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diff --git a/77326-h/77326-h.htm b/77326-h/77326-h.htm new file mode 100644 index 0000000..9a311c0 --- /dev/null +++ b/77326-h/77326-h.htm @@ -0,0 +1,1923 @@ +<!DOCTYPE html> +<html lang="en"> +<head> + <meta charset="UTF-8"> + <meta name="viewport" content="width=device-width, initial-scale=1"> + <title> + Insomnia: its causes and cure | Project Gutenberg + </title> + <link rel="icon" href="images/cover.jpg" type="image/x-cover"> + <style> + +body { + margin-left: 10%; + margin-right: 10%; +} + +h1,h2,h3 { + text-align: center; /* all headings centered */ + clear: both; +} + +p { + margin-top: .51em; + text-align: justify; + margin-bottom: .49em; +} + +.p4 {margin-top: 4em;} + +hr { + width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: 33.5%; + margin-right: 33.5%; + clear: both; +} + +hr.tb {width: 45%; margin-left: 27.5%; margin-right: 27.5%;} +hr.chap {width: 65%; margin-left: 17.5%; margin-right: 17.5%;} +@media print { hr.chap {display: none; visibility: hidden;} } + +div.chapter {page-break-before: always;} +h2.nobreak {page-break-before: avoid;} + +table { + margin-left: auto; + margin-right: auto; +} + +.pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: small; + text-align: right; + font-style: normal; + font-weight: normal; + font-variant: normal; + text-indent: 0; +} /* page numbers */ + +blockquote { + margin-top: 0; + margin-bottom: 0; + margin-left: 5%; + margin-right: 10%; +} + +.center {text-align: center;} + +.smcap {font-variant: small-caps;} + +/* Images */ + +img { + max-width: 100%; + height: auto; +} +img.w100 {width: 100%;} + + +.figcenter { + margin: auto; + text-align: center; + page-break-inside: avoid; + max-width: 100%; +} + +/* Transcriber's notes */ +.transnote {background-color: #E6E6FA; + color: black; + font-size:small; + padding:0.5em; + margin-bottom:5em; + font-family:sans-serif, serif; +} + +/* >>+++ START ADDITIONS +++<< */ + +.p1 {margin-top: 1em;} + +h2.nobreak {page-break-before: avoid; padding-top: 0em;} +.nobreak {page-break-before: avoid; padding-top: 0em;} + +/*Table of Contents format*/ +table.toc { max-width: 30em;} +td.tocchapter{ text-align: right; vertical-align: top; padding-right: 1em;} +td.toctitle { text-align: left; vertical-align: top; text-indent: -1.3em; padding-left: 1.3em;} +td.toctitle1 { text-align: left; vertical-align: top; padding-left: 2.5em;} +td.tocpage { text-align: right; vertical-align: bottom; padding-left: 1em;} + +/*CSS to set font sizes*/ +/*font sizes for non-header font changes*/ +.xlargefont{font-size: x-large} +.largefont{font-size: large} +.smallfont{font-size: small} +.italicfont{font-style:italic} + +/* Half-title page */ +.half-title{ + page-break-before: always; + page-break-after: always; + text-align: center; + font-size: x-large; + padding: 6em 0; +} + +/* >>+++ END ADDITIONS +++<< */ + +/* >>+++ START MODIFICATIONS +++<< */ + +/* Footnotes */ +.footnotes {border: dashed 0.05em;} +.footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} +.footnote .label {position: absolute; right: 84%; text-align: right;} +.fnanchor { + vertical-align: top; + font-size: .66em; + text-decoration: none; +} + +/* >>+++ END MODIFICATIONS +++<< */ + +/* Illustration classes */ +.illowp50 {width: 50%;} +.x-ebookmaker .illowp50 {width: 100%;} +.illowp47 {width: 47%;} +.x-ebookmaker .illowp47 {width: 100%;} + </style> +</head> +<body> +<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 77326 ***</div> + + +<figure class="figcenter illowp50" style="max-width: 107.5em;"> + <img class="w100" src="images/cover.jpg" alt="Cover."> +</figure> + +<p class="half-title"> +INSOMNIA: ITS CAUSES AND CURE. +</p> + +<figure class="figcenter illowp47" style="max-width: 40.625em;"> + <img class="w100" src="images/title.jpg" alt="Title page."> +</figure> + + +<hr class="chap x-ebookmaker-drop"> +<div class="chapter"> + <h1 class="nobreak" style="line-height:1.5"> + INSOMNIA:<br> + <span class="xlargefont">ITS CAUSES AND CURE.</span> + </h1> +</div> + + +<p class="center p4"><span class="smallfont">BY</span><br> +<span class="xlargefont" style="line-height:2">JAMES SAWYER,</span><br> +<span class="smallfont">SENIOR CONSULTING PHYSICIAN TO THE QUEEN’S<br> +HOSPITAL, BIRMINGHAM.</span></p> + +<p class="center p4 largefont" style="line-height:1.5"><span class="italicfont">Birmingham:</span><br> +<span style="letter-spacing:0.2em">CORNISH BROS</span>.,<br> +1904.</p> + + +<hr class="chap x-ebookmaker-drop"> +<div class="chapter"> + <h2 class="nobreak"> + PREFACE. + </h2> +</div> + + +<p>The following pages are the first two of the chapters +of “Contributions to Practical Medicine,” as they +stand in the fourth edition, 1904, of that book. They +include my lectures on the causes and treatment of +insomnia, in the necessarily colloquial style in which +they were uttered. For the convenience of my professional +brethren, these chapters now are offered to +them in a separate form in this little book. Every +word has been revised and many additions have been +made, by the fruits of later experience, for the sake +of clearness, completeness, and precision; this has been +done with hope of usefulness in medical practice, and +with the aim of accuracy in diagnosis and success in +therapeutics.</p> + +<p><span class="smcap p1">31, Temple Row,<br> +<span style="padding-left:3em">Birmingham, 1904.</span></span></p> + + +<hr class="chap x-ebookmaker-drop"> +<div class="chapter"> + <h2 class="nobreak"> + CONTENTS. + </h2> +</div> + + +<div class="center"> +<table class="toc" style="border:0em; padding:0em; border-spacing:0em"> +<tr><td class="tocchapter"></td><td class="tocpage"><span class="smallfont">PAGE</span></td></tr> + +<tr><td class="toctitle">I. <span class="smcap">The Causes of Insomnia.</span></td><td class="tocpage"></td></tr> + +<tr><td class="toctitle1">The appetite of sleep.—The physiology of sleep.—Etiology +of insomnia.—Symptoms of insomnia.—Intrinsic +insomnia.—Varieties of intrinsic +insomnia.—Psychic insomnia.—Emotional +shock and prolonged mental strain as causes +of insomnia.—The nervous temperament.—Symptoms +of intrinsic insomnia.—Toxic +insomnia.—Insomnia from tobacco.—Alcoholic +insomnia.—Insomnia from tea or from coffee.—Gouty +insomnia.—Senile insomnia.</td><td class="tocpage"><a href="#I">9</a></td></tr> + + +<tr><td class="toctitle">II. <span class="smcap">The Cure of Insomnia.</span></td><td class="tocpage"></td></tr> + +<tr><td class="toctitle1">No “rule of thumb” cure.—Hypnotic drugs.—Risks +from hypnotics.—Causal treatment.—Bromide +of potassium.—Cure of anæmia.—Alcohol.—Carminatives.—Adjuvant +remedies.—Popular +remedies.—Rhythmic sleep.—Physical exercise.—Sunshine.—Monotonous +impressions.—Bedclothes.—Ventilation.—Food.—Cold.—Toxic +insomnia.—Senile insomnia.</td><td class="tocpage"><a href="#II">47</a></td></tr> +</table></div> + + +<hr class="chap x-ebookmaker-drop"> +<div class="chapter"> + <h2 class="nobreak" id="I"> + I.<br> + THE CAUSES OF INSOMNIA.⁠<a id="FNanchor_1_1" href="#Footnote_1_1" class="fnanchor">[1]</a> + </h2> +</div> + + +<blockquote> +<p><em>The appetite of sleep.—The Physiology of sleep.—Etiology +of insomnia.—Symptomatic insomnia.—Intrinsic +insomnia.—Varieties of +intrinsic insomnia.—Psychic insomnia.—Emotional +shock and prolonged mental +strain as causes of insomnia.—The nervous +temperament.—Symptoms of intrinsic insomnia.—Toxic +insomnia.—Insomnia from +tobacco.—Alcoholic insomnia.—Insomnia from +tea or from coffee.—Gouty insomnia.—Senile +insomnia.