ROYAL MEDICAL AND CHIRURGICAL SOCIETY

1851 The Lancet  
THE author began by observing, that although very interesting observations on the subject would be found scattered through medical writings, it had not hitherto received any thing approaching the attention which it merited. There were a variety of cases in which spasmodic movements were well known to be wont to surprise the sleeper, as might be proved by epilepsy, laryngismus stridulus, tetanus, asthma, cramp, the muscular coatractions provoked by fractures, the startings, more or less severe
more » ... re or less severe and general, which almost every one must i have experienced on falling into slumber, &c. Epilepsy would ensuejust before, during, or immediately after sleep; sometimes it was quite restricted to that period, and in so remarkable a manner, that sleep and epilepsy might, in such a case, be held to be related as cause and effect. A broad distinction was to be made between the epilepsy of imperfect and perfect sleep; the former was, most probably, oftentimes owing to troubled dreams; whereas the latter was generally, if not always, referrible to physical irritation, centric or eccentric. The sleep, too, which followed this appalling affection, should be industriously watched, as it was very likely to merge into a coma, wherein other convulsions would occur. The author then spoke of the spasmodic actions which took place, or could be excited, in paralytic limbs during the time of slumber; this division of the subject, whereof the contribution contained some illustrations, had, though very instructive, been almost entirely neglected. The author, after mentioning some indications of treatment, passed on to the consideration of the causes of the convulsions, direct or predisposing, which happened during slumber. They might be chiefly comprised under the four heads of-1. The state of the circulation and respiration. 2. The condition of the motor-force and muscular irritability. 3. The emotion of dreaming. 4. The withdrawal of the will. The author entered largely into the two latter topics. Dreaming had a very ample, and not seldom unsuspected, connexion with the event of convulsions. There was the horror of the dream, which was sometimes most intense, and there was the impression also which remained; and agitation of mind was surely never likely to be more hurtful than when the brain was congested, the irritability replenished, the passions ungoverned, the respiration unmodified, volition at rest. The causes of dreaming had a most wide, though in great part indirect relation to those of convulsions. Of this the paper contained illustrations. Great stress was laid on the withdrawal of the will. The fact had been abundantly and variedly proved that, cceleris paribus, reflex movements, and also involuntary movements not reflex, were occasioned with a facility that was inverse to the power of volition; but it was one, how glaringly important soever, which had by no means been duly and fully applied to the solution of the nature of certain convulsions which surprised in sleep. This was it that would furnish the key of explanation to very many of them. The author then drew the attention of the Society to some observations made by him on sleeping children; to some ingenious remarks by Professor Volkmann, which tended to support his own conclusions; to some experiments of Dr. Marshall Hall; and some others which he himself had recently made on hybernant animals; and to various phenomena to be witnessed in man, animals, and insects, which, however unlike in some respects, uniformly and emphatically concurred to show how often and how extremely a quiescent will tended to the production of spasmodic affections. Some convulsive affections of the sleeper and waker often contrasted greatly in this; in the first there could be no opposition from volition, no effort to subdue them; in the second there was, not rarely, an evident, and sometimes a successful, striving of the will. The author, availing himself of an expression to be found in the " Novum Organum," proposed to call those instances, wherein there was a manifest contention between causes of action, "wrestling instances." The withdrawal of the will had an indirect relation to the convulsions of sleep, from being the cause of dreaming, the emotion of which was more perilous, speaking generally, than that of the waking state, on account of its being free from antagonism, for the dreamer was unable to reason on* his delusion and so dispel it. The author dwelt finally on those convulsive affections which were benignly influenced by sleep, their temporary cure, and so contrasted as much as possible with those he had already discussed. The convulsive affections might be separated, as to kind, by a broad line of demarcation drawn between them by sleep. How often did it happen, in perplexing instances, that the influence of sleep directed the diagnosis ! Emotion took much part in all those convulsive affections which were wont to subside when the mind was at rest. The reason of their being thus potently affected was easily readable in their history. The author instanced certain motor local nervous affections, paralysis agitans, mercurial erethism, and chorea, as being wonderfully under the sway of slumber, and concluded that some convulsive motions which had been observed in these diseases during the sleeping period, were owing to mental agitation, and formed no exception to that general law whereby the tranquillizing effects of sleep upon them were so correctly expressed. A considerable portion of the paper was, owing to its extent, left necessarily unread. Dr. MAYO said the very clever paper which they had just heard related to a subject so full of interesting topics, that it tempted the author into a descriptive rather than an inductive consideration of them. In the latter part of it he had in some degree obviated a tendency to undervalue the blessings of sleep which was observable in the first part. There was no doubt that in certain states of certain disorders, sleep led to evil, not by producing it, so much as by preventing efforts which would obviate it; as in the accumulation of mucus, and the dryness of the fauces in bronchitis, and the accidents that in his (Dr. Mayo's) own experience had happened to the epileptic for want of assistance under paroxysms during sleep. In regard to the accumulation of power under s!eep, which the author seemed to consider unfavourable to spasmodic disease, he would call his attention to the fact, that such disorders were, in great measure, instances of the presence of action without power; and that sleep as a restoring power, should have a beneficial tendency in regard to them, according to his own reasoning have overlooked the fact, that in insanity, another disease of that kind, the absence of sleep for four or five days and nights is ordinarily fatal. Dr. WEBSTER coincided in opinion with Dr. Mayo respecting the great utility of sleep in the amelioration of insanity; it was always of the highest importance in attacks of that malady. The same result was equally advantageous in delirium tremens, as every practitioner knew; indeed, to produce balmy sleep was most essential in its management. Dr. Webster, however, dissented from the doctrine now laid down that a case of mania would end in death, if the patient did not sleep during two or three days consecutively. This was contrary to his own experience; and as any observation on such subjects by Dr. Mayo would carry much weight, he trusted there was some misunderstanding upon the point, and would therefore wish to be set right if labouring und'er any mistake in regard to the remark made by that gentleman. Dr. MAYO explained that he meant entire absence of sleep during the period mentioned; a very small modicum might be sufficient to act somewhat as a restorative. Dr. J. A. WILSON said that the paper was suggestive in the highest degree, but he could not help regretting what appeared to him to be an omission in it; the author had attended too exclusively to the nervous influence and the mechanical state of the vessels, instead of inquiring into the contents of the vessels. He had considered that congestion was the cause of sleep; but he (Dr. Wilson) thought the red face, fiery eyes, and other symptoms of congestion, were suggestive of anything but sleep. His own (Dr. Wilson's) opinion was more in favour of anaemia being the cause of sleep; and he particularly well recollected the case of a man in St. George's Hospital, who was so thin that he was almost a living skeleton; he was the subject of diuresis, making large quantities of limpid water, twelve, fourteen, and sixteen pints daily, of the specific gravity of 10020. This man eventually died of phthisis, and he was always asleep. Dr. Wilson then referred at some length to a paper which he had published upwards of twenty years since, in which he suggested that the periodicity of sleep might possibly have to do with the large quantity of carbonic acid gas which was periodically accumulated in the system, and he referred to suicide by the inhalation of carbonic acid gas, as practised by the French; and more particularly to the narrative of a Frenchman who had fastened himself in a room with a carbonic acid stove, and wrote a history of his sensations as long as consciousness
doi:10.1016/s0140-6736(02)75544-x fatcat:uaimuf6o7neencqmaxqbmnxj4i