THE PATHOLOGY OF WAKEFULNESS.
As nations advance in civilization and refinement, affections of the
nervous system become more frequent, because progress in these directions
is necessarily accompanied by an increase in the wear and tear of those
organs through which perceptions are received and emotions excited; and,
in addition, the mode of life, as regards food, clothing, occupation, and
habits, is being constantly removed farther from that standard which a
regard for hygienic considerations would establish as most advantageous.
If, as we have every reason to believe, each thought involves the
destruction of a certain amount of nervous tissue, we can very well
understand why, as we go forward in enlightenment and in all the elements
of material and intellectual progress, we are at the same time, unless we
also advance in the knowledge of the laws of our being, hurrying ourselves
with rapid strides to a state of existence in which there is neither waste
nor repair.
I am far, however, from desiring to be understood as intimating that a
high state of civilization is antagonistic to long life or health. What is
lost in these directions as regards the nervous system is more than made
up by the increased provision afforded for comfort in other ways. But
while we have improved the hygienic condition of our cities and dwellings;
while we as a rule clothe our bodies according to the principles of
sanitary science and common sense; and while cleanliness of person has
become the rule, and filthiness the exception, we have made little or no
progress in the hygienic management of those organs which place us in
relation with the world, and a healthy condition of which is so essential
to our happiness.
Among the many derangements in the normal operation of the nervous system,
induced by irregular or excessive cerebral action, those which relate to
the function of sleep are certainly not the least in importance, whether
regard be had to the actual comfort of the individual or to the serious
consequences to which they may give rise. To the consideration of some of
these morbid conditions I propose to devote the remainder of the present
volume, and first to inquire into the most important of them, wakefulness
or insomnia.
As a symptom of various diseases which affect the human organism,
wakefulness is sufficiently well recognized by systematic writers on the
practice of medicine, though, even here, it is very certain that its
pathology has seldom been clearly made out. As a functional disorder of
the brain, arising from inordinate mental activity, it has received
scarcely any notice. This neglect has, doubtless, been in a great measure
due to the fact that it is only within late years that the condition in
question has become so common as to attract much attention. At present
there are, probably, but few physicians engaged in extensive practice in
any of our large cities who do not in the course of the year meet with
several cases of obstinate wakefulness, unaccompanied, in the early stages
at least, by any other prominent disorder of the system.
In my opinion, no one cause is so productive of cerebral affections as
persistent wakefulness, for not only is the brain prevented from obtaining
rest, but it is kept in a state of erethism, which, if not relieved, must
sooner or later end in organic disease. Southey laid the seeds of that
disorder which terminated in the loss of his intellect, by watching at the
bedside of his sick wife during the night, after the excessive literary
labors of the day.[121] Newton’s mind also suffered in the later years of
his life through deprivation of sleep;[122] and Dr. Forbes Winslow, in
remarking on Southey’s case, says: “No brain can remain in permanent
health that has been overtasked by nightly vigils still more than by daily
labor.”[123]
Renaudin,[124] in a very philosophical essay, calls attention to the fact
that persistent wakefulness is sooner or later followed by insanity; and
Maury[125] states his opinion to the same effect. The remarks of Dr.
Ray[126] upon this subject are so apposite that I reproduce them in part,
commending at the same time the little book from which they are taken to
the attention of the reader.
“A periodical renewal of the nervous energies as often as once a day is an
institution of nature, none the less necessary to the well-being of the
animal economy, because in some degree under the control of the will. To
disregard its requirements with impunity is no more possible than it is to
violate any other organic law with impunity, and no man need flatter
himself that he may systematically intrench upon the hours usually devoted
to rest and still retain the freshness and elasticity of his faculties.
With the same kindliness that marks all the arrangements of the animal
economy, this condition is attended with many pleasing sensations and
salutary effects, gently alluring us to seek the renovation which it
offers. ‘While I am asleep,’ says the immortal Sancho Panza, ‘I have
neither fear nor hope; neither trouble nor glory; and blessings on him
who invented sleep,--the mantle that covers all human thoughts; the food
that appeases hunger; the drink that quenches thirst; the fire that warms;
the cold that moderates heat; and, lastly, the general coin that purchases
all things; the balance and weight that make the shepherd equal to the
king and the simple to the wise.’ The ill effects of insufficient sleep
may be witnessed on some of the principal organic functions, but it is the
brain and nervous system that suffer chiefly and in the first instance.
