of
therapeutical attention. Constipation is usually present. This may be
relieved by the use of compound rhubarb powder or any other gently
stimulating laxative. Digestion should be aided with pepsin as soon as
the catarrhal condition of the alimentary canal, so uniformly present,
has been measurably improved. Cod-liver oil or its substitutes should
be administered for a long period of time. If the nocturnal paroxysms
be frequently renewed, it may be well to employ the bromides, either
with or without chloral hydrate; but as a general rule it is better to
rely upon hygienic and restorative treatment, rather than upon any
form of merely hypnotic medication.
INSOMNIA.
The departures from the course of natural sleep which have been thus
considered are not so much the direct consequence of acute disease as
the result of structural deviation from the normal type of the nervous
system. We must now briefly review the strictly pathological
modifications to which sleep is liable.
Lithæmic Insomnia.
Among those who indulge freely in the pleasures of the table a form of
insomnia is not uncommon. Originating at first in mere overloading of
the stomach, and consisting in a direct irritation of the brain
through the medium of the intervening nervous apparatus, sleeplessness
finally becomes a symptom of more serious mischief. The tissues become
charged with nitrogenous waste, and a lithæmic[25] or gouty condition
is established. Such patients are wakeful, or if they sleep their
slumbers are imperfect and unrefreshing.[26] Grinding of the
teeth,[27] noticed by Graves during the sleep of the gouty, is a
symptom indicative of a highly irritable condition of important
ganglia at the base of the brain. These symptoms are sometimes
associated with turgidity of the superficial vessels of the head,
indicating imperfect function of the circulatory organs, with a
tendency to accumulation of the blood in the venous channels of the
body. The sleep of such partially-asphyxiated patients is fitful,
irregular, and akin to stupor. Occurring in the subjects of periodical
gout, these disturbances of sleep become increasingly serious as the
paroxysm is approached, until loss of sleep and the unrefreshing
character of such {380} slumber as may be obtained become important
factors among the causes of failing health.
[Footnote 25: DaCosta, “Nervous Symptoms of Lithæmia,” _Am. Journ.
Med. Sci._, Oct., 1881.]
[Footnote 26: Dyce Duckworth, “Insomnia in Persons of Gouty
Disposition,” _Brain_, July, 1881.]
[Footnote 27: Trousseau, _Clinical Medicine_, Am. ed., vol. iv. p.
362.]
For all such patients a proper recognition of the cause of their
disorder is essential. This must be corrected by measures appropriate
to the treatment of the gouty diathesis. Since the condition of the
cerebral tissues is a state of irritation caused by the presence of
excrementitious substances, such hypnotic remedies must be selected as
will not interfere with the defecation of those tissues. Bromide of
potassium, valerian, scutellaria, hyoscyamus, hops, and cannabis
indica are useful, together with all that class of drugs which quiet
the brain without hindering the process of excretion. Chloral hydrate
often produces an excellent result, but care should be taken to
prevent its habitual use.
Febrile Insomnia.
Closely related with the sleeplessness of lithæmia are the
disturbances of repose which attend the evolution of the various
specific fevers. In many cases the condition varies all the way from
stupor to delirium. Excessive somnolence, such as often ushers in the
fever, is an indication for evacuant treatment. Cerebral excitement
calls for remedies like the bromides and chloral hydrate, which do not
interfere with elimination. If pain, like headache or backache, be a
symptom demanding attention, the addition of morphia in small doses
forms a valuable reinforcement for the hypnotic mixture; but, as a
general rule, opiates should be used with a sparing hand. The various
resources of hydrotherapy are often invaluable when wakefulness
results from the cutaneous irritability of the eruptive fevers. During
the later stages of a protracted illness the occurrence of insomnia
should direct attention to the nutrition of the patient. Wakefulness
is then the symptom of an irritable weakness of the brain, demanding
remedies which delay the process of disassimilation. The failing power
of the heart requires attention, and diffusible nutriment must be
given to convey the elements needful for restoration of the exhausted
brain. These indications are most perfectly answered by the associated
administration of opiates with alcohol, milk, and beef-juice in small
and frequent doses.
