Chapter XXIV: Introduction: The term neurasthenia, signifying nervous weakness, and (2)

It appears, therefore, that the harmonious activity of all parts of the nervous system is indispensable to the highest exercise of the conscious mind. Healthy intellectual life is the perfectly-balanced outcome of the complex polygon of forces which has its seat within the brain. But the suppression of certain lines of this polygon does not suppress life, nor does it necessarily destroy consciousness. It only occasions a redistribution of force and a proportionate narrowing of the stream of related {370} ideas. Since the suppression just mentioned is not an absolute quantity, but a variable factor, the polygon of forces in the brain and the corresponding succession of ideas in consciousness must necessarily be in a state of continual change. Accordingly, our dreams are as variable as the clouds that drift upon the currents of the air. As on a hot day in summer, when the steady equatorial draught has ceased to guide the wind, we may observe all manner of local tides in the masses of vapor which arise from the earth, so in sleep, when the guiding influence of the senses is withdrawn from the brain, the ideas that still arise are chiefly dependent upon its automatic and reflex action for their origin and association. Undisturbed by impulses from the external world, the brain seems then more sensitive to impressions that originate within the body. An overloaded stomach, an enfeebled heart, a turgid sexual apparatus, or an irritable nervous ganglion may become the source of irregular and uncompensated movements which may invade the cerebral cortex, and may there set in motion a whole battery of mechanisms whose influence upon consciousness would be quite unnoticed were the external senses in full operation.

Night-Terrors.

The preceding argument will render it easy to comprehend the phenomena of night-terrors. These are commonly observed in young children of a highly nervous temperament before the conclusion of their second dentition. The subjects of the disorder are generally of neurotic descent. Insanity, hysteria, neurasthenia, epilepsy, chorea, and nervous dyspepsia are often discovered among their near relatives. Not infrequently they have been or will become themselves choreic.

The attack is often preceded by symptoms of indigestion, but it may result simply from the commotion of a brain wearied by the excitement and effort of the previous day. The little patient starts up out of an apparently sound sleep crying with alarm, calling for his mother, and staring wildly with every possible expression of terror. Sometimes he springs from his couch and runs headlong into a corner or seeks to hide under the bed, as if escaping from some frightful object. The eyes are open, tears flow, perspiration covers the skin, there is the greatest excitement, and the little one, convulsively clinging to its parent, will not be quieted. Only after fifteen or twenty minutes, as tranquillity gradually returns, does the child seem to recover the power of recognizing his friends. Presently, however, he lies down and falls quickly asleep, waking in the morning without the slightest recollection of the unpleasant event.

Such paroxysms occur during the early part of the night, one or two hours after the child has been put to bed, just at the time when, according to the previously-quoted experiments of Kohlschütter, sleep is passing from its maximum intensity to a lesser degree of depth. This, then, is the time when the controlling power of the sensory apparatus over other portions of the nervous system has already reached its minimum. The spinal centres and those intracranial ganglia which do not share in the full measure of this repose are therefore in a condition of relative {371} exaltation. Disturbances of internal organs consequently produce inordinate excitement of these waking portions of the nervous apparatus. The morbid quality of this excitement is attested both by the history of the patient and by the fact that it does not arouse the whole brain. The distribution of motion in the cerebrum is impeded, so that certain portions of the organ remain asleep while other regions are thrown into a state of tumultuous uproar. Disconnection of these different organs of the nervous system, by withdrawing particular portions from the inhibitory influence of the remaining parts, gives opportunity for violent explosions of nervous force analogous to the convulsions of a headless fowl or to the course of an epileptic paroxysm. Now, in sleep, in somnambulism, in hypnotism, in delirium, in certain stages of intoxication with alcohol or with narcotics, such ungearing of the different nervous ganglia is more or less completely effected. In narcotic and anæsthetic sleep besides the disassociation of ganglia there is paresis of the nervous molecules; hence the phenomena soon merge into insensibility and coma. But in natural sleep, in somnambulism, or in hypnotism there is no toxic paresis; hence the dissociated portions of the brain and nervous system, if aroused, are in a physiological condition to dispense great stores of force. Hence the vividness of certain dreams and the astonishing vigor of particular nervous functions in somnambulism and hypnotism.

Somnambulism.

The phenomena of night-terrors constitute merely a special form of somnambulism, a condition of which the mechanism, so far as the present state of cerebral physiology will permit, has been already suggested. The affection should not be ranked by itself as a particular variety of disease, but should rather be considered a violent perturbation in the cerebral organs of a neurotic subject during the period of sleep. In ordinary dreaming the muscular apparatus usually remains passive, even though the dream be a nightmare or an incubus of the most terrifying character. But when the desires and the emotions are powerfully addressed by the dream, a certain amount of muscular movement may ensue, as when a dog barks in his sleep, or when a child laughs upon his nurse's lap, or when a weary soldier marches on though overpowered by sleep. One night, when parched with thirst during a voyage at sea,[9] I saw in sleep a sparkling fountain, by the side of which appeared a young girl holding out a cup of cold water. Awakened by the excitement, I found myself sitting up in bed with my right arm extended in the direction of the tantalizing vision: my dream had merged itself in action. In like manner, the victim of night-terrors not only moves his body, but gives vocal expression of his feeling of apprehension and alarm. In like manner, projecting his dream into action, a sleep-walker may arise from his bed; he climbs out of the window and descends to the ground, executing all manner of complicated and dangerous movements; he walks long distances, and finally returns to his couch without waking. In the morning no recollection of the event of the night survives. Again, the movement {372} may be less locomotive in its character. The intellectual faculties chiefly may be aroused, and then only such movements are executed as may be necessary to give expression to the mental process.

