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. Homœopathy 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.