Insomnia from Exhaustion.
Cerebral exhaustion is a not uncommon cause of wakefulness in cases
uncomplicated with fever. It is usually the result of chronic
conditions of ill-health and depression, such as are often encountered
as the result of various cachexias or of dyspepsia, with or without
the abuse of alcohol, tea, coffee, or tobacco. Overwork, debilitating
discharges, pregnancy, parturition, mental anxiety, depressing
emotions, chronic heart disease, and incipient insanity are fruitful
causes of the exhaustion which produces this most distressing form of
insomnia. In such cases the cessation of healthy nutrition leads to a
condition of excessive instability in the cerebral tissues. The oxygen
which they receive from the blood is not stored with any degree of
permanence, but tends to pass directly into {381} stable combinations
with the oxidizable elements of the brain. Consciousness is thus
continually aroused. The state of such a patient presents a very close
analogy to the condition of the victim of diabetes whose liver refuses
to retain its glycogen. The inordinate discharge of sugar into the
blood not only exhausts the tissues of the liver, but also excites
other organs—notably the kidneys—to excessive and unwholesome
activity. In somewhat similar fashion, the failure of the brain to
assimilate and to retain oxygen leads to an abnormal intramolecular
oxidation, which excites an excessive and unwholesome activity on the
part of the Ego in another region—namely, in the field of
consciousness. Such wakefulness might justly be termed a psychical
diabetes.
This variety of insomnia has frequently been ascribed to cerebral
anæmia occurring as a part of a general spanæmia. But this universal
impoverishment of the blood, though a sufficient cause of the morbid
instability, the irritable weakness, of the cortical tissues, does not
necessarily imply a comparatively bloodless condition of the brain.
Unequal circulation and local hyperæmia in different organs of the
body are no unusual consequences of the anæmic state. Slight
disturbances suffice to arouse the brain of such a patient. The
vaso-motor apparatus shares in the general irritability, permitting
blood to inundate the cortical substance almost without provocation.
The unstable protoplasm is only imperfectly renovated, usually at the
expense of the other tissues of the body. The weary patient, busying
himself with an unwilling review of the events of the day, tosses long
upon his couch before he can secure the approach of “tired Nature's
sweet restorer, balmy sleep.” When at length he yields, his slumbers
are brief, and the latter part of the night is but a repetition of the
earlier vigil.
Such patients need a very radical course of general treatment. A
complete change of habits should be effected. A long vacation in the
country, or, best of all, a protracted voyage in a sailing vessel, is
desirable. Hot foot-baths, with cold affusion upon the head, and warm
sponge-baths, or even the full bath in tepid water, at bedtime, are of
great service as means of tranquillizing the nervous system. The
indications for medicinal treatment, besides attention to the
predisposing cachexia, are twofold—to calm and to nourish the
enfeebled nervous substance. Opiates calm, but do not nourish—they
hinder the process of nutrition; hence the sufferer wakes unrefreshed
by the sleep which they procure, and is soon in a condition worse than
ever. The same objection lies against the continuous use of the
bromides. But alcohol and its hypnotic derivatives (chloral,
paraldehyde, etc.) not only calm the excitable brain, but they also
furnish to the tissues a certain amount of diffusible nutriment which
suffices to steady the brain until a change of occupation, with rest
and wholesome food, can produce a complete restoration of its normal
stability. To this effect of alcohol must be ascribed its value as an
hypnotic in the wakefulness of old people who cannot sleep without a
preliminary nightcap. A moderate draught of hot toddy in such cases
serves to arouse the feeble heart and to equalize the circulation by
the production of a moderate degree of general vascular dilatation.
