THE PATHOLOGY OF WAKEFULNESS.

As nations advance in civilization and refinement, affections of the nervous system become more frequent, because progress in these directions is necessarily accompanied by an increase in the wear and tear of those organs through which perceptions are received and emotions excited; and, in addition, the mode of life, as regards food, clothing, occupation, and habits, is being constantly removed farther from that standard which a regard for hygienic considerations would establish as most advantageous. If, as we have every reason to believe, each thought involves the destruction of a certain amount of nervous tissue, we can very well understand why, as we go forward in enlightenment and in all the elements of material and intellectual progress, we are at the same time, unless we also advance in the knowledge of the laws of our being, hurrying ourselves with rapid strides to a state of existence in which there is neither waste nor repair.

I am far, however, from desiring to be understood as intimating that a high state of civilization is antagonistic to long life or health. What is lost in these directions as regards the nervous system is more than made up by the increased provision afforded for comfort in other ways. But while we have improved the hygienic condition of our cities and dwellings; while we as a rule clothe our bodies according to the principles of sanitary science and common sense; and while cleanliness of person has become the rule, and filthiness the exception, we have made little or no progress in the hygienic management of those organs which place us in relation with the world, and a healthy condition of which is so essential to our happiness.

Among the many derangements in the normal operation of the nervous system, induced by irregular or excessive cerebral action, those which relate to the function of sleep are certainly not the least in importance, whether regard be had to the actual comfort of the individual or to the serious consequences to which they may give rise. To the consideration of some of these morbid conditions I propose to devote the remainder of the present volume, and first to inquire into the most important of them, wakefulness or insomnia.

As a symptom of various diseases which affect the human organism, wakefulness is sufficiently well recognized by systematic writers on the practice of medicine, though, even here, it is very certain that its pathology has seldom been clearly made out. As a functional disorder of the brain, arising from inordinate mental activity, it has received scarcely any notice. This neglect has, doubtless, been in a great measure due to the fact that it is only within late years that the condition in question has become so common as to attract much attention. At present there are, probably, but few physicians engaged in extensive practice in any of our large cities who do not in the course of the year meet with several cases of obstinate wakefulness, unaccompanied, in the early stages at least, by any other prominent disorder of the system.

In my opinion, no one cause is so productive of cerebral affections as persistent wakefulness, for not only is the brain prevented from obtaining rest, but it is kept in a state of erethism, which, if not relieved, must sooner or later end in organic disease. Southey laid the seeds of that disorder which terminated in the loss of his intellect, by watching at the bedside of his sick wife during the night, after the excessive literary labors of the day.[121] Newton’s mind also suffered in the later years of his life through deprivation of sleep;[122] and Dr. Forbes Winslow, in remarking on Southey’s case, says: “No brain can remain in permanent health that has been overtasked by nightly vigils still more than by daily labor.”[123]Renaudin,[124] in a very philosophical essay, calls attention to the fact that persistent wakefulness is sooner or later followed by insanity; and Maury[125] states his opinion to the same effect. The remarks of Dr. Ray[126] upon this subject are so apposite that I reproduce them in part, commending at the same time the little book from which they are taken to the attention of the reader.

