THE EXCITING CAUSES OF WAKEFULNESS.
Every cause capable of increasing the amount of blood ordinarily
circulating through the brain may give rise to wakefulness. As these
causes are more or less under the control of the individual, it is
important that they should be fully considered.
An increased amount of blood is attracted to the brain, and wakefulness is
produced:
1st. _By long-continued or excessive intellectual action, or any powerful
emotion of the mind._--Every organ of the body, the condition of which
admits of being ascertained by ocular examination, invariably contains
more blood in its tissues when in a state of activity than when its
functions are temporarily suspended. We are hence, _a priori_, justified
in assuming that the law is equally applicable to the brain, but we are
not forced to rely entirely upon reasoning from analogy. It has been shown
already that during sleep the circulation of blood within the cranium is
at its minimum, both as regards quantity and rapidity, and that as soon as
the individual awakes there is an immediate afflux of this fluid to the
cerebral tissues. All of us are familiar with the facts that, during
severe mental labor, or while under the influence of some exciting
emotion, the vessels of the head and neck become distended, the head feels
full, the face is flushed, and the perspiration of the parts in question
is increased in quantity. Within certain limits the more blood there is in
the brain the more actively its functions are performed, and so well known
is this fact that some persons, who require to exercise the several
faculties of the mind to an extreme degree, make use of stimulating
ingesta for the purpose of accomplishing the object in view.
A moderate degree of cerebral activity is undoubtedly beneficial. Exercise
strengthens the mind and improves its faculties, if it is succeeded by a
proper period of repose, during which the vessels are emptied to some
extent of their contents, and are thus enabled to recover their tone. If,
however, the brain is often kept for long periods on the stretch, during
which the vessels are filled to repletion, they cannot contract even when
the degree of cerebral activity is diminished. Wakefulness results as a
necessary consequence, and every day renders the condition of the
individual worse, because time also brings the force of habit into
operation.
It is not to be denied, however, that many individuals are able to live in
comparative health for long periods with but little or no sleep. Thus it
is stated[130] that Boerhaave did not “close his eyes in sleep for a
period of _six_ weeks, in consequence of his brain being overwrought by
intense thought on a profound subject of study.” Sir Gilbert Blane[131]
says he was informed by General Pichegru, that for a whole year, while
engaged in active campaign operations, he slept but one hour out of the
twenty-four. Such statements as these, however, and others to the same
effect which have been made, must be accepted with some allowance. Many
persons sleep unconsciously, and we all know how common it is for
individuals to deny having slept when we have been eye-witnesses of their
somnolency. I should consider it impossible for a person to enjoy good
health if deprived for even a few weeks of half his ordinary amount of
sleep; and it is very probable that Boerhaave’s standard of health, never
high, was very much lowered by his protracted vigils.
So long as the attention is kept fully aroused, the blood-vessels of the
brain are distended, and it is possible for an individual to remain awake
while this condition exists. When the attention begins to flag, the
tendency is for the vessels to contract, and for sleep to ensue. This
disposition may not, however, be strong enough to restore the full
measure of contractility to vessels that have been long overdistended, and
then insomnia results.
To this increase in the amount of blood circulating in the brain, many
instances of hallucination have been due. It has already been shown that
strong mental emotions determine an augmented flow of blood to the
cerebral vessels, and cause the production of spectral illusions. In all
such cases there is a marked tendency to insomnia present. The account
given by Nicolai, a celebrated German bookseller of the last century, of
his own disorder, is so interesting and appropriate that I quote it in
full. It has never to my knowledge been published in this country.
“During the ten latter months of the year 1790 I had experienced several
melancholy incidents which deeply affected me, particularly in September,
from which time I suffered an almost uninterrupted series of misfortunes
that affected me with the most poignant grief. I was accustomed to be bled
twice a year, and this had been done on the 9th of July but was omitted to
be repeated at the end of the year 1790. I had, in 1783, been suddenly
taken with a violent vertigo, which my physicians attributed to
obstructions in the fixed vessels of the abdomen brought on by a sedentary
life and a continual exertion of the mind. This indisposition was
successfully removed by means of a more strict diet. In the beginning I
had found the use of leeches applied to the arms particularly beneficial,
and they were afterward repeated two or three times annually when I felt
congestions in the head. The last leeches which had been put on previous
to the appearance of the phantasms of which I am about to speak, had been
applied on the 1st of March, 1790; less blood had consequently been
evacuated in 1790 than was usual with me, and from September I was
constantly occupied in business which required the most unremitted
exertions, and which was rendered still more perplexing by frequent
interruptions.
“I had, in January and February of the year 1791, the additional
misfortune to experience several extremely unpleasant circumstances, which
were followed on the 24th of February by a most violent altercation. My
wife and another person came into my apartment in the morning in order to
console me, but I was too much agitated by a series of incidents which had
most powerfully affected my moral feelings to be capable of attending to
them. On a sudden I perceived, at about the distance of ten steps, a form
like that of a deceased person. I pointed at it, asking my wife if she did
not see it. It was natural that she should not see anything; my question,
therefore, alarmed her very much, and she sent immediately for a
physician. The phantom continued for about eight minutes. I grew at length
more calm, and being extremely exhausted, fell into a restless sleep which
lasted about half an hour. The physician ascribed the appearance to
violent mental emotion, and hoped there would be no return; but the
violent agitation of my mind had in some way disordered my nerves and
produced further consequences which deserve a more minute description.