</em></p> +</blockquote> + +<p>The important subject of insomnia has engaged +my attention for a long time. In 1878 I delivered +a clinical lecture on the causes and cure +of insomnia to the students of the Birmingham +Medical School, in the Queen’s Hospital, and +the matter of this discourse was afterwards +<span class="pagenum">[10]</span>further published in <cite>The Lancet</cite>, on June 15th +and 22nd of that year. This lecture I revised +and rewrote entirely afterwards, embodying +in it some additions from my later experience +in practice, and, so enlarged, it was included +in each of the two editions, of 1886 and 1891, +of my “Contributions to Practical Medicine.” +In the autumn of the year 1900, I reviewed the +subject again in two clinical lectures which I +gave at my hospital, and these were issued in +print in <cite>The British Medical Journal</cite>, on +December 1st and 8th, 1900. These last lectures, +in which I have tried to bring their subject up +to a point at least abreast of our latest knowledge +in the principles and practice of medicine, +I have revised and rewritten; and I have +amplified them, especially in their therapeutic +parts. So rewrought, they form the contents +of the following essay. This work, done as +to the causes and cure of insomnia, that is, +done as to particular diagnostic and therapeutic +efforts in which the skill of the physician and +the resources of our art are often taxed severely, +in the intricacies of a difficult, delicate, and +abstruse subject, I have tried to accomplish in +the spirit of the Baconian philosophy, in the +spirit of that aphorism of Bacon which Sydenham +prefixed to his renowned “Tractatus de +<span class="pagenum">[11]</span>Podagra et Hydrope,” namely, “Non fingendum +aut excogitandum, sed inveniendum, +quid Natura faciat, aut ferat.” The result of +my pleasant labours I venture now to offer +to the judgment of my profession. My lectures +on insomnia were delivered for the instruction +of medical students in my clinical class; they +are further published in these pages in the hope +that they may help my medical readers in +practice. In view of the conditions of the +original delivery of these utterances, I have +decided, in revising them, to preserve their +colloquial style. Furthermore, in preparation +for this present publication of these lectures, +(1904,) I have revised them again, and made +some additions to the therapeutics of my +subject.</p> + +<p>Sleep is a function of life, and life, in +some sense, may be said to be a function +of sleep, in man, in the animals which are a +little lower than he is, in some sort in plants, +in everything which lives. The living organism +which cannot sleep cannot live. For all beings +endowed with the crowning mercy of consciousness +sleep is a pleasure as well as an appetite, +and it is a necessity as well as both. For +these conscious beings, strung as they are in +their sentience to the most exquisite responses +<span class="pagenum">[12]</span>in the world’s vast chorus of living harmonies, +sleep is indeed and in truth “tired nature’s +sweet restorer.” For man, at the head of such +beings, and perhaps the only of them which +knows the cark of a mind’s unrepose, or the +wear of “that unrest which men miscall delight,” +sleep it is indeed which smoothes out +life’s fretting creases and “knits up the ravelled +sleeve of care.” That you may become practitioners +of medicine you are students in this +place of the manifold sciences of medicine in +some of their chief practical bearings, mingled +with the inexorable simplicities and with the +endless intricacies of the art of healing. You +are clinical students here of that cherished art +of ours, an art which is of men philanthropic +and of time perennial, as its lovely figure stands +revealed in all its subtle and splendid details, +firm and broad based upon the blended foundations +of its great constituent sciences. You are +students in this hospital I love of that great art +of ours in clinical medicine, in its concrete +application to individual cases of human suffering, +no two of them indeed ever quite identical, +no more than are identical a tree’s waving +leaves or the billows of the rolling sea. Let us +press forward together, in all the absorbing zest +of the pursuit which is ours, to the brightest +<span class="pagenum">[13]</span>understanding which yet there may be of the +intimate nature of sleep. Let us collect, discriminate +and sort the causes which make for +insomnia. Let us sift and sum up all which our +sciences and our art, our experience, and even +our empiricism, of which last I am not ashamed, +have of tried adoption for its cure. In this +work your physiological training, your clinical +insight, your utilitarian aim, and even your +poetic fancy and your literary culture, may all +find coördinated play, in the comprehension +and in the verbal depiction of functions and +maladies which are intricate with our lives, +associate with our highest attributes, and woven +in woof and warp into the very texture of all +our pains and of all our pleasures.</p> + +<p>Favoured by your kind attention, I purpose +to offer you some considerations upon the vital +function of sleep, and upon the conditions, +causes, and cure of insomnia, based upon a +somewhat long and successful experience of +those subjects in practice, as a physician. These +subjects are certainly of first-rate importance +in relation to our knowledge of the science and +our practice of the art of medicine. Possibly +you may scarcely be able to appreciate their +relative importance while you are, as yet, only +hospital students. Later in your careers, when +<span class="pagenum">[14]</span>you become engaged in actual practice among +the sick, and especially when you take part in +what is called private practice, often will you +be confronted by the perplexities of insomnia, +and often will your pleasant duty lie in successfully +unravelling the causes of sleeplessness, +on that soundest principle of causation and of +therapeutics, <i lang="la">cessante causâ cessat et effectus</i>, and in +curing insomnia by counteracting those causes, +and by making their tiresome and diresome +effects to cease. I hope to be able to show you +that in such happy results the science and the +art of the physician may play a successful part. +Like thirst and like hunger, sleep is an appetite. +We may define an appetite, in the words +of the philosopher Bain, to be a craving produced +by the recurring wants and necessities +of our bodily or organic life.⁠<a id="FNanchor_2_2" href="#Footnote_2_2" class="fnanchor">[2]</a> An appetite, +strictly so-called, has two characteristic marks, +and these marks are strikingly characteristic of +sleep; these marks are two conditions which are +true to sleep—namely, its periodic recurrence +and its organic necessity. We know that the +natural course of a human life brings on sleep +without the volition of the individual willing +the event. The true character of sleep as a +<span class="pagenum">[15]</span>veritable appetite appears when it is resisted. +Under such resistance the individual person +experiences what is called, in metaphysical +parlance, a “massive” form of uneasiness, +discomfort, and pain. The will of the individual, +in the presence of this uneasiness, is +energetically urged to remove such discomfort +and unrest, and is urged from pain towards +pleasure, is urged to obtain the gratification +of relief in what Bain called “the corresponding +voluminous pleasure of falling asleep.”⁠<a id="FNanchor_3_3" href="#Footnote_3_3" class="fnanchor">[3]</a> In +this imperatively urgent volitional impulse is +the appetite of sleep. Sleep is a desire; with +the further characteristics of its organic necessity, +and its periodic recurrence, it ranks as +one of our appetites.</p> + +<p>The intimate physiology of sleep is a difficult +subject, and the difficulties of its explanations +have been the topics of much controversy, and +such controversy appears to have issued from +various combinations of the teachings of observation, +of experiment, and of analogical and +other reasoning, upon the phenomena of sleep. +I do not propose to follow at length the details +of this part of our subject. As a clinical teacher +I must not overload your memories, but rather +<span class="pagenum">[16]</span>must I try to make easy your mental digestion. +For our practical purposes I think we may +understand that two distinct, but associated +and related, vital changes occur in sleep. The +one is some intrinsic change in those ultimate +tissue elements of the brain which are concerned +in consciousness; the other and +“coarser” change is a diminished supply of +blood to the brain, and especially to the blood +vessels of the cortex of that organ. The former +change is at present undemonstrable, excepting +by inferential reasoning. Perhaps there is some +essential and intrinsic change in the brain, and +perhaps there also is some such change in the +spinal cord and ganglionic nervous system, both +of rhythmic occurrence, and both conditions +of healthy sleep. Perhaps there is a functional +depression of these parts in sleep, and especially +of the cerebral cells, arising from “an accumulation +in and around them,” as Sir Thomas +Lauder Brunton puts the matter as to the +cerebral cells in sleep, of some of the products +of normal tissue waste. Perhaps for normal +sleep an intrinsic change of this kind must +gain the wide distribution I have mentioned. +It is likely that there is in sleep a rhythmic +change such as I have indicated, and that this +change is sustained by the physiological effects +<span class="pagenum">[17]</span>of some of the issuants of those tissue changes, +muscular and nervous, which especially occur +in the active waking state of the body.