Sleep and Its Derangements

by William A. Hammond

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.