[Footnote 9: A proclivity to dreaming has often been remarked among the consequences of partial starvation.]

Such, then, are the principal characteristics of somnambulism, a state in which dreams are supplemented by more or less complete and appropriate action, ordinarily without subsequent recollection of either dream or action.

The somnambulistic dream generally occurs during or soon after the period of deepest sleep, when the influences of the external world are largely suppressed. Released from the control of its sensory portion, the remainder of the brain awakes and becomes aroused to a condition of functional exaltation. No longer distracted by the recollection of the special senses, the attention is concentrated upon the hallucinations which constitute the dream. In the simpler forms of noctambulism only the automatic locomotive apparatus is awakened, and the sleeper moves in accordance with the impressions derived from habit aided by exaltation of the muscular sense. But in some of the more complicated cases a certain amount of special sensibility seems to exist. The patient is capable of exercising just that amount of sensation which is necessary to accomplish his purpose, though blind and deaf and insensible to every other impression. The more complete the waking of the organs of sense, the closer the resemblance to the condition of ecstasy in which cerebral exaltation is the prominent feature. Accordingly, it sometimes happens that the somnambulist can recall the events of his paroxysm.[10] In such cases the power of recollection is due to the same conditions that control the recollection of our ordinary dreams. We remember very imperfectly, if at all, the dreams that occur during sound sleep, but the visions with which sleep sometimes commences (hypnagogic hallucinations) and those that occupy the period of morning slumber are very easily reviewed in memory, because they are associated with impressions directly derived from the partially-waking organs of sense. Such dreams are therefore chiefly recalled through their association with the train of our waking thoughts. But the dreams of somnambulism and the dreams of night-terrors, and all other visions during profound sleep, are as completely as possible cut off from all connection with the mental activities which arise directly from the action of the senses. By reason of such isolation the ordinary association of ideas affords no help to the memory, and the dream remains in the limbo of oblivion.

[Footnote 10: A. Bertrand, _Traité du Somnambulisme_, p. 80.]

Alfred Maury expresses the opinion[11] that the principal cause of forgetfulness of the events of somnambulism consists in the exhaustion of the cerebral elements through the intensity of the excitement to which they are subjected during the paroxysm. Doubtless this in certain cases may contribute to the loss of memory, but it should be remembered that the excitement may be relative rather than absolute. Certain elements wake while others are asleep, and the waking cells may be aroused to a degree far in excess of what is usual during the sleep of the brain without attaining to the level of their diurnal activity. The mind, undisturbed by external impressions, gives its attention to the activity of these waking organs, and a dream with all its consequences, somnambulic or otherwise, is the result. In other words, the plane of consciousness, so to speak, is lowered {373} during sleep to the level of these molecular vibrations. But when the whole brain is again awakened after sleep the residual vibrations of those elements which yielded the physical basis of the dream, and which, had they occurred during the waking state, might have persisted with energy sufficient to furnish a groundwork for recollection of the ideas which they had originally suggested, are no longer sufficiently energetic to be felt in consciousness. Recollection of mental states thus generated must necessarily be impossible so long as the mind is dependent upon the brain as its register of events. Sometimes, however, the somnambulist, who while awake had forgotten all the incidents of his somnambulic experience, can remember in a subsequent paroxysm all that occurred during the preceding attack. Facts of this kind have been observed in the waking life of certain hysterical persons,[12] but the apparent interruptions of their personality attach to the waking state, while in ordinary somnambulism it is only in sleep that the alternations of memory and forgetfulness occur. A similar recollection of previous visions is sometimes experienced in dreams, showing the close relation that subsists between the dreams of sleep and of somnambulism. The bond of association between these events thus isolated in time must be sought in a renewal of like conditions of the brain during the successive periods of somnambulic exaltation. We must suppose that the molecules which were in a state of functional excitement during the first paroxysm are again aroused in like manner after a period of waking quiescence. If, during sleep, their movements, though of an exalted character, have only just sufficed to arouse consciousness in the form of a dream, it would not be probable that during the phase of comparative inactivity which supervenes when the whole brain is awake their residual motion could disturb the sphere of consciousness. Hence the time occupied by their somnambulic vigor must remain a blank in memory during the waking state. But when the original state of exaltation has been reproduced by a second period of disorder, if the same molecular movements be in any way renewed, the conditions of memory are fulfilled; consciousness is once more aroused as before, and the patient remembers the dream or the events of the previous attack.

[Footnote 11: _Le Sommeil et les Rêves_, p. 226.]

[Footnote 12: _Annales Medico-psychologiques_, 5e Série, t. xvi. p. 5, 1876.]

Artificial Somnambulism, or Hypnotism.

The phenomena which have now been passed in review are of apparently spontaneous origin during the ordinary period of sleep. But from the remotest antiquity it has been known that certain persons may be thrown into an artificial sleep which closely resembles the condition of the somnambulist. During the persistence of this state certain portions of the nervous system become utterly insensible to external impressions, while other portions acquire an exalted degree of sensibility. The subject of the experiment can then by special methods be placed in such relations with other waking individuals that his surviving sensations, mental processes, and physical actions shall be no longer regulated by his own volition, but by the will of another. Such susceptibility is not common to all persons. About 20 per cent. of the ordinary population is, by some observers, considered capable of experiencing this condition. {374} Heidenhain,[13] experimenting upon a class of medical students, found only one in twelve who was thus susceptible. Charcot, whose field of observation covers the inmates of the Salpêtrière Hospital, finds the best exemplars of the hypnotic state among the hystero-epileptic females in that asylum. To these experimenters we are largely indebted for the most extended scientific observation of the phenomena of hypnotism, giving precision and publicity to the knowledge of facts which, though equally well known within a narrow circle of investigation[14] during the earlier decades of the present century, have been compelled to await the development of cerebral physiology before their full significance could become apparent to the mass of the medical profession.

