THE TREATMENT OF WAKEFULNESS.

The principles which should prevail in the treatment of wakefulness are indicated to some extent by the remarks which have already been made. If the views which I have given relative to the pathology of this affection be correct, there can be no doubt in regard to the means to be employed for its cure. Happily, theory and practice are in perfect accord in respect to the therapeutical measures to be adopted. These may be arranged into two classes:

1st. Those which by their tendency to soothe the nervous system, or to distract the attention, diminish the action of the heart and blood-vessels, or correct irregularities in their function, and thus lessen the amount of blood in the brain.

2d. Those which directly, either mechanically or through a specific effect upon the circulatory organs, produce a similar effect.

Under the first head are embraced many agencies which from time immemorial have been known to cause sleep. Among them are music, monotonous sounds, gentle frictions of the surface of the body, soft undulatory movements, the repetition by the insomnolent of a series of words till the attention is diverted from the exciting emotion which engages it, and many others of similar character which individuals have devised for themselves. In slight cases the measures belonging to this class often prove effectual, but in persistent insomnia they are generally altogether nugatory.

Under the second head we shall find comprehended the means which are chiefly to be relied on in the treatment of cases of morbid wakefulness.

Chief among them are embraced those measures which tend to improve the general health of the patient, and which are chiefly of a hygienic character. Whatever causes produce an irritable condition of the nervous system, indirectly at least increase the disposition to wakefulness. It is important, therefore, that these should be thoroughly understood and avoided, and I accordingly propose to consider them at some length.

Food.—While it is an error to suppose, as is generally done, that a moderately full meal, eaten shortly before bedtime, is necessarily productive of wakefulness, there is no doubt that this condition is induced by an excessive quantity of irritating or indigestible food. A hearty supper of plainly cooked and nutritious food rather predisposes to sleep. Most of us have experienced the drowsiness which so often follows dinner. This is due to the fact that the process of digestion requires an increased amount of blood in the organs which perform it, and consequently the brain receives a less quantity. A tendency to sleep is therefore induced. It is a natural and healthy predisposition, and when yielded to moderately conduces to a more complete assimilation of the food than would otherwise take place. When, however, the food ingested is not such as is merely sufficient for the wants of the system, but is inordinate in amount, or irritating in quality, the hypnotic effect is neutralized, and often a state of wakefulness supervenes, from the fact that the quantity of blood circulating in the brain is augmented instead of being diminished. This last result is induced either by the pressure of the overloaded stomach upon the abdominal vessels or through a reflex action on the heart, by which it is excited to increased activity.

In young children, who are very susceptible to the influence of causes acting upon the nervous system, we often see both sleep and wakefulness result as direct effects of eating. When the quantity of milk taken has not been excessive, the child quietly drops asleep at the breast. On the contrary, when a superabundance has been ingested, it either remains awake or the sleep is disturbed. In adults it is, as has already been mentioned, not uncommon for apoplexy to ensue upon a large meal of improper food.

In order, therefore, that a disposition to wakefulness may be removed, it is essential that attention should be paid to the diet of the affected individual. As a rule, people are underfed. This is especially the case with women, who too generally indulge in what may be called “slops,” to the exclusion of good, solid, nutritious food derived in great part from the animal kingdom. By such a faulty diet the tone of the system is lowered, and local congestions of different parts of the body are produced. If the brain be one of these, wakefulness results.

Most of the cases of insomnia which occur in women are of the passive variety, and require not only nutritious food, but stimulants. Of the latter, whisky is generally to be preferred as acting rapidly, as less likely to disagree with the stomach than many kinds of wine, and as being purer than the stuff ordinarily sold as brandy. As a good stimulant, and at the same time tonic, nothing can be preferable to Tarragona wine, drunk at dinner to the extent of a glass or two. It possesses all the essential qualities of pure port, and is much more reliable and wholesome than the mixture of elderberry juice and alcohol which passes for this latter wine. Next to Tarragona wine must be ranked good lager beer.

Although the effect of coffee is generally such as to induce sleeplessness, there are cases in which its action is directly the reverse. I have had several slight cases of passive wakefulness under my care which were entirely and speedily cured by a cup of strong coffee taken for three or four nights in succession at bedtime. It is especially useful in females of languid circulation, and a consequent tendency to internal congestions.

Stimulants such as those mentioned, and others which might be noticed, it must be clearly understood are only useful in the asthenic or passive form of insomnia; in the sthenic or active form of the affection they are altogether inadmissible, and if employed will certainly increase the difficulty.

The good effects of moderate but regular physical exercise in dissipating wakefulness can scarcely be overestimated. It is almost impossible to produce any permanently beneficial influence without the aid of this powerful tonic. To be of any material service, the exercise should be taken in the open air, and should extend to the point of inducing a slight feeling of fatigue.