“A periodical renewal of the nervous energies as often as once a day is an institution of nature, none the less necessary to the well-being of the animal economy, because in some degree under the control of the will. To disregard its requirements with impunity is no more possible than it is to violate any other organic law with impunity, and no man need flatter himself that he may systematically intrench upon the hours usually devoted to rest and still retain the freshness and elasticity of his faculties. With the same kindliness that marks all the arrangements of the animal economy, this condition is attended with many pleasing sensations and salutary effects, gently alluring us to seek the renovation which it offers. ‘While I am asleep,’ says the immortal Sancho Panza, ‘I have neither fear nor hope; neither trouble nor glory; and blessings on him who invented sleep,—the mantle that covers all human thoughts; the food that appeases hunger; the drink that quenches thirst; the fire that warms; the cold that moderates heat; and, lastly, the general coin that purchases all things; the balance and weight that make the shepherd equal to the king and the simple to the wise.’ The ill effects of insufficient sleep may be witnessed on some of the principal organic functions, but it is the brain and nervous system that suffer chiefly and in the first instance. The consequences of a too protracted vigil are too well known to be mistaken, and many a person is suffering, unconscious of the cause, from the habit of irregular and insufficient sleep. One of its most common effects is a degree of nervous irritability and peevishness, which even the happiest self-discipline can scarcely control. That buoyancy of the feelings, that cheerful, hopeful, trusting temper that springs far more from organic conditions than from mature and definite convictions, give way to a spirit of dissatisfaction and dejection; while the even demeanor, the measured activity, are replaced either by a lassitude that renders any exertion painful, or an impatience and restlessness not very conducive to happiness. Upon the intellectual powers the mischief is still more serious. They not only lose that healthy activity which combines and regulates their movements in the happiest manner, but they are no longer capable of movements, once perfectly easy. The conceptions cease to be clear and well defined, the power of endurance is weakened, inward perceptions are confounded with outward unhappiness, and illusory images obtrude themselves unbidden upon the mind. This kind of disturbance may pass sooner or later into actual insanity, and many a noble spirit has been utterly prostrated by habitual loss of rest.”

Case I.—Some years ago a case similar in several respects to that of Southey came under my observation. A gentleman of superior mind and of great powers of application spent from sixteen to eighteen hours each day in severe literary labor. This of itself would have been a heavy strain to most persons, but he went regularly to bed and slept soundly six hours each night, and it is possible that he might have continued this mode of life for several years without serious inconvenience, when his wife was suddenly taken ill. His anxiety on her account was very great, and he spent nearly the whole night by her bedside, sleeping only for about an hour toward morning. After three weeks passed in this manner, his wife was pronounced out of danger, but he found it impossible to resume his former habits. He could neither study nor sleep. The nights were passed in walking the floor of his chamber or in tossing restlessly on his bed. There were no pain, no fever, no disorder of any other organ. There was nothing but ceaseless activity of the mind and an utter inability to sleep. Stimulants and narcotics only increased the violence of his symptoms, and every other means employed failed to give relief. The danger of his situation was pointed out to him and travel recommended. He followed the advice, and though it was several months before he was completely relieved, his condition began at once to improve. He was taught a lesson which has not been without influence, in causing him to task his mental faculties less severely.

Case II.—Another, an intimate friend, who occupied an important public position, gave so much time and attention to his duties, which were of a highly laborious character, that he deprived himself of the amount of sleep to which he had previously been accustomed. It was rarely the case that he got to bed before two or three o’clock in the morning, and then an hour or two was always occupied in active intellection. The consequence was that he finally broke down through want of the mental repose so essential to him. Inflammation of the brain ensued, and this terminated in acute insanity, from which he died.

It would be easy to bring forward other instances of which I am perfectly cognizant, or which have been cited by authors in illustration of the point in question, but it is scarcely necessary to enlarge further upon this portion of the subject. We should be careful, however, not to mistake the effect for the cause, an error which is often committed in this as well as in other matters. It is well known that many cases of insanity are marked in the early stages by persistent insomnia. Doubtless this is frequently a consequence of the morbid action already set up in the brain; but much observation has satisfied me that it is more often the cause of the cerebral aberration, and that by proper medical treatment the mental excitement may be generally allayed. Certainly the means most commonly resorted to in such instances are adopted without the full consideration so imperatively necessary, and consequently are fully as liable to increase as to lessen the disturbance.