“At four in the afternoon the form which I had seen in the morning
reappeared. I was by myself when this happened, and being rather uneasy at
the incident, went to my wife’s apartment, but there likewise I was
accompanied by the apparition, which, however, at intervals disappeared,
and always presented itself in a standing posture. About six o’clock there
appeared also several walking figures which had no connection with the
first.
“After the first day the figure of the deceased person no longer appeared,
but its place was supplied by many other phantasms, sometimes representing
acquaintances, but mostly strangers. Those whom I knew were composed of
living and deceased persons, but the number of the latter was
comparatively small. I observed that the persons with whom I daily
conversed did not appear as phantasms, these representing chiefly persons
who lived at some distance from me.
“These phantasms seemed equally clear and distinct at all times and under
all circumstances, both when I was by myself and when I was in company,
and as well in the day as at night, and in my own house as well as abroad;
they were, however, less frequent when I was in the house of a friend, and
rarely appeared to me in the street. When I shut my eyes these phantasms
would sometimes vanish entirely, though there were instances when I beheld
them with my eyes closed; yet when they disappeared on such occasions,
they generally returned when I opened my eyes. I conversed sometimes with
my physician and my wife of the phantasms which at the moment surrounded
me. They appeared more frequently walking than at rest, nor were they
constantly present. They frequently did not come for some time, but always
reappeared for a longer or shorter period, either singly or in company,
the latter, however, being most frequently the case. I generally saw human
forms of both sexes, but they usually seemed not to take the smallest
notice of each other, moving as in a market-place where all are eager to
pass through the avenue; at times, however, they seemed to be transacting
business with each other. I saw also several times people on horseback,
dogs and birds. All these phantasms appeared to me in their natural size,
and as distinct as if alive, exhibiting different shades of carnation in
the uncovered parts as well as different colors and fashions in their
dresses, though the colors seemed somewhat paler than in real nature. None
of the figures appeared particularly terrible, comical, or disgusting,
most of them being of an indifferent shape, and some presenting a pleasing
aspect. The longer these phantoms continued to visit me the more
frequently did they return, while at the same time they increased in
number. About four weeks after they had first appeared, I also began to
hear them talk. The phantoms sometimes conversed among themselves, but
more frequently addressed their discourse to me: their speeches were
commonly short and never of an unpleasant turn. At different times there
appeared to me both dear and sensible friends of both sexes, whose
addresses tended to appease my grief, which had not yet wholly subsided:
their consolatory speeches were in general addressed to me when I was
alone. Sometimes, however, I was accosted by these consoling friends while
I was engaged in company, and not unfrequently while real persons were
speaking to me. These consolatory addresses consisted sometimes of abrupt
phrases, and at other times they were regularly executed.
“Though my mind and body were in a tolerable state of sanity all this
time, and these phantasms became so familiar to me that they did not cause
me the slightest uneasiness, and though I even sometimes amused myself
with surveying them, and spoke jocularly of them to my physician and my
wife, I yet did not neglect to use proper medicines, especially when they
began to haunt me the whole day and even at night, as soon as I waked.
“At last it was agreed that leeches should be again applied to me as
formerly, which was actually done, April 20th, 1791, at eleven o’clock in
the morning. No person was with me besides the surgeon, but during the
operation my chamber was crowded with human phantasms of all
descriptions. This continued uninterruptedly till about half an hour after
four o’clock, just when my digestion commenced. I then perceived that they
began to move more slowly. Soon after their color began to fade, and at
seven o’clock they were entirely white. But they moved very little, though
the forms were as distinct as before, growing, however, by degrees more
obscure yet not fewer in number, as had generally been the case. The
phantoms did not withdraw, nor did they vanish, a circumstance which,
previous to that time, had frequently happened. They now seemed to
dissolve in the air, while fragments of some of them continued visible for
a considerable time. About eight o’clock the room was entirely cleared of
my fantastic visitors.
“Since that time I have felt twice or three times a sensation as if these
phantasms were going to reappear, without, however, actually seeing
anything. The same sensation surprised me just before I drew up this
account, while I was examining some papers relative to these apparitions,
which I had drawn up in the year 1791.”
While it is doubtless true that variations in the amount of blood in the
brain are dependent upon nervous action, it is equally certain that this
latter is increased or lessened according as the brain is in a more or
less hyperæmic condition. These factors, therefore, react upon each other,
and consequently the resulting insomnia is more aggravated than would
otherwise be the case.
Instances of insomnia dependent upon intense intellectual exertion have
already been given, but the following, which I extract from my note-book,
will not, I think, prove uninteresting or uninstructive:
CASE V.--A gentleman, aged thirty-nine, unmarried, of correct habits, and
good general health, consulted me on the 19th of April, 1865, in reference
to a peculiar nervous affection with which he had suffered for several
months. He stated to me that, being engaged upon a literary labor of some
importance, he had given the greater part of his time to the studies
necessary to its being carried on with success, and was conscious of
having overtasked his mental powers. So great, however, was his ambition
to excel in his undertaking, that he had persevered notwithstanding the
admonitions of friends, and the still more pointed warnings he had
received from his own sensations. Instead of sleeping, as had been his
custom, from seven to eight hours, he rarely, for nearly a year, had slept
more than four hours out of the twenty-four, and frequently even less than
this. He did not, however, feel the want of sleep. In fact he was never
sleepy, and if this had been the only ill consequence of his severe
application I should probably not have had him under my charge at all, so
little weight did he attach to the condition which it was of the first
importance should be relieved.