</p> + +<p>Perhaps for our sleep we must drown our +cerebral cells in a kind of auto-intoxication with +the ashes of our waking fires. We may usefully +recall this view of the subject when we use +exercise and fatigue as remedies for insomnia. +The proof of the other broad change in sleep—namely, +diminished blood supply to the brain, +and especially to its cortex, rests on inference +from physiological analogies, on various observations, +and on the solid basis of direct experimental +evidence. We must note, however, that +the human brain, in its perceptive, cogitative, +and volitional functions, in these great divisions +of consciousness, is not the only part +which sleeps. The whole living body sleeps. +The changes which the event of sleep declares +certainly extend beyond mere loss of consciousness; +they extend to secretion, to the action of +the heart and blood vessels in the general +circulation of the blood, to respiration, to +“reflexes,” and so extend to all the tissue +modifications, and to all the other vital activities, +upon which such manifold transitions +depend. In order to complete your precognitions +of the physiology of sleep, before we pass +<span class="pagenum">[18]</span>on to consider the several conditions of +insomnia and their appropriate therapeutics, I +may refer your attention to the admirable +accounts of these subjects to be found in the +text-books of Dr. Augustus Waller⁠<a id="FNanchor_4_4" href="#Footnote_4_4" class="fnanchor">[4]</a> and of Sir +Michael Foster.⁠<a id="FNanchor_5_5" href="#Footnote_5_5" class="fnanchor">[5]</a> From each of these volumes +I offer a brief quotation, which sufficiently +illustrates our subject for my present purpose. +On that part of his subject which is so +important to us from a therapeutical standpoint—namely, +the state of the cerebral circulation +during sleep, Dr. Waller says:</p> + +<p>“Although there is no doubt that in coma—a +pathological state similar in some respects +to physiological sleep—the cerebral vessels are +congested, the observations of Durham on the +exposed cerebrum of sleeping dogs, and of +Jackson on the retinal vessels of sleeping +infants, are to the effect that vessels shrink in +sleep, and we may therefore feel reasonably +assured that the sleeping brain, in common with +other resting organs, receives less blood than in +its state of activity. Moreover, Mosso’s investigations +on exposed human brains afford +<span class="pagenum">[19]</span>evidence that the organ becomes more vascular +during mental activity....”</p> + +<p>That sleep concerns the whole body, and +not the brain alone, is well put by Sir Michael +Foster. He says:</p> + +<p>“Though the phenomena of sleep are largely +confined to the central nervous system, and +especially to the cerebral hemispheres, the +whole body shares in the condition. The pulse +and breathing are slower; the intestine, the +bladder, and other internal muscular mechanisms +are more or less at rest, and the secreting +organs are less active, some apparently being +wholly quiescent; the secretion of mucus +attending a nasal catarrh is largely diminished +during slumber, and the sleeper on waking rubs +his eyes to bring back to his conjunctiva the +needed moisture. The output of carbonic acid, +and the intake of oxygen, especially the former, +is lessened; the urine is less abundant, and the +urea falls. Indeed, the whole metabolism and +the dependent temperature of the body are +lowered; but we cannot say at present how far +these are the indirect results of the condition +of the nervous system, or how far they indicate +a partial slumbering of the several tissues.”</p> + +<p>You may find an interesting and instructive +employment if you follow Sir Michael Foster +<span class="pagenum">[20]</span>through his discussion of the exact state of the +body, and especially of the brain, in sleep. He +points out, what is now generally accepted, that +an alteration of the cerebral circulation is not +the whole of sleep. He judges that “the essence +of the condition is rather to be sought in purely +molecular changes,” and then he goes on to +suggest a resemblance between the systole and +diastole of the heart and the sleeping and +waking of the brain; and then he dwells on the +various periodicities which may be observed in +the activities of the human body, and even +suggests that the fundamental rhythm of the +heart may be a reflection of the mysterious +cycles of the universe, while it may yet be only +the result of the inherent vibrations of the +molecules of its own proper structure.</p> + +<p>If we exclude from our consideration the +insomnia which is a concomitant of some forms +of unsoundness of mind, and which kind of +insomnia I do not propose to deal with in these +lectures, you will find that absent or imperfect +sleep, inability to sleep at all, or at a convenient +time, or long enough, without the aid of drugs, +is a frequent consequence or complication of +numerous and varied conditions of disease. +Etiology, as you know, is that division of the +science of medicine which has to do with the +<span class="pagenum">[21]</span>causes of disease. The etiology of insomnia +embraces the enumeration of all the causes of +the malady. These causes are numerous, and a +classification of the varieties of insomnia, upon +the basis of their causal distinctions, is somewhat +difficult. Let me recommend to you, for +use in practice, the following classification of +the varieties of sleeplessness under our consideration. +It is the best etiological arrangement +I can form, of the causal intricacies of +our subject. It is a classification which you +will find of service clinically, when you pursue +the discovery of the particular causation of any +given case of sleeplessness. Cases of insomnia +seem to divide themselves naturally into two +groups, namely, of cases of what may be called +<em>symptomatic insomnia</em>, and of cases of what +may be called <em>intrinsic insomnia</em>. Symptomatic +insomnia attends a vast variety of morbid +states, and is secondary to them, or is part of +them. Intrinsic insomnia, as we shall see later +on, is capable of distinct definition, and it +breaks up naturally and simply into three +smaller divisions, upon a causal principle of +division.</p> + +<p>As to symptomatic insomnia, pain, if +severe enough, and from whatever cause +arising; pyrexial elevation of temperature; +<span class="pagenum">[22]</span>frequent coughing, such as often occurs in +pulmonary consumption; dyspnœa, such, for +instance, as results from obstructive dilatation +of the cardiac cavities, and appears to require +an extraordinary vigilance of the nervous +centres for the maintenance of the vital processes +of respiration and circulation—are +clinical conditions of disease which may prevent, +shorten, or break up sleep. Such +conditions are frequently met with in medical +practice, as single causes of insomnia, or as +conjoint causes of it in various combinations. +In such and in similar instances the cause of +the sleeplessness is obvious, and the consequential +character of the insomnia—that is, its +dependence upon a distinct and sufficient cause—is +clear. For the therapeutic control of this +kind of insomnia we may employ with success +one of two curative methods, or we may employ +a judicious combination of these methods, such +combination being founded upon a skilled +appreciation of the especial needs of each individual +case. We may control sleeplessness of +the kind in question either by the exhibition of +remedies