SOMNOLENCE.
Somnolence or drowsiness is generally regarded, when persistent, as being
more strongly indicative of organic changes in the structure of the brain
than is any other derangement of sleep.
This opinion is mainly, if not entirely, due to the fact that it is
confounded with stupor, from which, both in its causes and effects, as has
already been shown, it differs in every essential respect.
Somnolence is nothing more than an inordinate tendency to sleep. When
manifested in a slight degree it is difficult, without careful examination
and a thorough inquiry into the history of the case, to distinguish it
from moderate stupor. It is of course very important that the distinction
should be made; for, in reality, somnolence is ordinarily no very serious
disorder, and is generally symptomatic of eccentric disease, whereas
stupor almost invariably results from organic brain affections, from
cerebral injuries, or the circulation of poisoned blood through the
encephalic blood-vessels.
Whatever lessens the amount of blood normally circulating through the
cerebral vessels, tends to the production of somnolence. It is hence a
condition frequently witnessed in those whose powers of life have been
reduced by long-continued disease, by excesses of various kinds, or by
affections which essentially consist in enfeeblement of the organism. It
is generally met with in the aged, in whom the circulatory organs have
lost their pristine vigor.
Many cases of very troublesome and persistent somnolence, having an origin
such as I have mentioned, have come under my notice: ordinarily they
present no difficult features of treatment, the indications being to
increase the tone of the system by stimulants, tonics, nutritious food,
and moderate exercise in the open air. These measures will invariably
succeed if there be no organic difficulty.
Somnolence, however, is sometimes due to structural changes which
interfere with the free passage of blood through the cerebral vessels. It
may hence be caused by emboli, which, obstructing the arteries, prevent
the normal amount of blood reaching the brain substance. It may also be
caused by tumors, which, pressing on the arteries supplying the brain, act
in like manner. In such cases it is of secondary importance.
A very curious affection, known as the “Sleepy Disease,” has been
described as endemic in certain regions of Africa. The following
extract[143] gives a graphic description of the malady:
“Having procured a guide, we crossed the river, and at the mouth of
Logan’s Creek we exchanged our boat for a large canoe, in which we
followed the windings of the deep and narrow inlet for nearly two miles.
This brought us to a village of six huts. Without ceremony we entered the
dwelling of the old queen (who was busied about her household affairs),
and looked around for her granddaughter, to see whom was the principal
object of our excursion. On my former visit to Maumee’s town, four or five
months ago, this girl excited a great deal of admiration by her beauty and
charming simplicity. She was then thirteen or fourteen years of age--a
bright mulatto, with large and soft black eyes, and the most brilliantly
white teeth in the world. Her figure, though small, is perfectly
symmetrical. She is the darling of the old queen, whose affections exhaust
themselves upon her with all the passionate fire of her temperament, and
the more unreasonably because the girl’s own mother is dead.
“We entered the hut, as I have said, without ceremony, and looked about us
for the beautiful granddaughter; but, on beholding the object of our
search, a kind of remorse and dread came over us, such as often affects
those who intrude upon the awfulness of slumber. The girl lay asleep in
the adjoining apartment, on a mat that was spread over the hard ground,
and with no pillow beneath her cheek. One arm was by her side, the other
above her head, and she slept so quietly, and drew such imperceptible
breath, that I scarcely thought her alive.
“With some little difficulty she was aroused, and awoke with a frightened
cry,--a strange and broken murmur,--as if she were looking dimly out of
her sleep, and knew not whether our figures were real, or only the
fantasies of a dream. Her eyes were wild and glassy, and she seemed to be
in pain. While awake, there was a nervous twitching about her mouth and in
her fingers; but, being again extended upon the mat, and left to herself,
these symptoms of disquietude passed away, and she almost immediately sank
again into the deep and heavy sleep in which we found her. As her eyes
gradually closed their lids, the sunbeams struggling through the small
crevices between the reeds of the hut glimmered down about her head.
Perhaps it was only the nervous motion of her fingers, but it seemed as if
she were trying to catch the golden rays of the sun and make playthings of
them, or else to draw them into her soul and illuminate the slumber that
looked so misty and dark to us.
“This poor doomed girl had been suffering--no, not suffering; for, except
when forcibly aroused, there appeared to be no uneasiness,--but she had
been lingering two months in a disease peculiar to Africa: it is called
the ‘Sleepy Disease,’ and is considered incurable. The persons attacked by
it are those who take little exercise, and live principally on vegetables,
particularly cassady and rice. Some ascribe it altogether to the cassady,
which is supposed to be strongly narcotic--not improbably the climate has
much influence, the disease being most prevalent in low and marshy
situations. Irresistible drowsiness continually weighs down the patient,
who can be kept awake only for the few moments necessary to take a little
food. When this lethargy has lasted three or four months, death comes with
a tread that the patient cannot hear--and makes the slumber but a little
more sound.