The consequences of a too protracted vigil are too well known to be
mistaken, and many a person is suffering, unconscious of the cause, from
the habit of irregular and insufficient sleep. One of its most common
effects is a degree of nervous irritability and peevishness, which even
the happiest self-discipline can scarcely control. That buoyancy of the
feelings, that cheerful, hopeful, trusting temper that springs far more
from organic conditions than from mature and definite convictions, give
way to a spirit of dissatisfaction and dejection; while the even demeanor,
the measured activity, are replaced either by a lassitude that renders any
exertion painful, or an impatience and restlessness not very conducive to
happiness. Upon the intellectual powers the mischief is still more
serious. They not only lose that healthy activity which combines and
regulates their movements in the happiest manner, but they are no longer
capable of movements, once perfectly easy. The conceptions cease to be
clear and well defined, the power of endurance is weakened, inward
perceptions are confounded with outward unhappiness, and illusory images
obtrude themselves unbidden upon the mind. This kind of disturbance may
pass sooner or later into actual insanity, and many a noble spirit has
been utterly prostrated by habitual loss of rest.”
CASE I.--Some years ago a case similar in several respects to that of
Southey came under my observation. A gentleman of superior mind and of
great powers of application spent from sixteen to eighteen hours each day
in severe literary labor. This of itself would have been a heavy strain to
most persons, but he went regularly to bed and slept soundly six hours
each night, and it is possible that he might have continued this mode of
life for several years without serious inconvenience, when his wife was
suddenly taken ill. His anxiety on her account was very great, and he
spent nearly the whole night by her bedside, sleeping only for about an
hour toward morning. After three weeks passed in this manner, his wife was
pronounced out of danger, but he found it impossible to resume his former
habits. He could neither study nor sleep. The nights were passed in
walking the floor of his chamber or in tossing restlessly on his bed.
There were no pain, no fever, no disorder of any other organ. There was
nothing but ceaseless activity of the mind and an utter inability to
sleep. Stimulants and narcotics only increased the violence of his
symptoms, and every other means employed failed to give relief. The danger
of his situation was pointed out to him and travel recommended. He
followed the advice, and though it was several months before he was
completely relieved, his condition began at once to improve. He was taught
a lesson which has not been without influence, in causing him to task his
mental faculties less severely.
CASE II.--Another, an intimate friend, who occupied an important public
position, gave so much time and attention to his duties, which were of a
highly laborious character, that he deprived himself of the amount of
sleep to which he had previously been accustomed. It was rarely the case
that he got to bed before two or three o’clock in the morning, and then an
hour or two was always occupied in active intellection. The consequence
was that he finally broke down through want of the mental repose so
essential to him. Inflammation of the brain ensued, and this terminated in
acute insanity, from which he died.
It would be easy to bring forward other instances of which I am perfectly
cognizant, or which have been cited by authors in illustration of the
point in question, but it is scarcely necessary to enlarge further upon
this portion of the subject. We should be careful, however, not to mistake
the effect for the cause, an error which is often committed in this as
well as in other matters. It is well known that many cases of insanity are
marked in the early stages by persistent insomnia. Doubtless this is
frequently a consequence of the morbid action already set up in the brain;
but much observation has satisfied me that it is more often the cause of
the cerebral aberration, and that by proper medical treatment the mental
excitement may be generally allayed. Certainly the means most commonly
resorted to in such instances are adopted without the full consideration
so imperatively necessary, and consequently are fully as liable to
increase as to lessen the disturbance.