which directly cause sleep, that is to +say, by the administration of some of the drugs +which we know as hypnotics or soporifics, or we +may control it by the employment of measures +<span class="pagenum">[23]</span>which combat the cause of the insomnia, by +removing pain, by reducing the heat of fever, +by quelling cough, by relieving cardiac disturbance +and dyspnœal discomfort, and so on; +or by using in conjunction hypnotics and +remedies addressed to the removal of the cause +of the sleeplessness. In such cases of symptomatic +insomnia, as in medical practice +generally, you will find that it is convenient +to your duties, and that it tends to the +thoroughness of your ministrations, if you +regard the therapeutic indications of each case +from the well-known standpoints, respectively, +of the <i lang="la">indicatio causalis</i>, of the <i lang="la">indicatio morbi</i>, +and of the <i lang="la">indicatio symptomatica</i>. By a +judicious combination of the remedies so suggested +you will be able to deal successfully with +cases of symptomatic insomnia. By regarding +the cause of the illness with which you have to +deal as a medical attendant, by regarding the +various pathological processes which underlie +the progress of that illness, and by regarding +the symptoms of that illness, by regarding these +points in turn, or together, or in various combinations, +with a judicious therapeutic intention, +you may arrange your remedial efforts +upon a systematic and comprehensive basis.</p> + +<p>Now let us consider the details of intrinsic +<span class="pagenum">[24]</span>insomnia. There is a simple inability to sleep, +which you will often be required to cure—a +kind of insomnia which may be called for the +sake of simplicity, but perhaps scarcely with +strict truth, <em>insomnia per se</em>. This is a kind of +wakefulness for which we cannot discover an +objective or obvious physical cause; it is a kind +of wakefulness which seems to depend upon an +inability of the brain and nervous system +generally to adapt themselves to the conditions +which are necessary for sleep. We meet with +this disorder more in private than in hospital +practice. It occurs mostly in persons who are +members of what are known as the upper and +upper middle classes. It occurs mostly in persons +of high mental endowment and of neurotic +temperament. The malady is of extreme +importance, and, happily, if its causes be understood +and judiciously corrected and controlled, +there are few affections which are more within +the sphere of curative therapeutics. I think I +can succeed in showing you how to unravel the +complex causes and discover the successful +treatment of this kind of insomnia.</p> + +<p>The causes and the course of particular +instances of intrinsic insomnia present some +striking differences. You must know these +differences, and be ready to recognise them, +<span class="pagenum">[25]</span>for the knowledge of them clears up alike the +therapeutics, the successful treatment, and the +prognosis of individual cases of the malady. +I have found it to be convenient in practice to +arrange the different clinical varieties of such +insomnia into groups, in which the cause of the +affection is the principle of division. These +groups I call respectively the <em>psychic</em>, the <em>toxic</em>, +and the <em>senile</em>. Let us see how these divisions +work out in detail.</p> + +<p>The brain in natural sleep is, as we have +seen, relatively anæmic. The cerebral arteries, +as we have seen, are more filled with blood +than during sleep, when the brain is in full +waking and working activity. When thought +is active, the parts of the brain concerned are +living relatively rapidly; they are actively +receiving nourishment from the blood, and they +are, too, actively ridding themselves of the +waste products of their vitality. In sound +natural sleep the brain is inactive, excepting +those parts of it which are concerned in the +processes of organic life. In sleep the blood +flows to and through the brain in streams which +are smaller and gentler than in the waking +state. The cells concerned in thought, volition, +and feeling are not expending energy, they are +renewing it and storing it—they are resting. +<span class="pagenum">[26]</span>Any cause, however little we may be able to +trace the details of its operation, which directly +prevents a repose duly deep of a sufficient +number of those brain cells which are the +organs of conscious thought, will render sleep +impossible; relative cerebral hyperæmia is an +inseparable consequence of such activity, and +such relative cerebral hyperæmia becomes a +concurrent, but subordinate, cause of insomnia. +Here there is progression through a vicious +circle of two terms, in which the impulse of +the morbid movement springs from the cerebral +cells. So we see that there are causes +of insomnia which we may fairly regard as +acting primarily in sustaining cerebral activity, +and with it, and in consequence of it, relative +cerebral hyperæmia, which hyperæmia becomes +a contributory cause of the cells keeping awake.</p> + +<p>In some other cases of intrinsic insomnia I +think we may regard the malady as arising +primarily in a perversion of the cerebral blood +supply. Any cause which prevents the brain +from becoming relatively anæmic in a sufficient +degree for sleep will produce sleeplessness. Any +ingested agent which sustains cerebral hyperæmia, +or any pathological change which impairs +sufficiently the contractility of the smaller +cerebral arteries, may prevent wholly, or in +<span class="pagenum">[27]</span>part, the occurrence of such a degree and extent +of cerebral anæmia as is required for the production +of sleep, and without which sleep +cannot be.</p> + +<p>So there are causes of insomnia which act +primarily in exciting and in sustaining a +relative cerebral hyperæmia, and with it, and +in consequence of it a cerebral activity which is +wakeful. Here there is again a progression +through a vicious circle of two terms, but one +in which the impulse of the morbid movement +springs from the cerebral blood vessels. In +conscious cerebral activity, which, as we have +seen, is a complex condition of at least dual +causation, in which thought certainly implies +increased blood flow, and increased blood flow +sustains thought, perhaps it may be considered +that we cannot, with strict accuracy, allow +initiative precedence to either of the causes +which are essential to the common result. In +medical reasoning there is little which is so +difficult as tracing effects up to their causes, +and there is little so easy as the invention of +causes for effects. Let this caution make you +wary. Take due pains in practice to analyse +the causation of each particular case of intrinsic +insomnia. When you make such analysis you +will find that in some cases of sleeplessness, as +<span class="pagenum">[28]</span>in the psychic group, undue and protracted +cerebral activity is the primary vice, and that +in others, as in the toxic and senile varieties, +relative cerebral hyperæmia is the initial error, +and wakeful cerebral action its direct consequence.