[Footnote 13: _Animal Magnetism: Physiological Observations_, by Rudolph Heidenhain.]

[Footnote 14: Braid, _Neuro-hypnology considered in Relation with Animal Magnetism_, London, 1843.]

The antecedent condition most favorable to the production of the hypnotic state is a highly unstable constitution of the nervous system. For this reason the larger number of qualified subjects is furnished by the female sex, especially by those who possess the hysterical temperament. Frequent repetition of hypnotic exercises renders the subject still more susceptible. Heidenhain was at first inclined to believe that such experiences were not prejudicial to the health of the subject, but the observation of Harting in the University of Utrecht, and of Milne-Edwards in Paris,[15] have demonstrated danger to the health of animals subjected to similar experiments. It is easy to discover, in the various clinical narratives published by Charcot and his pupils,[16] evidence that hysterical patients often manifest considerable exhaustion after hypnotic exhibitions; consequently, it cannot be admitted that the practice is devoid of risk to the health of the individual.

[Footnote 15: _Lancet_, July 29, 1882, p. 164.]

[Footnote 16: Paul Richer, _L'hystéro-Epilepsie_, Paris, 1881; _Le Progrès médical_, 1881-82.]

Numerous methods of inducing the hypnotic state have been employed by different experimenters. The greater number consist in modifications of the sensory impulses derived from the periphery of the body. Gentle pressure upon the closed eyelids; convergence of the axes of the eyeballs upon some object nearer than the proper focal distance of the eyes; fatigue of the retina by gazing upon any brilliant or luminous object; monotonous excitation or sudden surprise of the auditory nerve; various impressions through gentle friction or pressure upon different regions of the body,—all these are capable of inducing hypnotic sleep. An appeal to the imagination, or even the mere attempt to abnegate the possibility of vigorous thought by confining the attention to the most trivial of things, sometimes suffices to produce the desired phenomenon. Thus, Heidenhain put one of his students to sleep at a distance by merely informing him beforehand that at a certain hour he would hypnotize him in his absence. The state of ecstatic meditation into which the monks of Mount Athos plunged themselves by the practice of omphaloscopy affords an illustration of the hypnotic effects of concentrated attention.

The duration of hypnotic sleep is exceedingly variable, but if left to himself the patient usually wakes spontaneously, without recollection of anything that has happened. If it be desirable to awaken him before the natural termination of the paroxysm, consciousness can be restored by almost any sudden and energetic appeal to the senses, such as an {375} electric shock, a sudden illumination of the eye with vivid light, or a sharp puff of air upon the face.

According to Charcot,[17] three principal types may be remarked among the hysterical subjects upon whom he experimented: (1) the cataleptic, (2) the lethargic, and (3) the somnambulic. Of these, the first may be developed primarily by any abrupt and powerful impression upon an organ of sense, as a bright light or a loud noise (gong). Fixing the eyes upon some object may produce the same result. Dumontpallier, for example, has reported the case of a young woman[18] who accidentally hypnotized herself by gazing at her own image in the mirror before which she was dressing her hair. The cataleptic state may also be secondarily induced by merely opening the eyes of a patient in whom a condition of hypnotic lethargy has been previously developed. If only one eye is thus opened, the corresponding side of the body alone becomes cataleptic. Closing the eyes causes the disappearance of this symptom, with complete restoration of the purely lethargic state. During the cataleptic condition the several tendinous reflexes disappear, neuro-muscular hyperexcitability ceases; the skin becomes insensible, but the special senses, particularly those of sight and hearing, maintain a partial activity. In this state the senses may become avenues of suggestion for the production of muscular movements, but if left to themselves the limbs remain motionless.

[Footnote 17: _Le Progrès médical_, Feb. 18, 1882, p. 124.]

[Footnote 18: _Ibid._, March 25, 1882, p. 223.]

The lethargic state may be induced by simply closing the eyes of the patient or by causing him to fix his gaze upon some definite object. The paroxysm begins with a deep inspiration causing a peculiar laryngeal sound, followed by the appearance of a little foam on the lips. The eyelids are either wholly or partially closed, and are in a state of continual tremulous motion. The eyeballs are generally turned upward and inward. The muscles are completely relaxed. The tendinous reflexes are exaggerated; pressure over a muscle or upon a nerve arouses a peculiar contraction of synergic muscles and of groups of muscles which are supplied by the excited nerve-trunk. The facial muscles, however, do not thus become contractured: they merely contract during the application of the stimulus. If the lethargic patient be rendered cataleptic by opening the eyes, these contractions persist even after awaking, and they can only be dispelled by renewing the lethargic state before resorting to pressure upon the antagonistic muscles—a process by which the contractures peculiar to this species of lethargy may always be annulled. By the approach of a magnet to a contractured limb the phenomenon may be completely transferred to the corresponding muscles upon the opposite side of the body. If upon a limb of a lethargic patient who has been rendered cataleptic by opening the eyes an Esmarch's band be applied, pressure over the bloodless muscles excites no contracture until the band is removed. A contracture is then developed, and it may even be transferred to the opposite limb by the approach of a magnet. To this phenomenon has been applied the term latent contracture.

