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:

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.