The symptom of disordered action which attracted his attention most was an
inability to concentrate his mind upon subjects about which he wished to
write. There was no difficulty in maintaining a connected line of
reasoning, except when he attempted to put his ideas on paper, and then he
found it utterly impossible to direct his thoughts in a methodical way. He
conversed with me very intelligently in reference to his case, and was
perfectly conscious of the difficulty under which he labored. As an
instance of the character of his disease, he said that the day before he
came to see me he had reflected to his entire satisfaction upon certain
points in literature which he was investigating, and that when he came to
read over what he had written he found it was a tissue of the most arrant
nonsense. The subject of his thoughts was the Greek drama, and the ideas
in reference to it, which he communicated to me, were in the highest
degree logical and interesting. He then showed me the first page of what
he had written, and though he was annoyed at the nonsensical strains of
his language, he could not at the same time conceal his amusement at its
utter absurdity. I quote a few lines from this paper.
“The rise of the Greek drama is not to be associated with the Homeric age
of minstrelsy, nor to be discovered in the Cimmerian darkness of the
North. It rests upon a foundation far anterior to either. It is found in
the hearts of those men who look beyond a mere utilitarian idea, and who
are able to conceive of the existence of beauty without the disturbance
due to causes inseparably connected with the barbarism from which Greece
emerged into that mythical age which created a god for every river and
forest, and for every emotion of the heart or element of the mind. Lyric
poetry and philosophy may claim the precedence of antiquity, but the power
that could draw tears from eyes that had never before wept, or cause the
hardened lines of stoicism to relax in smiles, is not to be despised or
even elevated upon a pinnacle of greatness.”
At the time of writing, his thoughts flowed so rapidly that he was not
conscious of the disconnected nature of his composition. If he stopped,
however, to read it over, he at once saw how thoroughly it misrepresented
his conceptions. No matter what the subject, the same thing happened, and
even the most trivial notes could not be written without language being
used which was either perfectly without relation to the ideas he wished to
communicate, or else in direct opposition to them. For instance, wishing
to obtain a book from a friend, he found he had written the prayer of
Socrates which concludes the Phædrus of Plato. On another occasion,
intending to indite an epistle to a lady who had sent him a volume of her
poems, he discovered, when half through his letter, that he had requested
her to accept one of his own books, and had then gone on to give his views
relative to suicide and matrimony.
Upon questioning him, I ascertained that he went to bed generally about
two o’clock in the morning; that he lay awake for an hour at least, during
which his mind was exceedingly active; and that he rose between six and
seven, took a sponge-bath, and ate a light breakfast. He then went to
work, spending the day in reading, and in dictating to his sister, who
wrote out his language _verbatim_. At six o’clock he dined plainly, and
then again resumed his labors. He drank neither tea, coffee, nor any
alcoholic liquor. Occasionally he took a cup of chocolate at breakfast.
The only indications of a disordered system other than those I have
mentioned were, that his pulse was too frequent (104), that it was
irritable and irregular; that he had had several attacks of slight vertigo
and headache; that his eyes were brilliant and somewhat congested, and
that pressure upon the closed lids caused considerable pain. His bowels,
contrary to what might have been reasonably expected, were regular, and
his appetite was generally good. His urine contained an excess of urea and
of phosphates; oxalate of lime was also present. There was nothing in his
condition which appeared to give him the least anxiety, beyond the
impossibility of controlling his thoughts when writing, and this he
attributed directly to overexertion of his mental powers. He had, however,
tried the effect of suspending his studies for two or three weeks, but had
not perceived that any benefit was derived from this procedure. He had,
therefore, returned to his occupations.
I told him very plainly that, unless he was prepared to forego his
literary labors for several weeks at least, he would be in great danger of
permanent injury to his mind; but that with the avoidance of severe mental
exertion, and by the aid of other measures, I believed he could be
restored. He demurred somewhat to the first condition, but finally
promised to follow my advice implicitly.
Although I was unable to explain the fact that mental aberration should
only be manifested when he wrote, I was confident that his condition was
clearly the result of intense hyperæmia of the brain, and that if this
could be dissipated, and sound, regular, and sufficient sleep be produced,
the mental trouble would also vanish. I therefore directed that half a
dozen dry cups should be applied to the nape of the neck every evening,
that he should take a warm bath directly afterward, and that, while in the
bath, cold water should be poured on his head. Instead of lying down when
he attempted to sleep, I advised that he should assume the sitting
posture, supporting his head on a hair pillow. All literary labor was to
cease. Instead of the books he was in the habit of studying, he was to
read novels. He was to compose himself for sleep at eleven o’clock at
night, and was to rise punctually at seven; take his sponge-bath as usual,
and, after eating a moderate breakfast, to do anything he liked, except
studying or writing, till twelve o’clock, when he was to take a walk for
an hour, then eat a biscuit, read light literature till four, and then
ride on horseback till six, at which hour he was to dine, simply, but to
the extent his appetite prompted him. He had been in the habit of smoking
one cigar a day (after dinner), and I allowed him to continue in this
indulgence.