The extraordinary muscular excitability manifested by these hysterical hypnotics is further illustrated by an observation recorded by Dumontpallier.[19] If one end of a caoutchouc tube one centimeter in diameter and {376} five or six meters in length be applied over a muscle in the leg, and if the other end be in like manner connected with a watch, every movement of the second hand will be followed by a slight contraction in the muscle. The same result follows connection with the wire of a telephone, and if a microphone be introduced into the circuit the incidence of a ray of artificial light upon the instrument, or even its glancing reflection from the eye, will arouse a responsive muscular contraction. Charcot has sometimes observed muscular contractions upon the opposite side of the body when a mild galvanic current was applied to the parietal surface of the head. During the manifestation of muscular hyperexcitability there is complete analgesia, but the senses of sight and hearing seem to preserve some degree of activity. The patient, however, does not manifest any susceptibility to influence by suggestion.

[Footnote 19: _Ibid._, Jan. 14, 1882, p. 25.]

The somnambulic state may be directly induced by fixed attention with the eyes, by feeble and monotonous excitation of the senses, and by various other methods of an analogous character. This forms the most common variety of the hypnotic condition. It may very easily supervene during either the lethargic or the cataleptic state as a consequence of pressure or gentle friction upon the top of the head. Thus, Heidenhain caused muscular paralysis by rubbing the scalp. Unilateral friction of the same surface produced paralysis of the opposite side of the body without notable affection of consciousness. The eye and the eyelids behave as in the lethargic state. The patient seems asleep, but there is less muscular relaxation than in hypnotic lethargy. There is no exaggeration of the tendinous reflexes, and muscular hyperexcitability is absent. But by lightly touching or breathing upon the surface of a limb its muscles may be thrown into a condition of rigidity which differs from the contracture of the lethargic state in the fact that it does not yield to excitation of the antagonistic muscles, though yielding readily to a sudden repetition of the same form of excitement by which it was originally produced. From the immobility of the cataleptic state it also differs by a greater degree of resistance to passive motion. Though analgesia may be perfectly developed in this state, there is generally an exalted condition of certain forms of cutaneous sensibility and of the muscular sense. Strange perversions of other special senses are sometimes remarked. Cohn[20] discovered that a patient who was naturally color-blind “when unilaterally hypnotized was able to distinguish colors which were otherwise undistinguishable.” Conversely, when the cataleptic state is induced the eye becomes incapable of discerning colors. Spasm of accommodation is also present, and is one of the earliest demonstrable symptoms of the hypnotic condition.

[Footnote 20: _Brain_, vol. iii. p. 394.]

These remarkable exaggerations and perversions of special sensibility have been the cause of much scepticism on the one hand regarding the verity of the phenomena of hypnotism, and of much credulity on the other, extending even to a belief in the existence of supernatural and miraculous gifts. But when the fact is once comprehended that in this capacity for uncommon feats of vision, hearing, touch, etc. we observe merely the exaggeration of a process which occurs in every act of attention, the miraculous semblance of the phenomena disappears. Attention implies an increase of activity in certain portions of the brain, with {377} diminution of the function in the remainder of the organ. In the wild excitement of a cavalry charge the soldier feels not the sabre cut which will fill his consciousness with pain so soon as his attention is released from the fetters imposed by the more engrossing events of the combat. So in the somnambulic sleep those parts of the brain which remain awake perform their functions with a vigor that is enhanced by a concentration of cerebral energy in certain restricted portions of an organ that, by reason of its naturally excessive instability, had been previously fitted for the liberation of an inordinate amount of molecular motion. Hence the slightest suggestion of sense may suffice for the most extraordinary perception. Such persons see through their eyelids and hear at a surprising distance. The memory of past events, the recollection of long-forgotten words and thoughts, supplies in this state an abundance of materials out of which an exalted imagination may construct the most astonishing scenes. By this method of combination are produced those remarkable oratorical utterances which by the ignorant have been so widely attributed to the supervision of guiding spirits from another world. In this condition the essential characteristics of the mind of the so-called medium become the real guides of his mental processes. Hence the infinite variety and contrariety of the utterances of such declaimers.

Among other consequences of this exalted susceptibility of the waking portions of the brain may be noticed the effect of suggestions by others upon the mind of the somnambulist. Numerous examples scattered through the literature of the subject[21] illustrate the manner in which the course of our ordinary dreams may be thus directed. The hypnotic dream is far more easily modified.[22] The simplest manifestations of such influence are exhibited in movements in obedience to the command of the hypnotizer. Next in rank are those more complicated actions that are effected by excitement of the imitative faculties of the subject. Every suggested movement that can be in any way perceived by the patient will be at once reproduced. Various emotions and passions may thus be aroused by simply placing the sleeper in the appropriately suggestive attitudes. Under the influence of a pregnant idea intruded upon the mind of the patient the subsequent association of ideas will suffice for the evolution of a complicated series of hallucinations, as in the case of a young woman, who on being directed to put out her tongue immediately began to feel sensations of uneasiness in her stomach, followed by nausea and attempts at vomiting, accompanied by the impression of being on shipboard. In the lowest grades of the hypnotic state consciousness may remain, and the subsequent recollection of the events of the paroxysm may be quite persistent. In such cases illusions that were produced by suggestions from other minds generally survive in memory and become the causes of serious delusion. Witness the manner in which susceptible individuals, partially hypnotized in a so-called spiritual circle, believe in the reality of the illusions which have occupied their senses during a séance.

[Footnote 21: Carpenter's _Physiology_, 8th ed., p. 765; _Le Sommeil et les Rêves_, par L.-F. Alfred Maury, 4th ed., p. 153 _et seq._]

[Footnote 22: _Loc. cit._, p. 357.]

