THE TREATMENT OF WAKEFULNESS.
The principles which should prevail in the treatment of wakefulness are
indicated to some extent by the remarks which have already been made. If
the views which I have given relative to the pathology of this affection
be correct, there can be no doubt in regard to the means to be employed
for its cure. Happily, theory and practice are in perfect accord in
respect to the therapeutical measures to be adopted. These may be arranged
into two classes:
1st. Those which by their tendency to soothe the nervous system, or to
distract the attention, diminish the action of the heart and
blood-vessels, or correct irregularities in their function, and thus
lessen the amount of blood in the brain.
2d. Those which directly, either mechanically or through a specific effect
upon the circulatory organs, produce a similar effect.
Under the first head are embraced many agencies which from time immemorial
have been known to cause sleep. Among them are music, monotonous sounds,
gentle frictions of the surface of the body, soft undulatory movements,
the repetition by the insomnolent of a series of words till the attention
is diverted from the exciting emotion which engages it, and many others of
similar character which individuals have devised for themselves. In slight
cases the measures belonging to this class often prove effectual, but in
persistent insomnia they are generally altogether nugatory.
Under the second head we shall find comprehended the means which are
chiefly to be relied on in the treatment of cases of morbid wakefulness.
Chief among them are embraced those measures which tend to improve the
general health of the patient, and which are chiefly of a hygienic
character. Whatever causes produce an irritable condition of the nervous
system, indirectly at least increase the disposition to wakefulness. It is
important, therefore, that these should be thoroughly understood and
avoided, and I accordingly propose to consider them at some length.
_Food._--While it is an error to suppose, as is generally done, that a
moderately full meal, eaten shortly before bedtime, is necessarily
productive of wakefulness, there is no doubt that this condition is
induced by an excessive quantity of irritating or indigestible food. A
hearty supper of plainly cooked and nutritious food rather predisposes to
sleep. Most of us have experienced the drowsiness which so often follows
dinner. This is due to the fact that the process of digestion requires an
increased amount of blood in the organs which perform it, and
consequently the brain receives a less quantity. A tendency to sleep is
therefore induced. It is a natural and healthy predisposition, and when
yielded to moderately conduces to a more complete assimilation of the food
than would otherwise take place. When, however, the food ingested is not
such as is merely sufficient for the wants of the system, but is
inordinate in amount, or irritating in quality, the hypnotic effect is
neutralized, and often a state of wakefulness supervenes, from the fact
that the quantity of blood circulating in the brain is augmented instead
of being diminished. This last result is induced either by the pressure of
the overloaded stomach upon the abdominal vessels or through a reflex
action on the heart, by which it is excited to increased activity.
In young children, who are very susceptible to the influence of causes
acting upon the nervous system, we often see both sleep and wakefulness
result as direct effects of eating. When the quantity of milk taken has
not been excessive, the child quietly drops asleep at the breast. On the
contrary, when a superabundance has been ingested, it either remains awake
or the sleep is disturbed. In adults it is, as has already been mentioned,
not uncommon for apoplexy to ensue upon a large meal of improper food.
In order, therefore, that a disposition to wakefulness may be removed, it
is essential that attention should be paid to the diet of the affected
individual. As a rule, people are underfed. This is especially the case
with women, who too generally indulge in what may be called “slops,” to
the exclusion of good, solid, nutritious food derived in great part from
the animal kingdom. By such a faulty diet the tone of the system is
lowered, and local congestions of different parts of the body are
produced. If the brain be one of these, wakefulness results.
Most of the cases of insomnia which occur in women are of the passive
variety, and require not only nutritious food, but _stimulants_. Of the
latter, _whisky_ is generally to be preferred as acting rapidly, as less
likely to disagree with the stomach than many kinds of wine, and as being
purer than the stuff ordinarily sold as brandy. As a good stimulant, and
at the same time tonic, nothing can be preferable to _Tarragona wine_,
drunk at dinner to the extent of a glass or two. It possesses all the
essential qualities of pure port, and is much more reliable and wholesome
than the mixture of elderberry juice and alcohol which passes for this
latter wine. Next to Tarragona wine must be ranked good _lager beer_.
Although the effect of _coffee_ is generally such as to induce
sleeplessness, there are cases in which its action is directly the
reverse. I have had several slight cases of passive wakefulness under my
care which were entirely and speedily cured by a cup of strong coffee
taken for three or four nights in succession at bedtime. It is especially
useful in females of languid circulation, and a consequent tendency to
internal congestions.
Stimulants such as those mentioned, and others which might be noticed, it
must be clearly understood are only useful in the asthenic or passive form
of insomnia; in the sthenic or active form of the affection they are
altogether inadmissible, and if employed will certainly increase the
difficulty.
The good effects of moderate but regular _physical exercise_ in
dissipating wakefulness can scarcely be overestimated. It is almost
impossible to produce any permanently beneficial influence without the aid
of this powerful tonic. To be of any material service, the exercise should
be taken in the open air, and should extend to the point of inducing a
slight feeling of fatigue.