“I found the aspect of Maumee’s beautiful granddaughter inconceivably
affecting. It was strange to behold her so quietly involved in sleep from
which it might be supposed she would awake so full of youthful life, and
yet to know that this was no refreshing slumber, but a spell in which she
was fading away from the eyes that loved her. Whatever might chance, be it
grief or joy, the effect would be the same. Whoever should shake her by
the arm--whether the accents of a friend fell fully on the ear, or those
of strangers like ourselves,--the only response would be that troubled
cry, as of a spirit that hovered on the confines of both worlds and could
have sympathy with neither. And yet, withal, it seemed so easy to cry to
her, ‘Awake! Enjoy your life! Cast off this noontide slumber!’ But only
the peal of the last trumpet will summon her out of that mysterious
sleep.”
Another and later account of this singular disease has recently been given
by M. Dumoutier,[144] surgeon in the French Navy.
According to this observer, the affection commonly called the
“sleep-disease” (maladie du sommeil) is met with only among the negroes of
the coast, and principally those of the Gaboon and of Congo, becoming more
rare towards the north. The most prominent symptoms are an irresistible
tendency to sleep, and a feeling of torpor and numbness. The patient does
not complain of pain, and yet there is a general weakness of the limbs,
the gait is tottering, the sensibility is perverted, and the hands
imperfectly grasp the objects they attempt to seize. During the sleep the
fecal matters and the urine are passed involuntarily. The respiration is
normal, and the digestion regular. These were the principal symptoms
observed in those cases which came under M. Dumoutier’s notice: observing
the disease only in the persons of captives coming from the interior, he
ascribes it to nostalgia, _ennui_, and other moral causes. Two autopsies
made by his colleagues revealed no abnormal condition of the brain, the
spinal cord, or their membranes.
The treatment employed--quinia, strychnia, and iron--had no effect. A
temporary improvement was obtained by causing the patients to take part in
the amusements of their companions. Electricity seemed likewise to retard
somewhat the progress of the disease.
The fact that no organic difficulty of the brain was discovered after
death, is strong proof that the somnolency was due to some cause affecting
the intra-cranial circulation. That the amount of blood was lessened, and
that thus a permanent anæmia of the brain was produced, can scarcely be
doubted, when regard is had to the observations and experiments recorded
in the foregoing pages of this work. Probably the primary derangement was
seated in the sympathetic nerve and its ganglia, it having been well
settled by familiar observations, and by recent contributions to
physiology and pathology, that one of the chief functions of this system
is to regulate the caliber of the blood-vessels, and thus to determine the
amount of blood circulating through an organ or part of the body.
Numerous cases of protracted sleep are on record. Some of them are
evidently fanciful and exaggerated, but others are doubtless well founded.
One of the most remarkable of these is related, among many others, by
Wanley.[145]
“One Samuel Chelton, of Finsbury, near Bath, a laboring man, about
twenty-five years of age, of a robust habit of body, not fat, but fleshy,
and of dark-brown hair, happened, on the 13th of May, 1694, and without
visible cause, to fall into a very profound sleep, out of which he could
by no means be aroused by those about him till after a month’s time, when
he arose of himself and went to his husbandry business as usual. He slept,
ate, and drank as before, but did not speak a word till about a month
after. All the time he slept, victuals and drink stood by him, which were
spent every day, and used by him, as was supposed, though no person saw
him eat or drink all the while. After this period he continued free from
drowsiness or sleepiness till the 9th of April, 1696, when he fell into
his sleeping fit again, as he had done before. After some time his friends
were prevailed on to try what effect medicines might have upon him.
Accordingly, Mr. Gills, an apothecary, bled, blistered, cupped, and
scarified him, and used all the external irritating medicines he could
think of, but to no purpose; and after the first fortnight he was never
observed to open his eyes: victuals stood by him as before, which he ate
of now and then, but no one ever saw him eat or evacuate, though he did
both very regularly, as he had occasion; and sometimes he was found fast
asleep with the pot in his hand in bed, and sometimes with his mouth full
of meat. In this manner he lay about ten weeks, and then he could eat
nothing at all, for his jaws seemed to be set, and his teeth clinched so
close that, notwithstanding all the art that could be used with
instruments, his mouth could not be opened to put anything into it to
support him. At last, those about him observing a hole in his teeth, made
by holding his pipe, they now and then poured some tent into his mouth
through a quill. And this was all he took for six weeks and four days; but
it amounted to no more than three pints or two quarts. He had made water
only once, and never had a stool all that time.