A higher degree of insensibility to ordinary impressions is necessary to the production of the phenomena of passive obedience and of automatic {378} imitation. It is probable that the degree of sensory hyperæsthesia which enables certain hypnotic patients to read the thoughts of others belongs rather to the first than to the last of these classes. This capacity is usually associated with preservation of consciousness and memory, and is, essentially, a mere exaggeration of that power which all possess in greater or less degree. Numerous well-authenticated examples of a surprising manifestation of this faculty have been recorded, so that the possibility of its existence no longer admits of doubt.[23] In all cases it has been remarked that the hypnotic mediums can only respond correctly to questions for which the true answer is present in the mind of the questioner. For all other interrogations the replies are delivered purely under the influence of random suggestion. In certain of these cases the pathway of communication lies through actual physical contact, as in ordinary mind-reading, where the insensible molecular oscillations of the muscular elements of one individual serve to guide the movements of another. But more frequently the transmission of ideas is effected through the eyes. With these organs the table-rapper or the planchette-writer reads the unspoken words of the questioner in a manner very like, yet vastly more deliberate than, that by which deaf-mutes now learn to interpret the movements of the lips of persons with whom they converse. This fact is well illustrated by the experience of Maury[24] in an interview with a celebrated table-rapper, who without the slightest hesitation made known to him the age, name, and date of death of a brother whom he had lost. She also gave the same information regarding his father, and related the names of other persons upon whom he had fixed his attention. But if he turned away his face or concealed his eyes, so that the woman could no longer watch their expression, her responses ceased to be of any value.

[Footnote 23: Luther V. Bell, _Two Dissertations on what are termed the Spiritual Phenomena_, read at the meetings of the Association of Medical Superintendents of American Insane Hospitals at Washington and Boston in 1854 and 1855.]

[Footnote 24: _Le Sommeil et les Rêves_, 4th ed., p. 361.]

In these partial developments of the hypnotic state it is worthy of note that the phenomena of sleep are so few and so comparatively insignificant that they are usually overlooked. Hence the veil of mystery which has so often obscured the interpretation of such cases. Careful observation, however, will always detect some characteristic departure from the normal standard—some loss of balance between the different parts of the nervous system—by means of which the true relations of each example may be determined.

TREATMENT.—A large proportion of the phenomena of somnambulism and hypnotism depend rather upon an originally irritable organization than upon a specially diseased condition of the nervous system. Their treatment, therefore, frequently resolves itself into the management of hysteria or of cerebrasthenia. But if the manifestations of somnambulism develop for the first time in a person advanced in years, who has previously enjoyed good health and a sound mind, it should be regarded as an omen of grave import, signifying the imminence of organic cerebral disease. Though the meaning of such incidents is less sinister in early life, they reveal an ill-balanced state of the nervous system and an imperfect process of nutrition in the growing body. Such children are the {379} frequent victims of night-terrors, the form of disorder most commonly evolved by their somnambulistic proclivities. The treatment of night-terrors should therefore be chiefly directed to the invigoration of the general health of the patient. Indigestion and malnutrition are among the most prominent antecedents, and they should constitute the principal objects of therapeutical attention. Constipation is usually present. This may be relieved by the use of compound rhubarb powder or any other gently stimulating laxative. Digestion should be aided with pepsin as soon as the catarrhal condition of the alimentary canal, so uniformly present, has been measurably improved. Cod-liver oil or its substitutes should be administered for a long period of time. If the nocturnal paroxysms be frequently renewed, it may be well to employ the bromides, either with or without chloral hydrate; but as a general rule it is better to rely upon hygienic and restorative treatment, rather than upon any form of merely hypnotic medication.

INSOMNIA.

The departures from the course of natural sleep which have been thus considered are not so much the direct consequence of acute disease as the result of structural deviation from the normal type of the nervous system. We must now briefly review the strictly pathological modifications to which sleep is liable.

Lithæmic Insomnia.

Among those who indulge freely in the pleasures of the table a form of insomnia is not uncommon. Originating at first in mere overloading of the stomach, and consisting in a direct irritation of the brain through the medium of the intervening nervous apparatus, sleeplessness finally becomes a symptom of more serious mischief. The tissues become charged with nitrogenous waste, and a lithæmic[25] or gouty condition is established. Such patients are wakeful, or if they sleep their slumbers are imperfect and unrefreshing.[26] Grinding of the teeth,[27] noticed by Graves during the sleep of the gouty, is a symptom indicative of a highly irritable condition of important ganglia at the base of the brain. These symptoms are sometimes associated with turgidity of the superficial vessels of the head, indicating imperfect function of the circulatory organs, with a tendency to accumulation of the blood in the venous channels of the body. The sleep of such partially-asphyxiated patients is fitful, irregular, and akin to stupor. Occurring in the subjects of periodical gout, these disturbances of sleep become increasingly serious as the paroxysm is approached, until loss of sleep and the unrefreshing character of such {380} slumber as may be obtained become important factors among the causes of failing health.

[Footnote 25: DaCosta, “Nervous Symptoms of Lithæmia,” _Am. Journ. Med. Sci._, Oct., 1881.]

[Footnote 26: Dyce Duckworth, “Insomnia in Persons of Gouty Disposition,” _Brain_, July, 1881.]

[Footnote 27: Trousseau, _Clinical Medicine_, Am. ed., vol. iv. p. 362.]

For all such patients a proper recognition of the cause of their disorder is essential. This must be corrected by measures appropriate to the treatment of the gouty diathesis. Since the condition of the cerebral tissues is a state of irritation caused by the presence of excrementitious substances, such hypnotic remedies must be selected as will not interfere with the defecation of those tissues. Bromide of potassium, valerian, scutellaria, hyoscyamus, hops, and cannabis indica are useful, together with all that class of drugs which quiet the brain without hindering the process of excretion. Chloral hydrate often produces an excellent result, but care should be taken to prevent its habitual use.