</p> + +<p>Our present consideration of our subject +has advanced to a point at which we may usefully +illustrate our generalizations with some +sketches of particular instances of intrinsic +insomnia, as they are met with in medical +practice. In a case of psychic insomnia some +sudden emotional shock of a depressing kind, +as grief at the death of a beloved relative, will +sometimes be found to have produced at once +persistent sleeplessness, which sleeplessness will +only yield to carefully directed therapeutic +procedures. Again, prolonged mental strain, +in all its varied phases, is a common cause of +the psychic variety of insomnia. Our patient +may be a student preparing for an examination. +For weeks, in spite of fatigue, he may have +shortened his hours for sleep that he might +lengthen his time for reading; and he may +have been in the habit of keeping himself +awake, when he could have readily fallen +asleep, by drinking strong tea or coffee, or by +smoking tobacco. But he could always go to +<span class="pagenum">[29]</span>sleep at once when he went to bed, and sleep +soundly, until, after some weeks of his abnormal +work, with the nearer approach of the +examination bringing increased anxiety as to +the result of the ordeal, he found he began to +sleep badly or almost not to sleep at all. He +grew miserable; he could not remember what +he read; he felt unfit for any exertion; and he +could not face his examination. Or, our patient +may be a young professional man. He has commenced +practice, or rather to wait for practice, +as a barrister, a solicitor, a physician, or a +surgeon. He begins to find that causes or cases +have not been waiting for his advent; clients +or patients are “few and far between.” For a +time he manfully struggles on, his hope and +his health sustaining him; but these at last +yield under the continued pressure of new +disappointments and accumulating anxieties. +He may want money; his friends will give it +to him readily if he will ask for it, but his pride +prevents him. It is not a gift or a loan he +needs; he does not want to beg or to borrow +money; he yearns to earn it. And while he has +been hoping and waiting, and growing sick +with the failure of his expectations, he has +been working early and late in his exacting +studies—perhaps straining his powers in preparation +<span class="pagenum">[30]</span>for some higher examination, and, it +may be withal, adding the denial of due sleep +and exercise, and so he has been wasting and +wearing his psychical and physical energies, in +the trust that he might thus so skill himself the +more as to secure the longed-for practice. At +last he has fairly broken down. He has grown +thinner; he looks haggard; he is filled with +groundless fears; he is weighed down with the +ineffable misery of insomnia; he has headache +constantly, and noises in his ears; he thinks +his memory is failing; he is dull and listless; +he has been lying awake for hours after going +to bed, or, waking in the “small hours,” he has +been unable to sleep again, and when he has +slept he has had horrid dreams; and he comes +to us for help because he can scarcely sleep at +all, and he is possessed by the fear that he is +going mad. His misery is urgent; it excludes +all other joys and most other pains; it is the +unspeakable misery of intrinsic insomnia, the +insomnia which hangs on no solacing peg of +causal pain. Here we observe particular +instances in which acute or continued mental +strain is the primary cause of the sleeplessness. +Where the shock has been sudden and severe +it has been sufficient to rouse a given group +of cells into persistent activity, and to produce +<span class="pagenum">[31]</span>psychic insomnia suddenly. So produced, the +sleeplessness may become a persistent trouble, +which yields only to judicious therapeutic procedures. +In other cases, and more commonly, +the insomnia has only arisen after prolonged +mental strain, as that which a student may +undergo in over-reading for an examination, as +that of continued financial anxiety, or that of +arduous and sustained literary composition. +Where the shock has been sudden and severe +enough, there has resulted a persistent wakeful +activity. Where the strain has been less intense, +but kept up long, a monotonous group of ideas +has been maintained in exhausting recurrence. +In either case it would appear that sleeplessness +did not occur until there arose from exhaustion +partial or complete vasomotor paralysis of the +intra-cranial blood vessels; it arose when the +arterioles of the brain had no longer that contractility +without which sleep is impossible. In +these forms of insomnia unnatural excitation +of the cerebral cells is probably the initial fault. +This point of view, we shall find just now, gives +the best working hypothesis for our treatment.</p> + +<p>Here I must further direct your attention +to the question of the causal association of what +is known as the nervous temperament with +intrinsic insomnia, and especially with this +<span class="pagenum">[32]</span>psychic variety of the malady. In my experience, +the subjects of the psychic variety of +insomnia are mostly men, and almost invariably +men of the temperament which is known in +medicine as the nervous temperament. I +advise you to study temperaments. Their recognition +is of much value in diagnosis, in +prognosis, and in therapeutics. A temperament +may be defined as “that individual peculiarity +of physical organisation by which the manner +of acting, feeling, and thinking of every person +is permanently affected,” and the nervous temperament +is marked by great sensitiveness and +activity of the nervous system.⁠<a id="FNanchor_6_6" href="#Footnote_6_6" class="fnanchor">[6]</a> We have lately +been too ready to ignore temperaments; our +fathers studied them better and regarded them +more than we do. But I shall not go to any +authority for a portrait of the nervous temperament; +I shall describe it to you as I judge I +have found it in a physician’s practice. I use +the phrase nervous temperament to indicate a +distinct type of outward form, of manner, of +habits, of tendencies, and of personal aptitudes, +physiological and pathological. Temperaments +present their various types most frequently in +<span class="pagenum">[33]</span>men. Comparatively few women exhibit a well-marked +temperament; but when a woman is +of the nervous temperament, in her the temperament +is mostly very distinct indeed. In +frequent instances, two or more of the different +kinds of temperament may appear to be +blended in one patient; we have a compound +of reciprocally modified temperaments.⁠<a id="FNanchor_7_7" href="#Footnote_7_7" class="fnanchor">[7]</a> A man +of distinctly nervous temperament has a quick +manner; he is nearly always in a hurry; he is +apt to talk volubly and to eat quickly; if he does +not know us well, he fidgets in his hands, or +legs, or face when he is speaking; he talks +abruptly, earnestly, and fluently, often splitting +up his phrases, or recalling and correcting +them, and especially modifying qualifying +words, such as adverbs and adjectives, in his +anxious desire to express what he conceives to +be the finest shades of truth. A man of this +temperament is apt to “overdo” everything +into which his feelings enter, and his feelings +enter prominently into most of his doings. He +is apt for hobbies; and he is often a diligent +collector of curiosities. When he becomes a +<span class="pagenum">[34]</span>patient, he is harassed about some trivial symptom; +he has felt his heart beating, and he +thereupon fancies he has some deadly cardiac +disease; he thinks his memory is failing, and +he forthwith imagines he is going mad. Your +elucidation of temperamental details in medical +practice will develop your clinical observation +and acumen. <i lang="la">Ars medici est in observationibus</i> +is a maxim of our schools which was a favourite +one of that excellent clinician and successful +physician, the late Sir Andrew Clark, and this +proverb of ours is very true in the detection of +the signs of the nervous temperament.</p> + +<p>A man who has suffered much from +intrinsic insomnia becomes the subject of a +well-marked group of symptoms, subjective and +objective. Most of them are given by certain +writers amongst the signs of cerebral hyperæmia. +It is probable that they mark a +particular variety of exhaustion of the brain, +attended by more or less of an abnormal +increase of blood in the brain, and accompanied +by some general prostration of the bodily +powers. These concomitants of insomnia, as +I have found them, I now describe to you. +The patient has a dull and listless look; +his eyes are wanting in vivacity; the upper +lids may droop a little, and they may be +<span class="pagenum">[35]</span>slightly swollen. The complexion is sallow. +There is headache; of this there are two kinds, +which either co-exist or occur separately. The +commoner variety of headache is a dull pain +felt over the whole of the vertex, together with +a vague and widespread feeling of oppression +in the head; the other is a sharp, shooting +pain, which comes on suddenly, and usually +in single flashes, and which gives the idea of +a knife being driven through the head from one +temple to the other. Occasionally the patient +feels giddiness momentarily; this may cause a +false step, but it never lasts long