“On the 7th of August, which was seventeen weeks from the 9th of April,
when he began to sleep, he awaked, put on his clothes, and walked about
the room, not knowing he had slept above a night; nor could he be
persuaded he had lain so long, till, going into the fields, he found
everybody busy getting in their harvest, and he remembered very well when
he fell asleep that they were sowing their barley and oats, which he then
saw ripe and fit to be cut down. There was one thing remarkable: though
his blood was somewhat wasted with lying so long in bed and fasting for
about six weeks, yet a gentleman assured Dr. Oliver that when he saw
him--which was the first day of his coming abroad--he looked brisker than
ever he saw him in his life before; and on asking him whether the bed had
made him sore, he assured this gentleman that he never felt this or any
other inconvenience, and that he had not the least remembrance of anything
that passed, or what was done to him, all that while. So that he went
again to his husbandry, as he was wont to do, and remained well till
August 17th, 1697, when, in the morning, he complained of a shivering and
a coldness in his back. He vomited once or twice, and the same day fell
into his sleeping fit again. Dr. Oliver, going to see him, found him
asleep, with a cup of beer and a piece of bread and cheese upon a stool by
his bed, within his reach. The doctor felt his pulse, which at that time
was regular, and he also found his heart beat very regular, and his
breathing easy and free. The doctor only observed that his pulse beat a
little too strong. He was in a breathing sweat, and had an agreeable
warmth all over his body. The doctor then put his mouth to his ear, and
called him as loud as he could several times by his name, pulled him by
the shoulders, pinched his nose, stopped his nose and mouth together as
long as he could without choking him, but to no purpose, for all this time
he did not give the least sign of being sensible. The doctor lifted up his
eyelids, and found his eyeballs drawn up under his eyebrows and fixed
without any motion. The doctor then held under one nostril, for a
considerable time, a vial with spirits of sal ammoniac, extracted from
quicklime; he then injected it several times up the same nostril; and
though he had poured into it almost half an ounce of this fiery spirit, it
only made his nose run, and his eyelids shiver and tremble a little. The
doctor, finding no success with this, crammed that nostril with white
powder of hellebore, and waited some time in the room to see what effects
all these together might have upon him; but he never gave any sign that he
felt what the doctor had done, nor discovered any manner of uneasiness, by
stirring any part of his body, that the doctor could observe.
“After all these experiments the doctor left him, being pretty well
satisfied that he was asleep, and no sullen counterfeit, as some people
supposed. On the doctor’s relating what he had observed, several gentlemen
from Bath went out to see him, and found him in the same condition the
doctor had left him in the day before, only his nose was inflamed and very
much swelled, and his lips and the inside of his nostrils were blistered
and scabby, occasioned by the spirits and the hellebore. About ten days
after the doctor had seen him, Mr. Woolner, an apothecary, finding his
pulse beat very high, drew about fourteen ounces of blood from the arm,
and tied it up, and left it as he found him; and Mr. Woolner assured the
doctor that he never made the least motion when he pricked him, nor all
the while his arm was bleeding. Several other experiments were tried by
those who went to see him from Bath, but all to no purpose. The doctor saw
him again the latter end of September, and found him just in the same
position, lying in his bed, but his pulse now was not so strong, nor had
he any sweats, as when the doctor saw him before. He tried him again by
stopping his nose and mouth, but to no purpose; and a gentleman ran a
large pin into his arm to the very bone, but he gave no signs of his being
sensible to what was done to him. During all this time the doctor was
assured that nobody had seen him either eat or drink, though they watched
him as closely as possible,--but food and drink always stood by him, and
they observed that sometimes once a day, and sometimes once in two days,
all was gone. It was further observed that he never dirtied his bed, but
always went to the pot. In this manner he lay till the 19th of November,
when his mother, hearing him make a noise, immediately ran up to him and
found him eating. She asked him how he did. He replied, ‘Very well, thank
God.’ She asked him again which he liked best, bread and butter, or bread
and cheese. He answered, ‘Bread and cheese.’ Upon this the woman,
overjoyed, left him to acquaint his brother, and both coming straight up
into the chamber to speak to him, they found him as fast asleep as ever,
and could not by any means awake him. From this time to the end of
January, or beginning of February, he did not sleep so profoundly as
before; for, when they called him by his name, he seemed to hear them, and
became somewhat sensible, though he could not make them any answer. His
eyes were not shut so close, and he had frequently great tremblings of his
eyelids, upon which they expected every day that he would awake, which did
not happen till about the time mentioned, when he awoke perfectly well,
but remembered nothing that had happened all the while. It was observed
that he was very little altered in his flesh; he only complained that the
cold hindered him more than usual, but he presently went to his labor, as
he had done before.”