Febrile Insomnia.

Closely related with the sleeplessness of lithæmia are the disturbances of repose which attend the evolution of the various specific fevers. In many cases the condition varies all the way from stupor to delirium. Excessive somnolence, such as often ushers in the fever, is an indication for evacuant treatment. Cerebral excitement calls for remedies like the bromides and chloral hydrate, which do not interfere with elimination. If pain, like headache or backache, be a symptom demanding attention, the addition of morphia in small doses forms a valuable reinforcement for the hypnotic mixture; but, as a general rule, opiates should be used with a sparing hand. The various resources of hydrotherapy are often invaluable when wakefulness results from the cutaneous irritability of the eruptive fevers. During the later stages of a protracted illness the occurrence of insomnia should direct attention to the nutrition of the patient. Wakefulness is then the symptom of an irritable weakness of the brain, demanding remedies which delay the process of disassimilation. The failing power of the heart requires attention, and diffusible nutriment must be given to convey the elements needful for restoration of the exhausted brain. These indications are most perfectly answered by the associated administration of opiates with alcohol, milk, and beef-juice in small and frequent doses.

Insomnia from Exhaustion.

Cerebral exhaustion is a not uncommon cause of wakefulness in cases uncomplicated with fever. It is usually the result of chronic conditions of ill-health and depression, such as are often encountered as the result of various cachexias or of dyspepsia, with or without the abuse of alcohol, tea, coffee, or tobacco. Overwork, debilitating discharges, pregnancy, parturition, mental anxiety, depressing emotions, chronic heart disease, and incipient insanity are fruitful causes of the exhaustion which produces this most distressing form of insomnia. In such cases the cessation of healthy nutrition leads to a condition of excessive instability in the cerebral tissues. The oxygen which they receive from the blood is not stored with any degree of permanence, but tends to pass directly into {381} stable combinations with the oxidizable elements of the brain. Consciousness is thus continually aroused. The state of such a patient presents a very close analogy to the condition of the victim of diabetes whose liver refuses to retain its glycogen. The inordinate discharge of sugar into the blood not only exhausts the tissues of the liver, but also excites other organs—notably the kidneys—to excessive and unwholesome activity. In somewhat similar fashion, the failure of the brain to assimilate and to retain oxygen leads to an abnormal intramolecular oxidation, which excites an excessive and unwholesome activity on the part of the Ego in another region—namely, in the field of consciousness. Such wakefulness might justly be termed a psychical diabetes.

This variety of insomnia has frequently been ascribed to cerebral anæmia occurring as a part of a general spanæmia. But this universal impoverishment of the blood, though a sufficient cause of the morbid instability, the irritable weakness, of the cortical tissues, does not necessarily imply a comparatively bloodless condition of the brain. Unequal circulation and local hyperæmia in different organs of the body are no unusual consequences of the anæmic state. Slight disturbances suffice to arouse the brain of such a patient. The vaso-motor apparatus shares in the general irritability, permitting blood to inundate the cortical substance almost without provocation. The unstable protoplasm is only imperfectly renovated, usually at the expense of the other tissues of the body. The weary patient, busying himself with an unwilling review of the events of the day, tosses long upon his couch before he can secure the approach of “tired Nature's sweet restorer, balmy sleep.” When at length he yields, his slumbers are brief, and the latter part of the night is but a repetition of the earlier vigil.

Such patients need a very radical course of general treatment. A complete change of habits should be effected. A long vacation in the country, or, best of all, a protracted voyage in a sailing vessel, is desirable. Hot foot-baths, with cold affusion upon the head, and warm sponge-baths, or even the full bath in tepid water, at bedtime, are of great service as means of tranquillizing the nervous system. The indications for medicinal treatment, besides attention to the predisposing cachexia, are twofold—to calm and to nourish the enfeebled nervous substance. Opiates calm, but do not nourish—they hinder the process of nutrition; hence the sufferer wakes unrefreshed by the sleep which they procure, and is soon in a condition worse than ever. The same objection lies against the continuous use of the bromides. But alcohol and its hypnotic derivatives (chloral, paraldehyde, etc.) not only calm the excitable brain, but they also furnish to the tissues a certain amount of diffusible nutriment which suffices to steady the brain until a change of occupation, with rest and wholesome food, can produce a complete restoration of its normal stability. To this effect of alcohol must be ascribed its value as an hypnotic in the wakefulness of old people who cannot sleep without a preliminary nightcap. A moderate draught of hot toddy in such cases serves to arouse the feeble heart and to equalize the circulation by the production of a moderate degree of general vascular dilatation. The sugar and water afford an easily assimilated food, while the alcohol benumbs the cortical protoplasm to a degree which favors the cessation of conscious perception. If administered in excessive doses, it is not sleep but anæsthetic intoxication {382} which follows. If this condition be unduly repeated, the phenomena of chronic alcoholism supervene, with all the horrible forms of insomnia that accompany cerebral starvation and delirium tremens. Non-alcoholic nerve-stimulants and tonics, with careful administration of easily-digested food, are then more than ever needed to overcome the neurasthenic wakefulness.

Insomnia from Active Cerebral Congestion.