enough to +give rise to staggering. The skin of the scalp, +especially near the sagittal suture, may be +tender. There are noises in the ears, in one or +in both, usually of a low-pitched whistling +character. This tinnitus aurium may come on +suddenly, and without apparent cause, as when +the patient is talking quietly, or it may only +arise when the patient’s attention is more +closely occupied, as in writing a letter or in +casting up figures. A striking sign in the group +of symptoms we are considering is a slight +impairment of hearing. The patient may be +unaware of it, but those with whom he lives +have noticed that he often asks them to repeat +what they say to him because he could not quite +<span class="pagenum">[36]</span>catch their words. He may also complain of +seeing spots before his eyes—little cobwebby +black lines, <i lang="la">muscæ volitantes</i>, which come and +go and float about, or, perhaps, bright, bluish, +phosphorescent-like specks, phosphenes, which +seem fixed for a moment, one before each eye, +and which only appear when he first directs his +eyes towards an object. There are usually some +abnormal sensations in the skin; not formication, +such as is apt to arise in organic nervous +disease, but a sharp, transitory, and isolated +prickling, as of the movement of a single pin, +which lasts only for an instant, and affects +either the limbs or the trunk, mostly the former. +There may be a peculiar twitching of muscles. +This is a state of involuntary muscular movement +of which I have made original and independent +observation, and of which I know of +no previous description, either oral or written. +It is not a vibratory tremor, like that of +progressive muscular atrophy, nor is it a contraction +of a whole muscle, or of a group of +muscles, such as arises in true convulsion. But, +while the patient is sitting still, a considerable +part of a muscle becomes the subject of rapid +clonic movements, and these are wholly independent +of his volition. These movements +mostly occur in one of the lower extremities, +<span class="pagenum">[37]</span>and they are rarely sufficient to move the +position of the limb; they usually affect the +lower part of one vastus internus, and last for +about a minute. The patient can feel the movements +by attending to the affected part, and he +can also feel that the muscle moves by applying +his hand to it. In such a case there is often +also an unnatural and painful sensitiveness to +external impressions. The patient craves for +quiet. A bright light troubles him. Noises, +the sight of moving objects, touches, as of the +hand of a friend upon his shoulder, annoy him. +There is not an increased sensitiveness to +external impressions, but impressions which +are enjoyed or unnoticed in health become +irritants.</p> + +<p>In the toxic variety of intrinsic insomnia +the cause of the sleeplessness acts primarily +upon the blood vessels of the brain, giving rise +to some degree of arterial hyperæmia. Cerebral +vascularity, especially the arterial supply of +the cortex of the brain, is maintained at such +a height and so long by some poisonous agent +that conscious cerebral activity—that is, wakefulness—is +an inevitable consequence. Such a +poison may be introduced into the body from +without, or it may be a product of diseased processes +arising within the body itself. Of course, +<span class="pagenum">[38]</span>I use the word “poison” in a restricted sense; +I do not mean something which kills, but only +something which produces abnormal manifestations +in the living body. The poisons with +which we have here to do are not lethal poisons, +but milder noxious agents which produce +certain distinct and abnormal manifestations. +Tobacco, alcohol, tea and coffee are the external +poisons which most frequently cause sleeplessness; +internal or autogenetic poisons causing +intrinsic insomnia may be found in certain +waste products of tissue metamorphosis which +accumulate in the bodies of gouty persons, or +in the bodies of persons whose kidneys are +inadequate.</p> + +<p>Possibly, as our knowledge of auto-intoxication +shall increase, some other forms of auto-intoxication +may be found to cause intrinsic +insomnia, and the exact details of the causal +chain may be made out. Clinical experience +has suggested to me that insomnia may sometimes +be a neurosis having its origin in toxic +absorptions by the gastro-intestinal mucous +tract. Certainly intrinsic insomnia is found +in practice to come and go with constipation +and the relief of constipation. The explanation +of such association of symptoms may be a toxic +one. The word “copræmia” is coming into +<span class="pagenum">[39]</span>medical use, to signify a kind of poisoning of +the blood by noxious principles derived from +retained fæces. Sallowness of the skin, what +may be called fæcal anæmia, anorexia, +“biliousness,” and asthenia mark this condition, +and, in some cases, intrinsic insomnia +may be added to its characteristics.</p> + +<p>With regard to the smoking of tobacco, +many a man cannot sleep either sufficiently or +soundly simply because he smokes excessively. +Smokers often find by their own experience +that they sleep badly if they smoke more than +their usual quantity of tobacco, or if they smoke +tobacco of a stronger kind than that to which +they are accustomed. So a smoker who suffers +from insomnia may find the cure of his sleeplessness +in the restriction of his smoking. He +need not give up, nor shorten, nor change his +work, nor need he change his “surroundings”; +if he restrict his smoking, he soon sleeps well. +So also as to snuff-taking in relation to insomnia. +Men of nervous temperament, or men into whose +temperament there enters a distinct and considerable +blending of the nervous element, often +smoke tobacco or take snuff largely. The consumption +of tobacco by smoking or snuff-taking +stimulates the cerebral circulation. This +stimulation, if pushed to undue limits, induces +<span class="pagenum">[40]</span>cerebral vasomotor debility, with a consequent +tendency to persistent conscious thought, and +so to wakefulness.</p> + +<p>Similarly, too, the drinking of alcoholic +beverages causes insomnia. The man who +drinks to commencing drunkenness mostly +sleeps soundly, if not well. But many a so-called +moderate drinker knows that he sleeps +badly if he take a little more than his usual +quantity of wine, for instance, after dinner, or +even his usual quantity of some unusual wine. +Alcohol, when it passes from the stomach to +the blood, flushes and dilates the smaller blood +vessels, especially those of the brain; if such a +condition be maintained, sleep is disturbed or +wanting. We have all seen clinical examples +of the insomnia of delirium tremens: the +patient cannot sleep because the lesser arteries +of his brain are weakened, perhaps paralysed, +by alcohol, and sleepless cerebral activity is +the inevitable consequence. Far short of what +is usually called alcoholism, we often meet with +cases of insomnia in which alcohol alone is the +cause of shortened, interrupted, and disturbed +sleep. The patient may pride himself upon his +moderate use of fermented stimulants, and he +may be wholly ignorant of the cause of the +sleeplessness for which he consults us. We fail +<span class="pagenum">[41]</span>to find any sufficient psychic cause for his +insomnia; but if we take away or diminish +his wine or his grog, or induce him to consume +it before the evening, we find he soon begins +to sleep well.