We cannot employ too much care in doing everything in our power to prevent
the occurrence of those slight attacks of cerebral congestion, which,
though perhaps scarcely observable at the time, are yet fraught with very
serious consequences. Persons have had their whole characters changed by
an apparently trifling interference with the circulation of blood in the
head. A person of my acquaintance was naturally of good disposition,
amiable in his character, and considerate in his dealings with others; but
after an attack of vertigo, attended with unconsciousness of but a few
moments’ duration, his whole mental organization underwent a radical
change. He became deceitful, morose, and exceedingly overbearing and
tyrannical toward all with whom he came in contact, and whom it was safe
for him to maltreat. Tuke and Bucknill[127] refer to the case of a lady
whose character had always been distinguished for conscientiousness, whose
religious education had been of a somber kind, and who, suffering under an
attack of small-pox attended with congestion of the brain, recovered, with
the natural bent of her disposition greatly exaggerated. The irritability
of conscience had become an actual disease, destroying the happiness of
the individual and rendering her incompetent to discharge any of the
duties of life. The same authors also mention the instance of a
distinguished admiral who had always been remarkable for pride and
liability to passionate anger, becoming the subject of cerebral
excitement, loss of sleep, and general feverishness consequent upon the
chagrin caused by a supposed neglect by the government.
In primary insomnia there is always an increase in the quantity of blood
circulating in the brain. This is either absolute or relative. The former
is the case when there has been no exhausting disease, hemorrhage, or
other debilitating influence in operation, and while, though general good
health exists, the amount of blood in the cranium is augmented; the
latter, when from any cause the system has become reduced, and when, while
this condition prevails, a temporary activity takes place in the cerebral
circulation. The first may properly be called active, the latter passive
insomnia. In the one there is more blood in the brain than is normally
present; in the other, though there may be less blood than in health, the
quantity is increased over the amount to which the brain has in a measure
accustomed itself.
Thus if we suppose the cerebral vessels of a healthy brain to contain
ordinarily a pint of blood, and the amount to be increased to a pint and a
half, and continued at this standard for several consecutive days, a state
of active insomnia ensues. If, on the other hand, this pint should be
reduced to a gill by any cause producing general debility, such as
hemorrhage, starvation, or disease, and then by some exciting mental
emotion, the excessive use of alcoholic liquors, or other influence acting
for a considerable period, be increased to half a pint, a condition of
passive insomnia would be produced--the latter condition resulting not
from a disturbance of the normal relation existing between the _intra_ and
_extra_ cranial blood, but of that which has been established by morbific
causes, and to which the organism has become habituated.
CASE III.--The following is a good example of the active form of morbid
wakefulness:
A short time since a gentleman was under my charge in whose case the only
deviation from health which could be perceived was an utter inability to
sleep. Being by profession a broker, and passing his days, and a great
portion of his nights, in the stock and gold rooms, during a period of
great financial excitement, his brain had been kept so continually in a
state of intense action that it was impossible for him, when he went to
bed, to compose his mind so as to allow of sleep ensuing. Thoughts similar
to those which were excited during his business operations were in full
flow, notwithstanding all his efforts to banish them. Calculations were
entered into, and speculations were constantly being formed with as great
or even greater facility than during the day. Many of the latter were of
the most extravagant character, a fact of which he was fully aware at the
time, but he nevertheless found it impossible to refrain from indulging in
them. All his other functions were performed with regularity. His appetite
was good, he took a not inconsiderable amount of exercise, and he
committed no excesses of any kind except as regarded his brain. When I
first saw him he had not slept for six nights, although he had taken large
quantities of brandy, morphine, and laudanum; but beyond a slight feeling
of confusion in his mind at times, and a little pain in his eyeballs, he
experienced no unpleasant sensations during the day. As soon, however, as
his head touched the pillow, and he tried to get to sleep, a feeling of
the most intense uneasiness came over him, while at the same time his face
and ears became hot and flushed. His mental faculties were roused into
increased action; he tossed restlessly from one side of the bed to the
other, and by the time morning came he was thoroughly exhausted, mentally
and physically. A cold bath and a breakfast of two large cups of coffee,
beefsteak and eggs, set him up for the balance of the day, till he retired
to bed, when the phenomena of the previous night would be repeated.