I am thus particular in stating my instructions, because I determined to
see what could be done by hygienic measures, and others directed to the
relief of the supposed cerebral congestion, without resorting to the use
of drugs, so long as it was probable they would not be required. Opium and
other medicines of the narcotic class would, I was satisfied, do more harm
than good; bromide of potassium I reserved for use, should it become
necessary to employ it.
I have every reason to believe that he complied faithfully with the
directions given him, and ere long marks of decided improvement were
visible. His pulse had fallen to 80, was regular and full; there was no
more headache or vertigo; his eyes had lost their bloodshot appearance,
and above all, his sleep had become sound, and was of from seven to eight
hours’ duration nightly. As soon as he got settled in his easy chair for
the night his eyelids began to close, and he slept steadily on till it was
time for him to get up for the day. Three weeks were necessary to bring
about these results in full, although amendment was manifested from the
first. Yesterday, May 18th, I wrote him a note, requesting his permission
to make use of his case in illustration of this memoir. The following is
his answer: it is the first time he has written a line for a month:
“MY DEAR DOCTOR:--If, in your opinion, my case is possessed of any
value in a pathological point of view, I hope you will make such use
of it as will best serve the ends of science. I make only one
condition. You know I am a literary man, and that my reputation as a
student and author would suffer in the estimation of the critics were
I suspected of insanity. It takes very little to form a foundation for
such an assumption, and, perhaps, in my case, there would be more
truth than fiction in the notion as applied to me. With the exception,
therefore, of giving my name, you are at perfect liberty to dish me up
for the satisfaction of all your medical friends.
“I shall come and see you to-morrow, and in the mean time believe me
ever,
“Yours sincerely and gratefully,
“---- ---- ----.”
“P.S.--I have read the above over, and to my great delight find that I
have said what I wanted to say. I would stand on my head with joy,
were it not that you were desirous of keeping as much blood out of my
noddle as possible. _Laus Deo._ Can I go to work Monday?”
I had no intention of letting him “go to work” on Monday, or for at least
two weeks subsequently. I was of the opinion, however, that after that
time he could resume his labors to a slight extent, and gradually extend
them--not to the limit they formerly reached, but to that degree which,
while they would add to his reputation as a man of learning, would not
exhaust the organ which it was so essential for his objects to preserve in
a condition of unimpaired vigor. The result has been all that either he or
myself could have desired.
CASE VI.--A youth of fifteen was brought to me by his father, on the 16th
of August, to be treated for obstinate wakefulness, the consequence of
severe mental exertion at school several weeks previously. He had not
attended school since the last of June, but had scarcely slept more than
an hour or two each night since that time, according to his own and his
father’s statement. He was a healthy, well-grown lad, with a good
appetite, and nothing unusual in his appearance beyond a slight look of
weariness and anxiety in his face. During the day there were no
hallucinations of any kind, and toward evening he invariably felt
overpowered with sleep. As soon, however, as he lay down he heard voices
repeating extracts from the lessons he had recently been learning, and his
mind became occupied with imaginary scenes in which the gods and goddesses
of mythology and the heroes and poets of antiquity played prominent parts,
and the whole power of his attention was thus kept engaged with these and
other scenes which were formed with astonishing rapidity. Toward morning
he fell into an uneasy slumber, and awoke feeling more weary even than
when he had gone to bed.
Medicines, among which opium was the chief, had been employed without
success. On the contrary, his condition was manifestly rendered worse
through their influence. Laudanum, of which he had taken large quantities,
always caused headache, without producing the least amelioration in his
symptoms. Notwithstanding the palpable connection which existed between
the wakefulness and his former intense mental application, he had been
allowed to continue his studies, and when he came to me had a Latin
grammar in his hand, which he had been diligently studying in the street
railway car!
After some very plain conversation with the father, relative to the great
danger to which he was subjecting his son, by thus inordinately taxing his
mind, I directed the entire cessation of all studies for the present, and
an entire change of associations by a visit to the sea-shore, and free
indulgence in bathing, fishing, and other recreations. I likewise advised
the use, for a few nights, of small doses of bromide of potassium. My
advice was implicitly followed, and a few days since I received a visit
from the boy’s father, and was told by him that his son’s health had been
completely restored. I recommended that the visit to the sea-side should
be prolonged a week or two, that the return to study should be gradual,
and that the boy’s eagerness to learn should be somewhat restrained by
occupations and amusements requiring but little mental exertion.
CASE VII.--An eminent banker consulted me for the purpose of being, as he
said, “put to sleep.” He informed me that he was engaged in a series of
financial operations which, if successful, would be the means of adding
largely to his fortune, but that owing to loss of sleep he was unable to
give them that careful and full attention which their importance demanded.
“I go to bed,” he said, “feeling very much exhausted, and dead with sleep,
but I am kept awake nearly the whole night by the activity of my thoughts,
which run on with a rapidity which astonishes me. Toward morning I get a
little sleep, but I arise unrefreshed, and go to my business with a
feeling of fullness in my head, and a sensation of weariness, which
altogether unfit me for the duties of the day. The consequence is that I
cannot concentrate my attention upon the matters which ought to engage it,
and that I am in danger of losing a great deal of money simply from lack
of mental power to follow the train of operations which I have set in
action.”