</p> + +<p>Again, the effects of the consumption of +tea and coffee in causing sleeplessness are well +known. This effect is so obvious that patients +usually remedy it for themselves. As you well +know, tea in the form of an infusion and coffee +in the form of an infusion or of a decoction are +used generally in civilised countries as the daily +beverages of the people. Tea leaves contain +an alkaloid which has been called theine, and +coffee seeds contain an alkaloid which has been +called caffeine, and theine and caffeine have +been shown to be identical; both these leaves +and these seeds contain besides certain oily +principles. With regard to tea, what may be +called its physiological action appears to depend +on the joint action of its theine and of the +volatile oil which tea leaves contain. What is +called green tea is produced by drying the fresh +leaves on a heated iron plate until they become +shrivelled; while black tea is manufactured +by placing the leaves in heaps and allowing +them so to lie while they undergo a kind of +fermentation, after which they are dried. +<span class="pagenum">[42]</span>Green tea and black tea are powerful cerebral +stimulants, exciting the mental faculties and +the cerebral circulation, and tending to prevent +sleep. Coffee, too, is a cerebral stimulant and +antisoporific. It is sometimes used in medicine +for these properties, to counteract the effects of +opium and of its derivative narcotics, and of +other narcotic poisons. Some people are +extremely susceptible to the sleep-preventing +effects of tea or of coffee; others, by use, do not +feel such effects, even when considerable quantities +of those beverages are consumed. In all +cases of bad sleeping you should make sure that +tea or coffee is not taken to excess, neither near +bedtime.</p> + +<p>In gouty persons, quite apart from +secondary wakefulness caused by their gouty +pains, there may be some intrinsic insomnia, +of a kind which is probably toxic in its causation. +So, also, intrinsic insomnia may afflict +a patient whose kidneys are failing, who has +renal inadequacy. In such cases it would seem +to appear that the accumulation in the blood, +in consequence of deficient excretion, of the +products of tissue-metamorphosis causes a +general restlessness which disposes to insomnia. +Insomnia so caused is not severe, and it is +rarely complete. There is slumber rather than +<span class="pagenum">[43]</span>sleep. There is restlessness, perhaps some +excessive irritability to certain external impressions, +short and broken sleep, and what may +be called superficial sleep, rather than prolonged +wakefulness. In this connection I may +remind you that you should observe the tension +of your patient’s pulse. A patient may complain +that he sleeps very badly, that he lies in +bed awake for some hours and has great difficulty +in “getting off” to sleep, that he sleeps +lightly, awakens often, and dreams much. You +may find he has a pulse of increased and high +tension, with accentuation of the aortic second +sound, and with the cardiac first sound +lengthened and muffled, perhaps reduplicated, +at the apex of the heart. In a case of chronic +kidney disease there may be also the physical +signs which mark the characteristic cardiac +hypertrophy which accompanies chronic contracting +nephritis, and is an effect of it or a +concurrent effect of a remoter pathological +cause. Insomnia in such cases is likely to be +due to the maintenance of a state of high +tension in the cerebral arteries, the tension +in them not falling sufficiently for prolonged, +deep, and dreamless sleep. In practice you will +find the causation of many of these cases of +insomnia, and you will find sound therapeutic +<span class="pagenum">[44]</span>indications, too, in the signs of the gouty +diathesis or in the discovery of albuminuria. +Here I must give you a caution, which you may +usefully remember in practice, namely, never +accept a patient’s statement that he is gouty +without the establishment by your own observation +of facts sufficient for such a diagnosis. +Insomnia which is purely nervous may be +wrongly attributed to gout, and depletory +measures of treatment may be adopted when +corroborants are really indicated. The diagnosis +of gout is a diagnosis for which patients often +have a tender affection, and I am afraid it is a +diagnosis which is often erroneously made, and +wrongly handed on through a succession of +credulous advisers. Do not fall into the frequent +error of making a diagnosis of gout because a +specimen of your patient’s urine which is +brought to you shows a deposit which to the +naked eye is like unto grains of cayenne pepper, +and which deposit is made up of aggregated +crystals of uric acid. Such a sediment may be +only an innocent result of an acid fermentation, +such as frequently arises in urine after its +voidance, without any pathological significance +whatsoever.</p> + +<p>As I have already told you, there is a senile +form of intrinsic insomnia. Remember that +<span class="pagenum">[45]</span>senility is a term of which the primary absoluteness +is largely modified in particular cases +by relative qualifications. Some persons are +senile early, others only later. With much +truth it may be said that a person is not as old +as his years, at least in a pathological sense, +but as old as his arteries. You may perhaps +have observed amongst your friends that an +exaggerated appreciation of the merits and +value of early rising often increases as age +advances. The broken and short sleep of many +old persons is mainly, if not entirely, the result +of senile degeneration of the smaller cerebral +arteries. In such degeneration those blood +vessels are less elastic and less contractile than +in health, and a degenerative weakening of +their walls often leads to their permanent dilatation; +the smaller cerebral arteries, so changed +by a pathological process, are physically unable, +by reason of a diminution of their resilience +and of their contractility, to adapt themselves +normally to such a condition of relative arterial +anæmia as is of the essence of healthy sleep. +The tendency of this condition of the blood +vessels of the brain to prevent, to lessen, or to +interrupt sleep is probably to a great extent +counteracted, in many cases, by the cardiac +feebleness which so frequently, and which, +<span class="pagenum">[46]</span>within certain limits, it may be said fortunately, +co-exists with senile vascular changes. +When arteries are brittle, cardiac failure, +within certain limits, may be regarded as a +conservative lesion, in the sense that such +failure tends to save from arterial rupture and +the consequences of cerebral hemorrhage.</p> + + +<hr class="chap x-ebookmaker-drop"> +<div class="chapter"> + +<p><span class="pagenum">[47]</span></p> + + + <h2 class="nobreak" id="II"> + II.<br> + THE CURE OF INSOMNIA.⁠<a id="FNanchor_8_8" href="#Footnote_8_8" class="fnanchor">[8]</a> + </h2> +</div> + + +<blockquote> +<p><em>No “rule of thumb” cure.—Hypnotic drugs.—Risks +from hypnotics.—Causal treatment.—Bromide +of potassium.—Cure of anæmia.—Alcohol.—Carminatives.—Adjuvant +remedies.—Popular remedies.—Rhythmic sleep.—Physical +exercise.—Sunshine.—Monotonous impressions.—Bedclothes.—Ventilation.—Food.—Cold.—Toxic +insomnia.—Senile insomnia.</em></p> +</blockquote> + +<p>There is no “rule of thumb” cure for insomnia. +Each case must be separately studied; the +details of its cure can only be decided under +competent medical advice. I will help you all +I can now in this part of our subject; but +many remedial details are only suggested in +practice by the exigencies of particular cases, +and are only developed as the fruit of long +experience in the treatment of persons suffering +from sleeplessness. I shall tell you something +of the use of hypnotic drugs, and of the +dangers of some of them; I shall try to impress +<span class="pagenum">[48]</span>upon you the importance of stopping overwork, +when overwork is a cause of insomnia; +and I shall point out to you many hygienic +considerations which bear upon the cure of +insomnia, and some useful therapeutic adjuvants +which I have found helpful to that end +in my practice, and which may suggest to you +many other successful remedial procedures.