Still another form of sleeplessness is often experienced as a result of actual inflammation in some portion of the body, either involving the intracranial contents directly or reacting upon the brain through the medium of its circulation. In such cases many of the symptoms of acute inflammation are present. The head aches, the temples throb, the face and eyes are suffused with blood, the temperature is considerably increased. The senses become exalted, ideas pursue a tumultuous course, there may be actual delirium. These disturbances are due to an active hyperæmia of the brain. The substance of the cortex becomes hyperexcitable, and the ordinary incitements of sense produce an exaggerated effect in consciousness. The patient does not sleep, and he feels no need of sleep, because the nutrition of the brain is sustained at the expense of the remainder of the wasting body. The most speedy and effectual relief in such cases is obtained through a diminution of the current of blood in the brain. Moderate compression of the carotid arteries has been proposed as theoretically useful. Sedatives, like aconite, conium, digitalis, veratrum viride, ipecacuanha, and tartar emetic are useful, either alone if pain be absent or combined with opiates if the patient is suffering. Dover's powder or tartar emetic and morphia in small doses was formerly in general use. If there be a disposition to nausea the substitution of aconite for antimony is of great value. A combination of morphia, bromide of potassium, and chloral hydrate often gives excellent results. Paraldehyde may be preferable to chloral by reason of its more thoroughly sedative effect. Derivative measures—mercurial cathartics, cupping, leeching, or even general bleeding—may become necessary in certain cases. After the acute stage is passed blisters behind the ears should be employed. In the sleeplessness of acute mania Newington[28] has used mustard baths with great satisfaction.

[Footnote 28: _Brain_, vol. i. p. 126.]

Coma.

Turning now to the other extreme, we find a class of cases in which the disorder consists not in wakefulness, but in an excess of sleep. Excluding those exceptional cases in which healthy individuals, as a consequence of inordinate physical exertion, have slept for many hours beyond their ordinary limit, every extraordinary manifestation of sleep-like unconsciousness must partake of the nature of coma. Between natural sleep and this condition may be placed the distinction that the one is always the effect of natural physiological processes, while the other is always the result of injury, of disease, or of some form of intoxication. Comatose {383} unconsciousness may be the result of cerebral compression caused by traumatic impact or by the presence of inflammatory exudations. Intracranial tumors, embolisms, thrombi, degeneration of tissue, diseases of the arteries of the brain—in short, every morbid change of which the liquids and the solids within the cranium are capable—may become the causes of coma. So also the blood and lymph, contaminated with the products of internal disintegration, may benumb the brain with comatose sleep. Again, the tissues of the brain may be overwhelmed with poisons introduced from without the body, and thus a condition of coma may result. Few diseases, therefore, exist without the possibility of coma as one of their consequences—a coma which, however, must not be confounded with the genuine sleep which sometimes occupies the larger part of certain stages of convalescence from acute illness. During such convalescence there is a reversion to the infantile type of nutrition, with all its need of prolonged and frequent periods of repose. Like normal sleep, the comatose condition admits of considerable variation of intensity. The patient may sometimes be partially roused, as from the coma of alcoholic intoxication, and he may finally recover complete consciousness, but very often the reverse is the fact. The coma deepens into paralysis, and death terminates the scene without the slightest manifestation of sensibility or intelligence.

Sleeping Dropsy (Maladie du Sommeil).

A singular disorder, characterized by daily paroxysms of somnolence, tending to become more and more continuous and profound until merged in fatal coma, is encountered among the negro inhabitants of the Atlantic coast of tropical Africa. Similar cases have been occasionally reported in other regions of the world, but it is among the Africans that they have been principally observed. For our knowledge of this disease we are chiefly indebted to the writings of Clark,[29] an English surgeon residing at Sierra Leone, and of Guérin,[30] a surgeon in the French navy, who enjoyed unusual opportunities for its study among the laborers recently brought from Africa to the island of Martinique. According to these observers, the onset of the malady is gradual, commencing with a slight frontal headache. Very soon a disposition to sleep after meals is remarked. This becomes increasingly urgent, and the paroxysms of sleep are prolonged, until at length the patient becomes continually soperose. The wakeful intervals are marked by a sluggish state of the intellectual faculties. The pulse is not accelerated, but remains full and soft. The veins of the sclerotic become turgid and the eyeball seems unusually prominent. The temperature does not increase, but rather tends to diminish its figure. The skin becomes dry and moderately cool. The tongue continues moist, and is covered with a white fur. The contents of the bowels and of the bladder are regularly voided, and the appetite persists with considerable vigor. Finally, the patient becomes completely comatose and dies quietly. Sometimes, however, the evolution of the disease is less tranquil. Epileptiform convulsions, followed by {384} progressively deepening paroxysms of coma, interrupt its course, until a continuous muscular tremor marks the closing period. At the same time the pulse grows weaker and more frequent, until its movements cease in death. Recovery is almost unknown, though the duration of the disease often varies from three months to a year or longer. Examination of the body after death has thus far yielded very negative results: the sinuses and larger vessels of the brain are engorged with blood, but no evidence of inflammation is anywhere apparent. The other organs present no pathological alterations whatever. These observations seem to indicate that the disease originates in some form of general blood-poisoning rather than in any local inflammation or degeneration, and Clark has called attention to an enlargement of the cervical glands as a feature of the malady. According to G. H. Bachelder,[31] the native physicians cure the disease by extirpation of the affected glands. He has also observed an initial lesion in the nasal mucous membrane. If this be confirmed, the malady will take its place among the forms of coma produced by septic poisoning.

[Footnote 29: _Transactions of the London Epidemiological Society_, vol. i. p. 116.]

[Footnote 30: _De la Maladies du Sommeil_, 1869.]

[Footnote 31: _The Medical Record_, July 1, 1882, p. 23.]

Lethargy.