The warm bath is also a very valuable means of determining blood from the head, and calming nervous irritability. Frequently, especially in children, I have found that simply putting the feet in water of the temperature of 100° F. has been sufficient to induce a sound and healthy sleep, when laudanum and other means have failed.

Cold water, applied directly to the scalp, is often of great effect in diminishing the amount of blood in the brain. It is not admissible in the asthenic form of wakefulness. When the individual is strong, the heart beating with force and frequency, and the mental excitement great, its influence is almost invariably good. The exact temperature is a matter for the judgment of the physician. I have often used it as cold as ice could make it, 32° F., or thereabouts.

In the action of cold water, applied to the head in cases of insomnia, we have another proof of the real nature of this affection. It is known that in Thibet mothers place their wakeful children in such positions as will admit of a small stream of cold water falling from a slight elevation upon the head. I have in some work—on which I cannot now lay my hands—read a very full account of this custom, and seen a cut representing the process. The children very soon fall into a quiet sleep. I have often seen the application of the cold douche to the heads of refractory prisoners bring on a deep sleep.

The effects of position in aid of other remedies have also been alluded to. I make use of its advantages in all severe cases of insomnia which come under my charge, and we have, in its efficacy, additional confirmation of the correctness of the theory that the condition of the brain in such cases is one of hyperÆmia.

Among the more purely medicinal agents, bromide of potassium occupies the first place, and can almost always be used with advantage to diminish the amount of blood in the brain, and to allay any excitement of the nervous system that may be present in the sthenic form of insomnia. That the first named of these effects follows its use, I have recently ascertained by experiments upon living animals, the details of which will be given at another time. Suffice it now to say, that I have administered it to dogs whose brains had been exposed to view by trephining the skull, and that I have invariably found it to lessen the quantity of blood circulating within the cranium, and to produce a shrinking of the brain from this cause. Moreover, we have only to observe its effects upon the human subject to be convinced that this is one of the most important results of its employment. The flushed face, the throbbing of the carotids and temporals, the suffusion of the eyes, the feeling of fullness in the head, all disappear as if by magic under its use. It may be given in doses of from ten to thirty grains—the latter quantity is seldom required, but may be taken with perfect safety in severe cases.

Another very admirable preparation is the oxide of zinc. This substance appears to be especially beneficial in those cases of wakefulness due to excessive mental exertion or anxiety of mind. I usually prescribe it in doses of two grains, three times a day, the last dose being taken just at bedtime.

Opium I very seldom employ in the treatment of wakefulness, from the facts that its effects vary so greatly in accordance with the dose, and that its action is not limited to the simple induction of sleep. There are cases, however, in which its influence is decidedly beneficial. Care should be taken to give it in sufficiently large but not excessive quantities. The influence of opium in lessening the amount of blood in the brain is very distinctly recognized by Dr. Handfield Jones, and also by Dr. Alfred StillÉ.[141] Both these authors account in this manner for its hypnotic effect. As has been shown, my own experiments tend strongly to confirm this reasoning.

Hyoscyamus is more generally admissible. It is especially indicated in those cases which are accompanied by great nervous irritability. It is difficult to obtain any preparation of this drug which retains its virtues. I have usually employed the tincture in doses of from one to two drachms. I do not think, however, that it possesses any advantages over bromide of potassium, or that it is even equal in any respect to this agent.

In regard to valerian, assafoetida, and other antispasmodics, I have nothing to say in commendation. Tonics are, however, almost always useful, even in the active form of the affection. Among them quinine and iron are more generally indicated.

When wakefulness is a consequence of functional derangement of distant organs, the measures of relief must be directed to the cure of the primary disease, in order to produce any permanent alleviation of the cerebral difficulty.

In those cases of insomnia dependent upon severe and long-continued mental exertion, all means will fail to remedy the trouble unless the affected individual consents to use his brain in a rational manner. Proper intervals of relaxation should be insisted upon, and in some cases it may be necessary to suspend all intense intellectual effort for a time. When the means will permit, travel can always be undertaken with advantage. It is surprising sometimes to see how rapidly the brain recovers its tone, and the system generally recuperates through the change of associations and scenes incident to travel.

The disposition of the age seems to be to ignore the fact that the nervous system can exhaust itself by excessive intellectual labor. A short time since intelligence was received from abroad that one of the most distinguished men of Great Britain had committed suicide, in consequence of insanity produced by overexertion of his mind. Thus one more victim is added to the long list of those who have disregarded the laws of their being; and again we are reminded that there is a limit to the exercise of our intellectual powers, beyond which we cannot pass with safety.[142]