On examining this gentleman, I found his face flushed, his eyes bloodshot,
his pulse small, weak, and frequent (104), and his manner excited. He
complained of almost constant vertigo, and a feeling when he walked as
though his feet did not rest firmly on the ground or support his entire
weight. His appetite was capricious, and he maintained his strength mainly
by drinking champagne, of which he imbibed two bottles a day, taking in
addition “brandy and soda,” as occasion seemed to require.
I informed him that his case was a very simple one, and that I could
safely promise to put him to sleep provided he would agree to follow my
directions implicitly.
This he said he would do.
I told him that in the first place he must leave town and travel for a
week, and in the second place take the oxide of zinc. To the first
condition he objected strenuously; but the argument which I adduced, that
if he did not he would probably go to an insane asylum within the period
specified, somewhat startled him, and he yielded a reluctant consent.
He started off that day, and returned in exactly a week, having, as he
said, slept eight hours every night during his absence. All his
disagreeable symptoms had disappeared, and he was enabled to resume his
business with his mental faculties in their full vigor.
* * * * *
2d. _Those positions of the body which tend to impede the flow of blood
from the brain, and at the same time do not obstruct its passage through
the arteries, while causing hyperæmia, also produce insomnia._
Several cases have come under my observation in which the influence of
position as affecting the disposition to sleep was well marked. It is very
evident that the recumbent posture is more favorable to a state of
congestion of the brain than the erect, or semi-erect. Individuals who, by
excessive mental exertion, have lessened the contractility of the cerebral
vessels, almost always experience great difficulty in getting to sleep
after lying down, even though previous to so doing they may have been very
drowsy. A gentleman, who was a patient of mine a few weeks since, informed
me that several years ago he had an attack of wakefulness, which lasted
for three or four months, and which was particularly characterized by
inability to sleep while lying in bed. While sitting in his office he
would often fall asleep in his chair, and previous to going to bed he
would be overcome by drowsiness. The moment, however, that he lay down,
his mind was aroused into activity, and all sleepiness disappeared. He
left off work, traveled, and in a short time recovered perfectly. It will
be recollected that in the other cases I have cited in this memoir, the
phenomena were always more strongly marked after the persons affected lay
down; and I have always insisted upon the avoidance of the recumbent
posture as one of the most important means to be employed in the cure of
insomnia. The following is one of the cases referred to above.
CASE VIII.--A gentleman in extensive legal practice requested my advice
for persistent wakefulness, with which he had been affected for several
weeks, in consequence of unremitting attention to a case in which his
sympathies had become greatly interested. For somewhat over a month he
had, as he informed me, slept but for an hour or two each day. After
dinner he was able to procure this much sleep in his chair, but at night,
when he lay down, all his efforts were unavailing. He felt the want of
repose very much, and he described the sensation of weariness of body and
mind as almost insupportable. So great was this desire for sleep that,
notwithstanding repeated disappointments, he was confident each night of
being able to secure it, but invariably as soon as he lay down all
inclination vanished, and he passed the night in that condition of painful
restlessness which had now become horrible to him. There was no very great
mental activity, and no hallucinations of sight, but when his head touched
the pillow a low buzzing sound, which apparently had its origin in the
ears, was heard, and remained there to keep him awake. He could not shut
out this noise, no matter how energetically he endeavored to render
himself oblivious to it, and all the means, such as opium, chloroform, and
alcoholic liquors of various kinds, which he tried in the hope of
obtaining relief, only aggravated the difficulty.
His general health, ordinarily excellent, had latterly began to give way.
His bowels were torpid, he had little or no appetite, and he was almost
daily subject to severe attacks of headache. He was conscious, too, of a
very decided change in his disposition. From having been of rather social
tendencies, he had become morose and gloomy, disliking even the
companionship of his most intimate friends. There was also a very decided
impairment of his memory, and he was sensible of the fact that the power
of concentrating his attention upon subjects of even minor importance was
materially weakened. In conversation he miscalled names, and misplaced
events and things. Thus he called Pittsburg _Pittstown_, said _aunt_
several times when he should have said uncle, and confounded _Newark_ with
New York. By attention to hygienic measures, avoidance of the recumbent
position, and the use of moderate doses of bromide of potassium, he soon
obtained a due amount of sleep, and the other symptoms of a disordered
mental and physical organism gradually disappeared.
Dr. Handfield Jones[132] relates a case in which the influence of position
was strongly marked. “A gentleman aged twenty-four, after considerable
mental strain, experienced the following symptoms: He was thoroughly weary
and drowsy at the close of the day, and felt, as well he might, the need
of nature’s restorer; scarcely, however, had he laid down his head, when
the cerebral arteries began to throb forcibly, and soon all inclination
for sleep was banished, and for hours he lay wide awake, but deadly weary.
The _causa mali_ here was evidently deficient tonicity in the cerebral
arteries, or more exactly paresis of their vasa motor nerves. As the
arteries relaxed they admitted an undue flow of blood to the brain, which
goaded the weary tissue to abnormal action.”