The _warm bath_ is also a very valuable means of determining blood from
the head, and calming nervous irritability. Frequently, especially in
children, I have found that simply putting the feet in water of the
temperature of 100° F. has been sufficient to induce a sound and healthy
sleep, when laudanum and other means have failed.
_Cold water_, applied directly to the scalp, is often of great effect in
diminishing the amount of blood in the brain. It is not admissible in the
asthenic form of wakefulness. When the individual is strong, the heart
beating with force and frequency, and the mental excitement great, its
influence is almost invariably good. The exact temperature is a matter
for the judgment of the physician. I have often used it as cold as ice
could make it, 32° F., or thereabouts.
In the action of cold water, applied to the head in cases of insomnia, we
have another proof of the real nature of this affection. It is known that
in Thibet mothers place their wakeful children in such positions as will
admit of a small stream of cold water falling from a slight elevation upon
the head. I have in some work--on which I cannot now lay my hands--read a
very full account of this custom, and seen a cut representing the process.
The children very soon fall into a quiet sleep. I have often seen the
application of the cold _douche_ to the heads of refractory prisoners
bring on a deep sleep.
The effects of _position_ in aid of other remedies have also been alluded
to. I make use of its advantages in all severe cases of insomnia which
come under my charge, and we have, in its efficacy, additional
confirmation of the correctness of the theory that the condition of the
brain in such cases is one of hyperæmia.
Among the more purely medicinal agents, _bromide of potassium_ occupies
the first place, and can almost always be used with advantage to diminish
the amount of blood in the brain, and to allay any excitement of the
nervous system that may be present in the sthenic form of insomnia. That
the first named of these effects follows its use, I have recently
ascertained by experiments upon living animals, the details of which will
be given at another time. Suffice it now to say, that I have administered
it to dogs whose brains had been exposed to view by trephining the skull,
and that I have invariably found it to lessen the quantity of blood
circulating within the cranium, and to produce a shrinking of the brain
from this cause. Moreover, we have only to observe its effects upon the
human subject to be convinced that this is one of the most important
results of its employment. The flushed face, the throbbing of the carotids
and temporals, the suffusion of the eyes, the feeling of fullness in the
head, all disappear as if by magic under its use. It may be given in doses
of from ten to thirty grains--the latter quantity is seldom required, but
may be taken with perfect safety in severe cases.
Another very admirable preparation is the _oxide of zinc_. This substance
appears to be especially beneficial in those cases of wakefulness due to
excessive mental exertion or anxiety of mind. I usually prescribe it in
doses of two grains, three times a day, the last dose being taken just at
bedtime.
_Opium_ I very seldom employ in the treatment of wakefulness, from the
facts that its effects vary so greatly in accordance with the dose, and
that its action is not limited to the simple induction of sleep. There are
cases, however, in which its influence is decidedly beneficial. Care
should be taken to give it in sufficiently large but not excessive
quantities. The influence of opium in lessening the amount of blood in
the brain is very distinctly recognized by Dr. Handfield Jones, and also
by Dr. Alfred Stillé.[141] Both these authors account in this manner for
its hypnotic effect. As has been shown, my own experiments tend strongly
to confirm this reasoning.
_Hyoscyamus_ is more generally admissible. It is especially indicated in
those cases which are accompanied by great nervous irritability. It is
difficult to obtain any preparation of this drug which retains its
virtues. I have usually employed the tincture in doses of from one to two
drachms. I do not think, however, that it possesses any advantages over
bromide of potassium, or that it is even equal in any respect to this
agent.
In regard to _valerian_, _assafœtida_, and other _antispasmodics_, I have
nothing to say in commendation. _Tonics_ are, however, almost always
useful, even in the active form of the affection. Among them _quinine_ and
_iron_ are more generally indicated.
When wakefulness is a consequence of functional derangement of distant
organs, the measures of relief must be directed to the cure of the primary
disease, in order to produce any permanent alleviation of the cerebral
difficulty.
In those cases of insomnia dependent upon severe and long-continued mental
exertion, all means will fail to remedy the trouble unless the affected
individual consents to use his brain in a rational manner. Proper
intervals of relaxation should be insisted upon, and in some cases it may
be necessary to suspend all intense intellectual effort for a time. When
the means will permit, travel can always be undertaken with advantage. It
is surprising sometimes to see how rapidly the brain recovers its tone,
and the system generally recuperates through the change of associations
and scenes incident to travel.
The disposition of the age seems to be to ignore the fact that the nervous
system can exhaust itself by excessive intellectual labor. A short time
since intelligence was received from abroad that one of the most
distinguished men of Great Britain had committed suicide, in consequence
of insanity produced by overexertion of his mind. Thus one more victim is
added to the long list of those who have disregarded the laws of their
being; and again we are reminded that there is a limit to the exercise of
our intellectual powers, beyond which we cannot pass with safety.[142]