We cannot employ too much care in doing everything in our power to prevent the occurrence of those slight attacks of cerebral congestion, which, though perhaps scarcely observable at the time, are yet fraught with very serious consequences. Persons have had their whole characters changed by an apparently trifling interference with the circulation of blood in the head. A person of my acquaintance was naturally of good disposition, amiable in his character, and considerate in his dealings with others; but after an attack of vertigo, attended with unconsciousness of but a few moments’ duration, his whole mental organization underwent a radical change. He became deceitful, morose, and exceedingly overbearing and tyrannical toward all with whom he came in contact, and whom it was safe for him to maltreat. Tuke and Bucknill[127] refer to the case of a lady whose character had always been distinguished for conscientiousness, whose religious education had been of a somber kind, and who, suffering under an attack of small-pox attended with congestion of the brain, recovered, with the natural bent of her disposition greatly exaggerated. The irritability of conscience had become an actual disease, destroying the happiness of the individual and rendering her incompetent to discharge any of the duties of life. The same authors also mention the instance of a distinguished admiral who had always been remarkable for pride and liability to passionate anger, becoming the subject of cerebral excitement, loss of sleep, and general feverishness consequent upon the chagrin caused by a supposed neglect by the government.

In primary insomnia there is always an increase in the quantity of blood circulating in the brain. This is either absolute or relative. The former is the case when there has been no exhausting disease, hemorrhage, or other debilitating influence in operation, and while, though general good health exists, the amount of blood in the cranium is augmented; the latter, when from any cause the system has become reduced, and when, while this condition prevails, a temporary activity takes place in the cerebral circulation. The first may properly be called active, the latter passive insomnia. In the one there is more blood in the brain than is normally present; in the other, though there may be less blood than in health, the quantity is increased over the amount to which the brain has in a measure accustomed itself.

Thus if we suppose the cerebral vessels of a healthy brain to contain ordinarily a pint of blood, and the amount to be increased to a pint and a half, and continued at this standard for several consecutive days, a state of active insomnia ensues. If, on the other hand, this pint should be reduced to a gill by any cause producing general debility, such as hemorrhage, starvation, or disease, and then by some exciting mental emotion, the excessive use of alcoholic liquors, or other influence acting for a considerable period, be increased to half a pint, a condition of passive insomnia would be produced—the latter condition resulting not from a disturbance of the normal relation existing between the intra and extra cranial blood, but of that which has been established by morbific causes, and to which the organism has become habituated.

Case III.—The following is a good example of the active form of morbid wakefulness:

A short time since a gentleman was under my charge in whose case the only deviation from health which could be perceived was an utter inability to sleep. Being by profession a broker, and passing his days, and a great portion of his nights, in the stock and gold rooms, during a period of great financial excitement, his brain had been kept so continually in a state of intense action that it was impossible for him, when he went to bed, to compose his mind so as to allow of sleep ensuing. Thoughts similar to those which were excited during his business operations were in full flow, notwithstanding all his efforts to banish them. Calculations were entered into, and speculations were constantly being formed with as great or even greater facility than during the day. Many of the latter were of the most extravagant character, a fact of which he was fully aware at the time, but he nevertheless found it impossible to refrain from indulging in them. All his other functions were performed with regularity. His appetite was good, he took a not inconsiderable amount of exercise, and he committed no excesses of any kind except as regarded his brain. When I first saw him he had not slept for six nights, although he had taken large quantities of brandy, morphine, and laudanum; but beyond a slight feeling of confusion in his mind at times, and a little pain in his eyeballs, he experienced no unpleasant sensations during the day. As soon, however, as his head touched the pillow, and he tried to get to sleep, a feeling of the most intense uneasiness came over him, while at the same time his face and ears became hot and flushed. His mental faculties were roused into increased action; he tossed restlessly from one side of the bed to the other, and by the time morning came he was thoroughly exhausted, mentally and physically. A cold bath and a breakfast of two large cups of coffee, beefsteak and eggs, set him up for the balance of the day, till he retired to bed, when the phenomena of the previous night would be repeated.