In this case I conceived that the blood-vessels of the brain, from
overdistention, had lost, in a great measure, their contractile power, and
that a larger quantity of blood was, in consequence, circulating within
the cranium than was normal. The vessels were therefore in a condition
very similar to that of a bladder in which, from the desire to urinate
having been too long resisted, contraction cannot be induced even by the
most strenuous exertion of the will. As the gentleman was of strong,
athletic build, and otherwise in full health, blood-letting would
undoubtedly have proved of great service; but, for reasons which will
appear hereafter, I determined to try a remedy less likely to do harm, and
fully as capable of doing good. I administered thirty grains of the
bromide of potassium at six o’clock in the evening, and repeated the dose
at ten, directing him to go to bed half an hour subsequently. The first
dose produced a decided sedative action, and the second was still more
effectual in calming the mental excitement. When he lay down, his mind was
not disturbed by a flow of thoughts, and he fell almost unconsciously into
a quiet sleep, from which he did not awake till near seven o’clock the
following morning. There were no unpleasant symptoms of any kind; on the
contrary, he felt strengthened and refreshed. The next night one dose was
administered at about bedtime, which was also followed by a sound and
invigorating sleep. No further treatment was given, as on the following
night sleep came naturally.
Sir Benjamin Brodie,[128] without, however, making the distinction I have
insisted upon, refers to the active or sthenic type of wakefulness in the
following quotations from a little work which should be in the hands of
all who are interested in the philosophy of the mind.
Speaking of the causes of the wakefulness of some persons, he says: “At
the same time there is no doubt that there is sometimes a morbid condition
of the nervous system, the nature of which we cannot well explain, which
is incompatible with sleep. The patient says, ‘I feel fatigued and wearied
and want to go to sleep, but I cannot sleep.’”
In asserting as he does that this kind of wakefulness is sometimes the
forerunner of mental derangement, Sir Benjamin is supported by many cases
detailed by authors on psychological medicine, and the following, which he
gives,[129] is directly to the point:
“A gentleman of my acquaintance in whose family circumstances had occurred
which were to him sources of intense anxiety, passed six entire days and
nights without sleep. At the end of this time he became affected with
illusions of such a nature that it was necessary to place him in
confinement. After some time he recovered perfectly. He had never shown
any signs of mental derangement before, nor has any one of his family, and
he has never since been similarly affected. This was an extreme case. But
do not examples of the want of sleep, proving very similar results, though
in a very much less degree, occur under our observation constantly? How
altered is the state of mind in any one of us after even two sleepless
nights! Many a person who under ordinary circumstances is cheerful and
unsuspicious, becomes not only irritable and peevish, but also labors
under actual, though transitory, illusions; such, for example, as thinking
that others neglect him or affront him who have not the smallest intention
of doing either the one or the other.”
Cases similar to the following, which is one of the passive variety of
wakefulness, are by no means uncommon.
CASE IV.--A lady, aged about thirty-five, unmarried, and of rather
delicate constitution, consulted me in regard to persistent wakefulness,
with which she had been affected for nearly a month. According to the
account which she gave me, she had received a severe mental shock, which
had not lost its influence when a subject of great anxiety was forced upon
her consideration. Her menstrual period, which had been due about ten days
before she came under my notice, had been anticipated by a week, and the
flow was prolonged much above the ordinary time. She had, therefore, lost
a good deal of blood, and was, in consequence, greatly reduced in
strength. This, conjoined with the exhaustion due to the long-continued
wakefulness, rendered her condition a much more serious one than would
otherwise have been the case.
She had taken large doses of laudanum, of ether, and of valerian, together
with many other medicines, the names of which I do not now recollect,
besides employing a variety of means of traditional efficacy. All had,
however, been useless. Homœopathy was then tried with an equal want of
success. When I first saw her she was nervous and irritable, her hands
trembled violently upon the slightest exertion of their muscles, her eyes
were bloodshot, the pupils contracted, and the lids opened to the widest
possible extent. There was a constant buzzing in the ears, and the sense
of hearing was much more acute than was natural. There was also increased
sensibility of all that portion of the surface of the body (the skin of
the hands, arms, legs, back, and breast) which I submitted to examination
with the æsthesiometer. Her pulse was 98, irritable, small, and weak.