The sugar and water afford an easily assimilated food, while the
alcohol benumbs the cortical protoplasm to a degree which favors the
cessation of conscious perception. If administered in excessive doses,
it is not sleep but anæsthetic intoxication {382} which follows. If
this condition be unduly repeated, the phenomena of chronic alcoholism
supervene, with all the horrible forms of insomnia that accompany
cerebral starvation and delirium tremens. Non-alcoholic
nerve-stimulants and tonics, with careful administration of
easily-digested food, are then more than ever needed to overcome the
neurasthenic wakefulness.
Insomnia from Active Cerebral Congestion.
Still another form of sleeplessness is often experienced as a result
of actual inflammation in some portion of the body, either involving
the intracranial contents directly or reacting upon the brain through
the medium of its circulation. In such cases many of the symptoms of
acute inflammation are present. The head aches, the temples throb, the
face and eyes are suffused with blood, the temperature is considerably
increased. The senses become exalted, ideas pursue a tumultuous
course, there may be actual delirium. These disturbances are due to an
active hyperæmia of the brain. The substance of the cortex becomes
hyperexcitable, and the ordinary incitements of sense produce an
exaggerated effect in consciousness. The patient does not sleep, and
he feels no need of sleep, because the nutrition of the brain is
sustained at the expense of the remainder of the wasting body. The
most speedy and effectual relief in such cases is obtained through a
diminution of the current of blood in the brain. Moderate compression
of the carotid arteries has been proposed as theoretically useful.
Sedatives, like aconite, conium, digitalis, veratrum viride,
ipecacuanha, and tartar emetic are useful, either alone if pain be
absent or combined with opiates if the patient is suffering. Dover's
powder or tartar emetic and morphia in small doses was formerly in
general use. If there be a disposition to nausea the substitution of
aconite for antimony is of great value. A combination of morphia,
bromide of potassium, and chloral hydrate often gives excellent
results. Paraldehyde may be preferable to chloral by reason of its
more thoroughly sedative effect. Derivative measures—mercurial
cathartics, cupping, leeching, or even general bleeding—may become
necessary in certain cases. After the acute stage is passed blisters
behind the ears should be employed. In the sleeplessness of acute
mania Newington[28] has used mustard baths with great satisfaction.
[Footnote 28: _Brain_, vol. i. p. 126.]
Coma.
Turning now to the other extreme, we find a class of cases in which
the disorder consists not in wakefulness, but in an excess of sleep.
Excluding those exceptional cases in which healthy individuals, as a
consequence of inordinate physical exertion, have slept for many hours
beyond their ordinary limit, every extraordinary manifestation of
sleep-like unconsciousness must partake of the nature of coma. Between
natural sleep and this condition may be placed the distinction that
the one is always the effect of natural physiological processes, while
the other is always the result of injury, of disease, or of some form
of intoxication. Comatose {383} unconsciousness may be the result of
cerebral compression caused by traumatic impact or by the presence of
inflammatory exudations. Intracranial tumors, embolisms, thrombi,
degeneration of tissue, diseases of the arteries of the brain—in
short, every morbid change of which the liquids and the solids within
the cranium are capable—may become the causes of coma. So also the
blood and lymph, contaminated with the products of internal
disintegration, may benumb the brain with comatose sleep. Again, the
tissues of the brain may be overwhelmed with poisons introduced from
without the body, and thus a condition of coma may result. Few
diseases, therefore, exist without the possibility of coma as one of
their consequences—a coma which, however, must not be confounded with
the genuine sleep which sometimes occupies the larger part of certain
stages of convalescence from acute illness. During such convalescence
there is a reversion to the infantile type of nutrition, with all its
need of prolonged and frequent periods of repose. Like normal sleep,
the comatose condition admits of considerable variation of intensity.
The patient may sometimes be partially roused, as from the coma of
alcoholic intoxication, and he may finally recover complete
consciousness, but very often the reverse is the fact. The coma
deepens into paralysis, and death terminates the scene without the
slightest manifestation of sensibility or intelligence.
Sleeping Dropsy (Maladie du Sommeil).