In this case I conceived that the blood-vessels of the brain, from overdistention, had lost, in a great measure, their contractile power, and that a larger quantity of blood was, in consequence, circulating within the cranium than was normal. The vessels were therefore in a condition very similar to that of a bladder in which, from the desire to urinate having been too long resisted, contraction cannot be induced even by the most strenuous exertion of the will. As the gentleman was of strong, athletic build, and otherwise in full health, blood-letting would undoubtedly have proved of great service; but, for reasons which will appear hereafter, I determined to try a remedy less likely to do harm, and fully as capable of doing good. I administered thirty grains of the bromide of potassium at six o’clock in the evening, and repeated the dose at ten, directing him to go to bed half an hour subsequently. The first dose produced a decided sedative action, and the second was still more effectual in calming the mental excitement. When he lay down, his mind was not disturbed by a flow of thoughts, and he fell almost unconsciously into a quiet sleep, from which he did not awake till near seven o’clock the following morning. There were no unpleasant symptoms of any kind; on the contrary, he felt strengthened and refreshed. The next night one dose was administered at about bedtime, which was also followed by a sound and invigorating sleep. No further treatment was given, as on the following night sleep came naturally.

Sir Benjamin Brodie,[128] without, however, making the distinction I have insisted upon, refers to the active or sthenic type of wakefulness in the following quotations from a little work which should be in the hands of all who are interested in the philosophy of the mind.

Speaking of the causes of the wakefulness of some persons, he says: “At the same time there is no doubt that there is sometimes a morbid condition of the nervous system, the nature of which we cannot well explain, which is incompatible with sleep. The patient says, ‘I feel fatigued and wearied and want to go to sleep, but I cannot sleep.’”

In asserting as he does that this kind of wakefulness is sometimes the forerunner of mental derangement, Sir Benjamin is supported by many cases detailed by authors on psychological medicine, and the following, which he gives,[129] is directly to the point:

“A gentleman of my acquaintance in whose family circumstances had occurred which were to him sources of intense anxiety, passed six entire days and nights without sleep. At the end of this time he became affected with illusions of such a nature that it was necessary to place him in confinement. After some time he recovered perfectly. He had never shown any signs of mental derangement before, nor has any one of his family, and he has never since been similarly affected. This was an extreme case. But do not examples of the want of sleep, proving very similar results, though in a very much less degree, occur under our observation constantly? How altered is the state of mind in any one of us after even two sleepless nights! Many a person who under ordinary circumstances is cheerful and unsuspicious, becomes not only irritable and peevish, but also labors under actual, though transitory, illusions; such, for example, as thinking that others neglect him or affront him who have not the smallest intention of doing either the one or the other.”

Cases similar to the following, which is one of the passive variety of wakefulness, are by no means uncommon.

Case IV.—A lady, aged about thirty-five, unmarried, and of rather delicate constitution, consulted me in regard to persistent wakefulness, with which she had been affected for nearly a month. According to the account which she gave me, she had received a severe mental shock, which had not lost its influence when a subject of great anxiety was forced upon her consideration. Her menstrual period, which had been due about ten days before she came under my notice, had been anticipated by a week, and the flow was prolonged much above the ordinary time. She had, therefore, lost a good deal of blood, and was, in consequence, greatly reduced in strength. This, conjoined with the exhaustion due to the long-continued wakefulness, rendered her condition a much more serious one than would otherwise have been the case.

She had taken large doses of laudanum, of ether, and of valerian, together with many other medicines, the names of which I do not now recollect, besides employing a variety of means of traditional efficacy. All had, however, been useless. Homoeopathy was then tried with an equal want of success. When I first saw her she was nervous and irritable, her hands trembled violently upon the slightest exertion of their muscles, her eyes were bloodshot, the pupils contracted, and the lids opened to the widest possible extent. There was a constant buzzing in the ears, and the sense of hearing was much more acute than was natural. There was also increased sensibility of all that portion of the surface of the body (the skin of the hands, arms, legs, back, and breast) which I submitted to examination with the Æsthesiometer. Her pulse was 98, irritable, small, and weak.