The case of Mary Lyall is quoted by Macnish, from the 8th volume of the
Transactions of the Royal Society of Edinburgh, as follows:[146]
“This woman fell asleep on the morning of the 27th of June, and continued
in that state till the evening of the 30th of the same month, when she
awoke and remained in her usual way till the 1st of July, when she again
fell asleep, and continued so till the 8th of August. She was bled,
blistered, immersed in the hot and cold bath, and stimulated in almost
every possible way, without having any consciousness of what was going on.
For the first seven days she continued motionless, and exhibited no
inclination to eat. At the end of that time she began to move her left
hand, and, by pointing to her mouth, signified a wish for food. She took
readily what was given to her. Still she evinced no symptoms of hearing,
and made no other kind of bodily movement than of her left hand. Her right
hand and arm particularly appeared completely dead and bereft of feeling,
and even when pricked with a pin, so as to draw blood, never shrunk in the
least degree. At the same time she instantly drew back her left arm
whenever it was touched by the point of the pin. She continued to take
food whenever it was offered to her. For the first two weeks her pulse
generally stood at 50, during the third and fourth week about 60, and on
the day before her recovery at 70 or 72. Her breathing was soft and almost
imperceptible, but during the night-time she occasionally drew it more
strongly, like a person who has just fallen asleep. She evinced no symptom
of hearing till about four days before her recovery. On being
interrogated after this event upon her extraordinary state, she mentioned
that she had no knowledge of anything that had happened--that she had
never been conscious of either having needed or received food, or of
having been blistered; and expressed most surprise on finding her head
shaved. She had merely the idea of having passed a long night in sleep.”
Many other cases might be referred to; but as their general features are
similar to the two cited, it is unnecessary to quote them. The following
instance occurring in this country presents some features of interest. It
is reported by Dr. C. A. Hart,[147] of this city.
“Miss Susan C. Godsy, aged 22, of bilious temperament, has been in a
somnolent state since 1849, being then eight years of age. Up to within a
year of that period she had enjoyed excellent health, she being then
attacked with intermittent fever, in the treatment of which opium was
extensively used. This was erroneously supposed to have induced her
present condition. Soon after her recovery, excessive somnolency began to
develop itself, which in 1857 became more profound after an attack of
scarlatina anginosa, followed by measles. The lucid intervals will occur
from four to six times a day, and last for from five to six minutes; at
which periods she will generally take some nourishment, and then relapse
into a profound slumber, from which it is impossible to arouse her.
“In point of general physique there is nothing specially worthy of note,
except the comparative plumpness during such a long maintenance of the
recumbent posture, with very little muscular exercise. She is about the
average height of her sex, with cranial development possibly a little in
excess. The hands and feet are both exceedingly small, the nails of which
have not grown any since her present condition began.
* * * * *
“The catamenia commenced between the fourteenth and fifteenth years, and
are generally very irregular and painful; but, when anything like
regularity is attained, the flow occurs about every six weeks.
* * * * *
“None of the special senses are in the least diminished or perverted;
there has been neither squinting nor excessive dilatation of the pupils.
The irides both respond readily to the stimulus of light. While
interrogating the mother, a convulsive movement of the entire body took
place, apparently more violent in the upper than in the lower extremities.
The arms, hands, and feet were in rapid motion. At the subsidence of this,
consciousness was established; and the young lady herself, being
questioned about her condition, replied in a clear and comprehensible
manner, though merely using monosyllables. When asked if she suffered any
pain in her head, she replied yes, but without locating it; if in the
back, yes; if about the chest or abdomen, no. She was lucid about five
minutes, during which time a number of questions were asked her, but
without eliciting any further information. She took no food or medicine
during this interval of consciousness, and went to sleep while being
questioned, remaining in that state during the rest of the time we were
there--about half an hour--her rest being perfectly tranquil with the
exception of a slight convulsive movement.”
These cases of protracted sleep present many analogies with the condition
of hibernation which certain of the lower animals enter into at stated
periods. Doubtless the state of the brain is the same, and is one of
anæmia.
It has never been my fortune to witness a case of protracted sleep.
Regarding the starting-point of the disorder as being situated in the
sympathetic system, I should be disposed to employ the direct galvanic
current in the treatment--placing the positive pole over the sympathetic
nerve in the neck, and the negative over the opposite scapula. This I
would do, using a battery of thirty-two or a less number of pairs, every
day, for from five to ten minutes.