De Boismont[133] refers to a case, on the authority of M. Moreau, in which
an individual was able to obtain hallucinations of sight by inclining his
head a little forward. By this movement the return of blood from the head
was impeded, and thus there was an exaltation of certain of the cerebral
functions. Wakefulness is nothing more than an exaggeration of the normal
functions of the brain. For this organ to act with vigor, an increased
flow of blood is necessary. If this flow is continued, without proper
periods of repose, a state of erethism and insomnia is produced. Instances
have been recorded in which persons have found it necessary to assume the
recumbent position whenever they had any severe mental labor to perform.
The following extract, bearing upon this point, from a work[134] already
quoted, is interesting:
“The posture of supination will unavoidably induce that increased flow of
blood to the brain which, under certain states of this fluid, is so
essential to the production of brilliant waking thoughts; and are indeed
attained so often by another mode--the swallowing of opium.
“A gentleman of high attainment was constantly haunted by a specter when
he retired to rest, which seemed to attempt his life. When he raised
himself in bed _the phantom vanished, but reappeared_ as he resumed the
recumbent position.
“Some persons always retire to bed when they wish to think; and it is well
known that Pope was often wont to ring for pens, ink, and paper in the
night, at Lord Bolingbroke’s, that he might record, ere it was lost, that
most sublime or fanciful poesy which flashed through his mind as he lay in
bed. Such, also, was the propensity of Margaret, Duchess of Newcastle, who
(according to Cibber, or rather Shiel, the _real_ author of the ‘Lives of
the Poets’) kept a great many young ladies about her person, who
occasionally wrote what she dictated. Some of them slept in a room
contiguous to that in which her grace lay, and were ready, at the call of
her bell, to rise any hour of the night to write down her conceptions,
lest they should escape her memory.
“Henricus ab Heeres (in his ‘Obs. Med.’) says that when he was a professor
he used to rise in the night, open his desk, compose much, shut his desk,
and again to bed. On his waking, he was conscious of nothing but the
happy result of his composition.
“The engineer Brindley even retired to bed for a _day or two_, when he was
reflecting on a grand or scientific project.
“I deny not that the darkness or stillness of night may have had some
influence during this inspiration. I may also allow that some individuals
compose best while they are walking, but this _peripatetic_ exertion is
calculated itself to produce what we term determination of blood to the
head. I have heard of a most remarkable instance of the power of position
in influencing mental energy in a German student who was accustomed to
study and compose with his head on the ground, and his feet elevated and
resting against the wall.
“And this is a fragment of a passage from Tissot, on the subject of
monomania.
“----‘Nous avons vu étudier dans cette académie, il n’y a pas long temps,
un jeune homme de mérite, qui _s’étant mis dans la tête_ de découvrir la
quadrature du cercle, est mort, fou, à l’Hôtel Dieu à Paris.’[135]
“You will smile when I tell you that the tints of the landscape are
brighter to our eyes if we _reverse the position of the head_.”
Tissot, in the work to which reference has just been made, cites an
instance in which position was taken advantage of to solve a problem in
mathematics. A gentleman, remarkable for his accuracy in calculation, for
a wager _lay down on a bed_ and wrought, by mere strength of memory, a
question in geometrical progression, while another person, in another
apartment, performed the same operation with pen and ink. When both had
finished, the one who had worked mentally repeated his product, which
amounted to sixteen figures, and, insisting that the other gentleman was
wrong, desired him to read over his different products. On this being done
he pointed out the place where the first mistake lay, and which had run
through the whole. He paid very dearly, however, for gaining his wager, as
for a considerable time he had a swimming in his head, pains in his eyes,
and severe headaches upon attempting any mathematical labor.
Sir Walter Scott has said somewhere, that the half hour _passed in bed_,
after waking in the morning, was the part of the day during which he
conceived his best thoughts.
Dr. Forbes Winslow[136] makes some excellent remarks upon the relations
existing between position and wakefulness. He says:
“In some types of insanity the patient’s mind is altogether absorbed in
the contemplation of a frightful spectral illusion. Under these
circumstances the unhappy sufferer is afraid to close his eyes in sleep
from an intense fear and dread that he will then fall an easy prey to the
horrible phantasms which his morbid imagination has called into existence,
and which, he imagines, follow him in all his movements. The patient so
afflicted declares he will not sleep, and resolutely repudiates and
perseveringly ignores all disposition to slumber. On many occasions he
obstinately refuses to go to bed, or to place himself in a recumbent
position. He will battle with his attendant if he attempts to convey him
to bed. He insists on remaining in the chair, in standing in an erect
position all night, and often determinately walks about the room when
those near him are in profound repose. In these cases the hallucinations
appear to be most exquisitely and acutely vivid when the patient is placed
in a recumbent position, on account, it is supposed, of the mechanical
facilities thus afforded for the blood gravitating freely to the head.
“A gentleman who appeared free during the day from any acute
hallucinations, never could lie on his back without being distressingly
harassed by a number of frightful imps, whom he imagined to be dancing
fantastically around him during the night. Under these circumstances,
undisturbed sleep, while in bed, could never be obtained. He was in the
habit of sleeping in an arm-chair for some time in consequence of these
symptoms. He, however, eventually recovered, and has been for several
years entirely free from all hallucinations.”
It has frequently occurred to me to notice the increase in the number and
intensity of the hallucinations of patients affected with delirium tremens
as soon as they assumed the recumbent position. The difficulty of sleeping
is in such cases always correspondingly augmented.