At night all her symptoms were increased in violence. Her mind was filled
with the most grotesque images which it was possible for the imagination
to conceive, and with trains of ideas of the most exaggerated and
improbable character. These succeeded each other with a regularity so well
marked that she was able to foresee the routine night after night. “No
one,” she said, “can imagine the weariness I feel, or the horror with
which I look forward to the long rows of too-familiar phantoms and
thoughts which I know will visit me before morning. There is one set,” she
continued, “which always comes as the clock strikes two. No matter what
may be passing through my mind it is banished by this. It consists of a
woman with very long hair, who sits on a rock by the sea-side, with her
face buried in her hands. Presently a man armed with a long sword comes up
behind her, and, clutching her by the hair, drags her to the ground. He
puts his knee on her breast, and still holding her hair, cuts it off, and
binds her with it, hand and foot. He then commences to pile stones on her,
and continues to do so till she is entirely covered, notwithstanding her
piercing shrieks, which I hear as distinctly as I do real sounds. Turning
then to the sea he cries out, ‘Julia, you are avenged. My vow is
accomplished. Come! come!’ He then draws a dagger from his breast and
stabs himself to the heart. He falls over the pile of stones he has
raised, and instantly hundreds of little devils not more than a foot high
swarm around his body, and finally carry it off through the air. My horror
at all this is extreme. For more than an hour the scene is passing before
me, and though I know it is all purely imaginary, I cannot shake off the
terror it induces.”
I questioned this lady closely, and found that she was very intelligent,
and fully sensible of the unreality of all her visions. There was no
evidence whatever of the slightest tendency to insanity, but there was a
condition present which would surely terminate in the loss of her reason
if not quickly removed. I regarded her symptoms as indicating a state of
passive cerebral congestion, and as calling for stimulants rather than
what are called sedatives. I directed, therefore, that she should take an
ounce of whisky, properly diluted, every hour, commencing six hours before
bedtime; that she should immerse her whole body except her head in water,
at the temperature of 98° F., for half an hour just before retiring for
the night, and, instead of lying down, should sit up in an easy chair and
try to sleep in that position.
I administered the whisky upon the same principle that governs us when we
apply stimulating lotions to an inflamed eye, or give alcoholic liquors in
passive congestions of other parts of the body. The warm bath was
prescribed with a view to its dilating action upon the blood-vessels
exposed to its influence; and the sitting position with the object of
facilitating the flow of blood from the head, and impeding its return
through the carotids and vertebrals.
All these measures I had employed previously with success, in many cases
of inability to sleep due to delirium tremens, and which is almost always
of the passive or asthenic form. In the instance under consideration their
action was all that could be desired. At ten o’clock, having taken the
whisky and bath as directed, she sat down to sleep in a comfortable
chair, and, as her mother informed me, was asleep in less than half an
hour. She awoke about three o’clock, but soon fell asleep again after
another dose of whisky, and remained in this condition till about nine
o’clock in the morning. She then took breakfast, feeling very much
refreshed, but was unable to remain awake longer than two or three hours,
but, taking to her chair, slept soundly till evening. That night she was
again overcome with sleep, and it was passed very much as was the previous
one. No further medicine was required, and after a few nights she went to
bed as had been her custom, and slept soundly till morning. Under the use
of iron and lager beer she recovered her health and strength.
The foregoing cases are given as examples of the two forms of morbid
wakefulness or insomnia to which I wish to call attention. They show that,
though the cause in each variety may be essentially the same, the means of
relief are not altogether identical. It is important, therefore, to
discriminate between them. But the main point upon which it is necessary
to insist is, that in morbid wakefulness, whether occurring in strong or
weak persons, there is always an excessive amount of blood circulating
through the substance of the brain. In the course of the discussion of the
points involved in the physiology of sleep, this subject was incidentally
noticed. In the following chapter, however, it will be dwelt upon with
more particularity.