At night all her symptoms were increased in violence. Her mind was filled with the most grotesque images which it was possible for the imagination to conceive, and with trains of ideas of the most exaggerated and improbable character. These succeeded each other with a regularity so well marked that she was able to foresee the routine night after night. “No one,” she said, “can imagine the weariness I feel, or the horror with which I look forward to the long rows of too-familiar phantoms and thoughts which I know will visit me before morning. There is one set,” she continued, “which always comes as the clock strikes two. No matter what may be passing through my mind it is banished by this. It consists of a woman with very long hair, who sits on a rock by the sea-side, with her face buried in her hands. Presently a man armed with a long sword comes up behind her, and, clutching her by the hair, drags her to the ground. He puts his knee on her breast, and still holding her hair, cuts it off, and binds her with it, hand and foot. He then commences to pile stones on her, and continues to do so till she is entirely covered, notwithstanding her piercing shrieks, which I hear as distinctly as I do real sounds. Turning then to the sea he cries out, ‘Julia, you are avenged. My vow is accomplished. Come! come!’ He then draws a dagger from his breast and stabs himself to the heart. He falls over the pile of stones he has raised, and instantly hundreds of little devils not more than a foot high swarm around his body, and finally carry it off through the air. My horror at all this is extreme. For more than an hour the scene is passing before me, and though I know it is all purely imaginary, I cannot shake off the terror it induces.”I questioned this lady closely, and found that she was very intelligent, and fully sensible of the unreality of all her visions. There was no evidence whatever of the slightest tendency to insanity, but there was a condition present which would surely terminate in the loss of her reason if not quickly removed. I regarded her symptoms as indicating a state of passive cerebral congestion, and as calling for stimulants rather than what are called sedatives. I directed, therefore, that she should take an ounce of whisky, properly diluted, every hour, commencing six hours before bedtime; that she should immerse her whole body except her head in water, at the temperature of 98° F., for half an hour just before retiring for the night, and, instead of lying down, should sit up in an easy chair and try to sleep in that position.

I administered the whisky upon the same principle that governs us when we apply stimulating lotions to an inflamed eye, or give alcoholic liquors in passive congestions of other parts of the body. The warm bath was prescribed with a view to its dilating action upon the blood-vessels exposed to its influence; and the sitting position with the object of facilitating the flow of blood from the head, and impeding its return through the carotids and vertebrals.

All these measures I had employed previously with success, in many cases of inability to sleep due to delirium tremens, and which is almost always of the passive or asthenic form. In the instance under consideration their action was all that could be desired. At ten o’clock, having taken the whisky and bath as directed, she sat down to sleep in a comfortable chair, and, as her mother informed me, was asleep in less than half an hour. She awoke about three o’clock, but soon fell asleep again after another dose of whisky, and remained in this condition till about nine o’clock in the morning. She then took breakfast, feeling very much refreshed, but was unable to remain awake longer than two or three hours, but, taking to her chair, slept soundly till evening. That night she was again overcome with sleep, and it was passed very much as was the previous one. No further medicine was required, and after a few nights she went to bed as had been her custom, and slept soundly till morning. Under the use of iron and lager beer she recovered her health and strength.

The foregoing cases are given as examples of the two forms of morbid wakefulness or insomnia to which I wish to call attention. They show that, though the cause in each variety may be essentially the same, the means of relief are not altogether identical. It is important, therefore, to discriminate between them. But the main point upon which it is necessary to insist is, that in morbid wakefulness, whether occurring in strong or weak persons, there is always an excessive amount of blood circulating through the substance of the brain. In the course of the discussion of the points involved in the physiology of sleep, this subject was incidentally noticed. In the following chapter, however, it will be dwelt upon with more particularity.