A pathological variety of sleep, in which the repose of the body is even more complete than in coma. The victim of coma often presents a countenance suffused with blood; the pulse beats vigorously, and respiration may become stertorous. But in lethargy the abolition of bodily movements is almost total. In the milder forms of this disorder the patient may be partially roused, so as to attempt an answer when addressed, appearing like a person in very profound sleep; but in the majority of cases he remains insensible, unconscious, and utterly irresponsive to ordinary forms of irritation. Respiration and circulation are reduced to a minimum, even becoming for a time imperceptible. Uncomplicated with hysteria, the disorder is rapidly fatal, but according to Rosenthal[32] hysterical lethargy is never mortal.

[Footnote 32: _Real Encyc. der ges. Heilkunde_, vol. viii. p. 276.]

Many examples of this disorder have been furnished by the records of apparent death.[33] I am well acquainted with a lady who in early childhood was laid out for burial at the supposed termination of some infantile disease. Her mother alone insisted that the child was still alive. After some time spent in weeping and expostulation, she applied a blister to the thorax of the babe, who at length began to exhibit signs of consequent irritation, followed by a complete recovery. Still more instructive is the case related by Rosenthal[34] of a young woman twenty-four years of age who in consequence of violent emotional excitement became unconscious and presented no sign of life, though tested with a mirror before the mouth and by dropping melted sealing-wax upon the skin. On raising her eyelids the pupils gave no response to light; the limbs remained perfectly placid and the radial arteries were motionless. Careful auscultation, however, detected a very feeble and intermittent sound in the cardiac region. The thorax exhibited no movement, but the lateral surfaces of {385} the abdomen presented a slow and almost imperceptible oscillation. Gentle faradization of the muscles and nerves of the face and hand aroused definite muscular contractions. By these observations Rosenthal became satisfied that, although the patient had remained for thirty-two hours in this condition, she was only apparently dead. In fact, after continuing forty-four hours in a state of suspended animation she awoke spontaneously, made a rapid recovery, and enjoyed as tolerable health as an excitable nervous temperament would permit.

[Footnote 33: See article “Mort apparente,” _Dic. Encyc. Sci. méd._, 2d Series, vol. ix. p. 598.]

[Footnote 34: _Loc. cit._, p. 272.]

Apparent Death.

Certain authors make a distinction between lethargy and apparent death. But, leaving out of view the cases of so-called lucid lethargy, a variety of the trance state, the difference is rather one of degree than of kind. The movements of respiration and of circulation, though greatly diminished, are readily observed in ordinary forms of lethargy, while in apparent death the pulse can no longer be discovered, and only the faintest sound can be distinguished in the region of the heart. It therefore becomes imperative to have within reach a crucial test of the persistence of general vitality. Such a test, according to Rosenthal, exists in the faradic current. Within two or three hours after genuine death the muscles cease to be excitable by the induced current, but in a case of apparent death this form of electro-muscular contractility never disappears. Every other test that has been proposed has failed under certain circumstances. This alone gives uniformly positive indications.

Lucid Lethargy.

In certain cases of apparent death the patient presents the external phenomena of suspended animation, but the power of conscious perception does not cease. The senses of sight and hearing remain, and are perhaps intensified by inhibition of the power of projecting cerebral volitions into space. The sufferer hears and sees; perception, memory, reasoning, judgment, emotion, volition, all persist. The possibility of centrifugal projection from the sphere of consciousness into the realm of space seems to be the only thing that is wanting.

The victims of this form of apparent death are usually women, or men who are characterized by a feminine nervous organization. Great mental excitement, fatigue, semi-starvation, and exhausting diseases are the principal proximate causes of the event. The following case, which was observed by my friend P. S. Hayes of Chicago, illustrates all these facts: A female physician, about thirty years of age and consumptively inclined, after a long and wearisome hospital service was attacked with typhoid fever. After a period of great prostration the hour of death seemed to have arrived. In the presence of her physician and surrounded by her relatives she ceased to breathe and the pulse stopped. Bottles of hot water were applied to the limbs, and other methods of restoration were employed, but a number of hours elapsed before these efforts yielded any result. At last she began to breathe once more; life was resumed and {386} a gradual recovery followed. During all this time of apparent death consciousness had been preserved. She seemed to be looking down from above her bed, by the side of which she could see the physician holding her wrist, and she felt grief at witnessing the sorrow of her friends. Ordinary sensation was suspended, for she did not feel the scalding heat of the bottles that were applied to her limbs. Borne upon the wings of a liberated imagination, she thought she beheld the celestial city, but might not enter within its gates. In this exaltation the reasoning faculties also shared, so that certain philosophical problems which had long baffled her intellect were now perfectly comprehensible, and the memory of their interpretation persisted after recovery.

Many similar narratives have been duly authenticated, but the limits of the present article will not permit a discussion which properly belongs to an investigation of the phenomena of trance. The important fact for present consideration is the persistence of conscious life despite the appearance of death. In this preservation of consciousness, notwithstanding temporary suspension of certain forms of sensibility, together with loss of the power of voluntary motion, may be discovered a relationship between the events of lucid lethargy and various somnambulic modifications of sleep which have been previously passed in review.

{387}

ACUTE AFFECTIONS PRODUCED BY EXPOSURE TO HEAT.

BY H. C. WOOD, M.D., LL.D.

There are two distinct diseases—or, more correctly, conditions—of the human body which are produced by exposure to heat, and which have a certain similarity in their symptoms, but are very different in their immediate pathology and require directly opposite methods of treatment. Although their individuality was pointed out as long ago as 1851 by the late D. F. Condie of this city,[1] yet they have been frequently confounded by writers upon the subject, and the terms heat-exhaustion and sunstroke have not rarely been used as strictly synonymous. In the present article it is proposed to consider them as separate affections under the respective names of heat-exhaustion and thermic fever.

[Footnote 1: _Amer. Journ. Med. Sci._, Jan., 1852.]

Heat-Exhaustion.