* * * * *
3d. _An increased amount of blood is determined to the brain, and
wakefulness is produced by certain substances used as food or medicine._
Daily experience assures us of the truth of this proposition. In general
terms, it may be said that all those substances which, when ingested into
the system, increase the force and frequency of the heart’s action, cause
also a hyperæmic condition of the brain and tend to the supervention of
wakefulness.
Chief among these agents are to be placed alcohol, opium, belladonna,
stramonium, Indian hemp, tea, and coffee. It is true that the first two of
these, when taken in large quantities, sometimes give rise to a comatose
condition. This, however, as has already been shown, is not a consequence
of an increased amount of blood in the brain, but results from the
circulation in that organ of blood which has not been duly oxygenated by
respiration. My experiments on this head have been many, and show
conclusively that neither alcohol nor opium possesses any stupefying
effect, if means be taken to insure the full aeration of the blood. If,
however, these substances be administered beyond a certain limit, they so
act upon the nerves which supply the respiratory muscles as to interfere
with the process of respiration, and hence the blood is not sufficiently
subjected to the action of the atmosphere. Unaerated blood therefore
circulates in the brain, and coma--not sleep--is produced.
No substance is capable of acting as a direct hypnotic, except that which
lessens the amount of blood in the brain. In small doses alcohol and opium
do this indirectly, through their stimulating properties exerted upon
overdistended blood-vessels, as has been shown in regard to the first
named in a case already cited; but they never so act upon the healthy
brain. In the normal state of this organ their action in small doses is
always that of excitants. The word “small” is of course used in a relative
sense. What is a small dose for one person may be a large one for another,
and _vice versa_.
In this connection it is scarcely necessary to dwell at any length upon
the wakefulness produced by delirium tremens from the excessive ingestion
of alcohol or opium. In the _post-mortem_ examinations--four only--which I
have made of individuals dying from this affection as the result of the
immediate use of alcohol, the brain was invariably found congested. Either
hyperæmia or its consequence, effusion of serum, is the ordinary
pathological condition discovered in such cases.
In regard to opium, most practitioners have doubtless noticed the effect
which it and its preparations frequently produce in preventing sleep. I
have known one dose of half a grain of opium keep a patient awake for
three consecutive days and nights, during the whole of which period
intense mental excitement was present. As is well known, the Malays, when
they wish _to run amuck_, bring on the necessary degree of cerebral
stimulation by the use of opium. During the condition thus produced
insomnia is always present. It is certainly true, however, that in
moderately large doses opium acts as a direct hypnotic, and the same may
be said of other narcotics.
Belladonna, stramonium, and Indian hemp likewise produce congestion of the
brain and wakefulness. The latter, under the name of hashish,[137] is
still used in the East to bring on a state of delirium, and, if rumor is
to be credited, has its votaries in this country. Tea and coffee act in a
similar but far less powerful manner. As one of the results of experiments
with these substances, instituted upon myself, I found that the
circulation of the blood was rendered more active.[138] Their influence in
preventing sleep is well known to the generality of people, and this
effect is doubtless entirely due to their action upon the heart and
blood-vessels by which the amount of blood in the brain is increased. In
persons of fair and thin skins, who are not accustomed to the use of
either of these beverages, the face can be seen to flush after they have
been taken; and I have frequently met with persons in whom their use was
always followed by suffusion of the eyes, and a feeling of fullness within
the head. Their power to increase the force and brilliancy of our
thoughts, and to sustain the mind under depressing influences, has long
been recognized, and is to be ascribed to the same cause as that which
prevents sleep.
* * * * *
4th. _Wakefulness is also caused by functional derangements of certain
organs of the body, whereby an increase in the amount of blood in the
brain is produced._
Under this head are embraced those cases of sleeplessness due to exalted
sensibility of the nervous system. They are chiefly met with in persons
of feeble constitution. The slightest impression made upon the skin, or
any other organ of sense, is converted into a sensation out of all
proportion to the exciting cause. There is thus a condition of general
hyperæsthesia which greatly tends to the prevention of sound and
refreshing sleep. The following case illustrates very well the phenomena
of the state in question:
CASE IX.--A lady recently came under my care for extreme wakefulness, the
result, as she correctly supposed, of debility. During the month of August
she had resided in a malarious region, and had had a series of attacks of
intermittent fever before she would consent to take quinine for its cure.
By the time the disease was conquered she had become very much reduced,
and her constitution had received a shock from which it will probably not
recover for several years. I saw her for the first time on the 26th of
September, and she was then so feeble that she was unable to be out of her
bed for more than an hour or two each day. Her nervous system was in an
exceedingly irritable condition, the least noise startled her, she was
unable to bear the full light of day, and so sensitive was her skin, that
the light clothes she wore caused her the greatest uneasiness. She
informed me that she had scarcely slept for seventeen days and nights, and
though I received this statement with some grains of allowance, I was very
sure, from her general appearance, that she was suffering from insomnia.
At night the feeling of general discomfort was greatly increased, the
weight of the bedclothes was insupportable, and she passed the hours
tossing restlessly on her bed or in walking the floor. By morning she was
feverish, irritable, and thoroughly exhausted. A cup of coffee and a
little buttered toast constituted her breakfast, after which she felt
somewhat revived.
