Sleep and Its Derangements

by William A. Hammond

Under this head are embraced those cases of sleeplessness due to exalted sensibility of the nervous system. They are chiefly met with in persons of feeble constitution. The slightest impression made upon the skin, or any other organ of sense, is converted into a sensation out of all proportion to the exciting cause. There is thus a condition of general hyperæsthesia which greatly tends to the prevention of sound and refreshing sleep. The following case illustrates very well the phenomena of the state in question:

Case IX.—A lady recently came under my care for extreme wakefulness, the result, as she correctly supposed, of debility. During the month of August she had resided in a malarious region, and had had a series of attacks of intermittent fever before she would consent to take quinine for its cure. By the time the disease was conquered she had become very much reduced, and her constitution had received a shock from which it will probably not recover for several years. I saw her for the first time on the 26th of September, and she was then so feeble that she was unable to be out of her bed for more than an hour or two each day. Her nervous system was in an exceedingly irritable condition, the least noise startled her, she was unable to bear the full light of day, and so sensitive was her skin, that the light clothes she wore caused her the greatest uneasiness. She informed me that she had scarcely slept for seventeen days and nights, and though I received this statement with some grains of allowance, I was very sure, from her general appearance, that she was suffering from insomnia. At night the feeling of general discomfort was greatly increased, the weight of the bedclothes was insupportable, and she passed the hours tossing restlessly on her bed or in walking the floor. By morning she was feverish, irritable, and thoroughly exhausted. A cup of coffee and a little buttered toast constituted her breakfast, after which she felt somewhat revived.

Conceiving that all the symptoms were referable to debility and passive cerebral congestion, I advised nutritious food, tonics, stimulants, exercise in the open air, the warm bath, cold water to the head, and the avoidance of the recumbent posture. Amendment began almost immediately, and by the end of a week the hyperæsthesia had disappeared, and she slept soundly and sufficiently.

In reference to this form of wakefulness, Dr. Handfield Jones[139] makes some judicious observations. He says: “A girl recently under my care with very various and marked signs of prostration of nerve-power, suffered for many months with exceedingly restless nights, the cause of which appeared to be chiefly great hyperæsthesia. Although she improved materially in other respects, she did not sleep well until she was removed from London to a healthy part of the country. I have had several patients, two especially, both temperate males, who for a length of time were quite dependent for good rest at night on wine taken either on going to bed or in the course of the night. * * * It is not easy to form a precise idea of the state of the nervous centers in which a ‘nightcap,’ as above mentioned, is so effectual in procuring sleep. Debility is certainly one marked pattern of it, but there must be surely another, even more important, as the most profound debility does not, by any means, always interfere with sound sleep, nay, rather seems to conditionate it. This other element, we are much disposed to think, is hyperæsthesia, or irritability, which, as already noticed, commonly increases pari passu with weakness. The condition may be compared with that of neuralgia, when it is beginning to give way under treatment, and is so readily reproduced by anything which causes exhaustion. Now, as the stimulant recruits the exhausted nerve force, the hyperæsthesia ceases, and the brain tissue subsides into a state of calm repose. It may be added here that it is often well to give not only a stimulant, but also some digestible nourishment about the time of going to rest, or even in the course of the night when debility to a serious extent exists. It is quite certain that a craving empty stomach is by no means favorable to quiet slumber, and in this point of view moderate suppers are far from being unsuitable to many invalids. I well remember the case of a lady who, the night after a natural confinement, woke up with severe gastric disorder and flatulence, which resisted various medications, but subsided immediately after a plate of cold meat and some brandy and water. Among the various soporifics, I doubt if there be any more potent, especially for the weakly and hyperæsthetic, than prolonged exposure to the cold open air. This should be so managed as not to cause great fatigue, and if well timed and followed by a sufficient meal, it will be found an admirable preparation for sound nightly slumber.”

In the foregoing remarks it is perceived that Dr. Jones fails to recognize the state of passive congestion of the brain which in cases such as he describes, and in many similar ones which have come under my care, is almost invariably present. It is this feature which, in addition to the debility, gives so marked a character to the species of insomnia under consideration. The hyperæsthesia, like the wakefulness, is merely a result of the cerebral hyperæmia.

Several cases of insomnia, the result of disordered menstruation, have come under my observation. We can very well understand how, in women suffering from suppression of this function, a slight degree of cerebral hyperæmia and consequent wakefulness should result. About the climacteric time of life, when irregularities in the menstrual flow are very common, there is quite generally extreme sleeplessness as each period approaches, which is not ordinarily relieved till the catamenia make their appearance. In such cases measures directed to the relief of the existent congestion of the brain will generally prove effectual in causing natural sleep.

Irregular or deficient action of the heart and blood-vessels is a frequent cause of wakefulness. One of the principal results of such disordered action of the circulatory organs is coldness of the extremities, and an attendant condition of repletion of the central vessels. As a consequence there is in these cases almost invariably great wakefulness. As Dr. Cheyne[140] has remarked, many a delicate female, from going to bed with cold feet, is deprived of hours of sleep in the early part of the night, and thereby falls into nervous complaints, obstinate dyspepsia, and uterine irregularity, who might have escaped had the circulation of the surface of the body been properly sustained.

There are cases, however, of habitual cold feet, accompanied by wakefulness, which are not so much due to deficient power in the heart as to disordered nervous action. But, whatever the cause, there is always, while the condition exists, an excessive amount of blood in the cranial vessels. An instance of the kind came under my observation several years ago in the person of an army officer, of strong constitution and otherwise of good health. Heat applied to the extremities gave only temporary relief, and stimulants taken internally were equally inefficacious. He was finally entirely cured by the repeated passage of the direct galvanic current through the sciatic and crural nerves and their branches.

Indigestion is quite a common cause of wakefulness, even when no marked disagreeable sensations are experienced in the digestive organs. A full meal, especially if it be of highly seasoned or otherwise improper food, will often keep the offending individual awake the greater part of the night. We know that apoplexy is especially apt to occur soon after the stomach has been overloaded with food. The return of the blood from the head is impeded, and the rupture of an intercranial vessel, or an effusion of serum, is the result of the cerebral congestion. Insomnia is a milder effect of the same cause.

There are several other abnormal conditions of the system in which wakefulness plays an important part, but their consideration would lead us into the discussion of the phenomena of many diseases of which it is simply a symptom, or of secondary consequence. The remarks which have been made in regard to it have reference to its existence as an evidence of slight cerebral congestion, and therefore as being of sufficient importance to demand the aid of both physician and patient in effecting its cure.