Conceiving that all the symptoms were referable to debility and passive
cerebral congestion, I advised nutritious food, tonics, stimulants,
exercise in the open air, the warm bath, cold water to the head, and the
avoidance of the recumbent posture. Amendment began almost immediately,
and by the end of a week the hyperæsthesia had disappeared, and she slept
soundly and sufficiently.
In reference to this form of wakefulness, Dr. Handfield Jones[139] makes
some judicious observations. He says: “A girl recently under my care with
very various and marked signs of prostration of nerve-power, suffered for
many months with exceedingly restless nights, the cause of which appeared
to be chiefly great hyperæsthesia. Although she improved materially in
other respects, she did not sleep well until she was removed from London
to a healthy part of the country. I have had several patients, two
especially, both temperate males, who for a length of time were quite
dependent for good rest at night on wine taken either on going to bed or
in the course of the night. * * * It is not easy to form a precise idea of
the state of the nervous centers in which a ‘nightcap,’ as above
mentioned, is so effectual in procuring sleep. Debility is certainly one
marked pattern of it, but there must be surely another, even more
important, as the most profound debility does not, by any means, always
interfere with sound sleep, nay, rather seems to conditionate it. This
other element, we are much disposed to think, is hyperæsthesia, or
irritability, which, as already noticed, commonly increases _pari passu_
with weakness. The condition may be compared with that of neuralgia, when
it is beginning to give way under treatment, and is so readily reproduced
by anything which causes exhaustion. Now, as the stimulant recruits the
exhausted nerve force, the hyperæsthesia ceases, and the brain tissue
subsides into a state of calm repose. It may be added here that it is
often well to give not only a stimulant, but also some digestible
nourishment about the time of going to rest, or even in the course of the
night when debility to a serious extent exists. It is quite certain that a
craving empty stomach is by no means favorable to quiet slumber, and in
this point of view moderate suppers are far from being unsuitable to many
invalids. I well remember the case of a lady who, the night after a
natural confinement, woke up with severe gastric disorder and flatulence,
which resisted various medications, but subsided immediately after a
plate of cold meat and some brandy and water. Among the various
soporifics, I doubt if there be any more potent, especially for the weakly
and hyperæsthetic, than prolonged exposure to the cold open air. This
should be so managed as not to cause great fatigue, and if well timed and
followed by a sufficient meal, it will be found an admirable preparation
for sound nightly slumber.”
In the foregoing remarks it is perceived that Dr. Jones fails to recognize
the state of passive congestion of the brain which in cases such as he
describes, and in many similar ones which have come under my care, is
almost invariably present. It is this feature which, in addition to the
debility, gives so marked a character to the species of insomnia under
consideration. The hyperæsthesia, like the wakefulness, is merely a result
of the cerebral hyperæmia.
Several cases of insomnia, the result of disordered menstruation, have
come under my observation. We can very well understand how, in women
suffering from suppression of this function, a slight degree of cerebral
hyperæmia and consequent wakefulness should result. About the climacteric
time of life, when irregularities in the menstrual flow are very common,
there is quite generally extreme sleeplessness as each period approaches,
which is not ordinarily relieved till the catamenia make their appearance.
In such cases measures directed to the relief of the existent congestion
of the brain will generally prove effectual in causing natural sleep.
Irregular or deficient action of the heart and blood-vessels is a frequent
cause of wakefulness. One of the principal results of such disordered
action of the circulatory organs is coldness of the extremities, and an
attendant condition of repletion of the central vessels. As a consequence
there is in these cases almost invariably great wakefulness. As Dr.
Cheyne[140] has remarked, many a delicate female, from going to bed with
cold feet, is deprived of hours of sleep in the early part of the night,
and thereby falls into nervous complaints, obstinate dyspepsia, and
uterine irregularity, who might have escaped had the circulation of the
surface of the body been properly sustained.
There are cases, however, of habitual cold feet, accompanied by
wakefulness, which are not so much due to deficient power in the heart as
to disordered nervous action. But, whatever the cause, there is always,
while the condition exists, an excessive amount of blood in the cranial
vessels. An instance of the kind came under my observation several years
ago in the person of an army officer, of strong constitution and otherwise
of good health. Heat applied to the extremities gave only temporary
relief, and stimulants taken internally were equally inefficacious. He was
finally entirely cured by the repeated passage of the direct galvanic
current through the sciatic and crural nerves and their branches.
Indigestion is quite a common cause of wakefulness, even when no marked
disagreeable sensations are experienced in the digestive organs. A full
meal, especially if it be of highly seasoned or otherwise improper food,
will often keep the offending individual awake the greater part of the
night. We know that apoplexy is especially apt to occur soon after the
stomach has been overloaded with food. The return of the blood from the
head is impeded, and the rupture of an intercranial vessel, or an effusion
of serum, is the result of the cerebral congestion. Insomnia is a milder
effect of the same cause.
There are several other abnormal conditions of the system in which
wakefulness plays an important part, but their consideration would lead us
into the discussion of the phenomena of many diseases of which it is
simply a symptom, or of secondary consequence. The remarks which have been
made in regard to it have reference to its existence as an evidence of
slight cerebral congestion, and therefore as being of sufficient
importance to demand the aid of both physician and patient in effecting
its cure.