</p> + +<p>In the treatment of insomnia you may find +it necessary to exhibit some of the drugs which +are known to you as hypnotics or soporifics; +these are remedies that induce sleep. When +you have to deal with a case of insomnia do not +assume that you must of necessity give a +hypnotic drug. I advise you rather to assume +that you can cure a given case of insomnia by +understanding its particular causation and by +remedying the same, rather than by attacking +the effect by dosing the patient with some +hypnotic. Prescribe hypnotics only in exceptional +cases; only administer such drugs when +you cannot help it. Your experience in practice +will enable you to decide, with increasing +precision, when such an exceptional case is +before you. Rely, whenever you can, upon an +intelligent causal treatment of insomnia, combining +such treatment with a judicious employment +of some of the non-medicinal helpers of +<span class="pagenum">[49]</span>sleep which I am about to describe to you, if +such addition to a strictly causal treatment be +needed in any particular case. As a rule, the +successful treatment of a case of sleeplessness +follows from the discovery of its cause. In the +severer forms of psychic insomnia, however, +it often happens in practice that we must at +once secure sleep by the action of some efficient +hypnotic. I prefer opium or chloral. By the +use alone of one of these drugs we can often +quickly cure acute insomnia depending upon +some sudden mental shock or strain. You will +find that a few nights of sound and sufficient +sleep, artificially induced by the exhibition of +a reliable hypnotic, will do more than anything +else to restore to the brain the power of sleeping +without further aid from drugs. Besides chloral +hydrate, opium, morphine, and the other +soporific derivatives of opium, the chief hypnotic +drugs are sulphonal, trional, paraldehyde, +amylene hydrate, and the bromides, to which +may be added alcohol and affusion of the head +with cold water. For details concerning the +comparative merits and demerits of chloral +hydrate, paraldehyde, amylene hydrate, sulphonal, +and trional, I must refer you to the +admirable writings of Professor Binz.⁠<a id="FNanchor_9_9" href="#Footnote_9_9" class="fnanchor">[9]</a></p> + +<p><span class="pagenum">[50]</span></p> + +<p>Sir T. Lauder Brunton insists upon a well-recognised +and valuable therapeutic consideration, +namely, that a combination of hypnotics +is sometimes more successful than any of them +singly. He recommends a combination of +“small quantities, such as 5 or 10 minims, of +solution of opium or morphine, with 5 grains +of chloral and 10 to 30 of potassium bromide.”⁠<a id="FNanchor_10_10" href="#Footnote_10_10" class="fnanchor">[10]</a> +These and other hypnotics may be variously +combined to meet the indications of each +particular case, according to the judgment of +a skilful adviser.</p> + +<p>Here I must warn you very plainly and +very seriously of the risks which attach to the +administration of powerful hypnotic drugs. +Many human lives are yearly lost as the consequence +of the taking by sufferers from insomnia +of overdoses of hypnotics. All drugs which +produce sleep as a physiological effect, and the +relief of insomnia as a therapeutic action, with +the exception, perhaps, of the bromides, produce +stupor rather than sleep in overdoses, +which deepens into the sleep which knows no +waking when they are ingested or injected in +larger doses still. So never allow a patient to +dose himself with hypnotics. Keep the matter +<span class="pagenum">[51]</span>quite within your own secure hands, upon well-recognised +limits of safety. In the less acute +and more chronic forms of psychic insomnia, +where the sleeplessness or wakefulness usually +depends upon prolonged worry or overwork, I +employ chloral or other powerful dormitives +sparingly. They should only be used as temporary +remedies, when it is necessary to secure +at once a fair amount of sleep. A patient +should never be allowed to swallow chloral or +any other of the dangerous but valuable hypnotics +whenever he feels so disposed, neither +should he apportion their doses for himself; +he can only safely take them under direct +medical control and observation.</p> + +<p>Another important point must not escape +from view. It is this: an overworked man or +woman must never be permitted to go on with +his or her overwork and habitually secure sleep +by chloral or by any other hypnotic. In such +a case we must relentlessly aim at preventing +the sleeplessness by removing its cause, instead +of pursuing the illogical and precarious course, +into which often a wilful and impatient +patient would persuade us, of permitting that +cause to continue, and of trusting to counteract +or suppress the resulting insomnia, a troublesome +effect of that cause, by medicine. +<span class="pagenum">[52]</span>Remember that work which prevents due sleep +is dangerous work. When a man cannot sleep +because he works his brain too much, we must +make as a condition of our help that he stop +or greatly lessen his labour. Especially should +he abstain from mental work for some hours +before going to bed. In many persons the +cerebral hyperæmia of severe mental toil does +not fall down to the circulatory limits required +for healthy sleep for several hours after the +cessation of such work. But I advise you to be +wisely suspicious in practice as to accepting +work as a cause of insomnia. Nature provides +that disposition to rest shall follow work. It +is mostly worry, not overwork, or it is work +under wrong conditions, which makes sleep +difficult.</p> + +<p>Whatever the cause of the insomnia, a +holiday, with complete change of scene and +with distinct change of activities, will often +do much to cure. Great as is the curative +influence of new surroundings and of new outlets +for energy, in many cases of psychic +insomnia we cannot, however, do without drugs. +Potassium bromide is by far the best hypnotic +in well-nourished patients, and in the slighter +cases generally. It is marvellously powerful +in producing nervous calm; it is a direct brain +<span class="pagenum">[53]</span>sedative, and quite a safe one. But it must +be given properly, and in full doses; after +getting into bed, 30 to 60 grains, dissolved in +water, should be the dose. Sometimes you may +usefully combine with it some drug which will +favour the contraction of the weakened cerebral +blood vessels. For this indication we may give +tincture of ergot or tincture of digitalis, one or +both.</p> + +<p>In many cases of chronic wakefulness +arising from prolonged mental strain, the +patient is distinctly anæmic. The insomnia +cannot be cured unless the anæmia be cured. +The pallor of the patient’s face, the lightened +tints of his visible mucous surfaces, and his +soft and small pulse, declare the condition of +his blood. Such a person mostly feels drowsy +when he is up and wakeful when he lies down. +He needs hæmatinics, of which the best are +iron and arsenic, singly or combined. His diet +must be generous, containing plenty of fish, +meat, and eggs. For such a patient alcohol is +often the best hypnotic; its form and dosage +need peculiarly precise prescription and careful +supervision.</p> + +<p>The prescription of alcohol as a remedy in +disease is often difficult and sometimes dangerous. +To many people a “nightcap” of +<span class="pagenum">[54]</span>toddy is a superfluous, perhaps hurtful, luxury. +It gives, however, perhaps better than anything +else, rest and sleep to the worried brain of +feeble persons whose blood is poor. I find that +alcohol is the best hypnotic in many cases of +chronic psychic insomnia, when the patient is +worried and weakly, sorrowful and anæmic. +We need not exaggerate our responsibility in +the prescription of alcohol; but we should +never forget it. I have been accustomed to +insist that when we use alcohol, in the form of +any of the fluids which contain it, in the treatment +of insomnia, we should explain to our +patient the reasons for the employment of the +remedy, and that we should discontinue this +remedy as we discontinue the use of other +drugs, when the conditions which called for +its exhibition shall have disappeared.</p> + +<p>I have found in practice that a carminative, +best taken just after the patient be entered into +bed for a night’s sleep, is an efficient remedy +in some cases of intrinsic insomnia. Such a +remedy is indicated when a sense of gastro-intestinal +discomfort, often described by a +patient as a feeling of “sinking” in the +stomach, with or without flatulence, appears +in any particular case to prevent sleep. A carminative +is a cheering and comforting remedy, +<span class="pagenum">[55]</span>which relieves gastro-intestinal discomfort, +stomach-ache, or belly-ache, disperses and prevents +flatulence, and promotes speedily a feeling +of local well-being, and all this so markedly +that its name may be justified either by the +song of joy which it almost inspires or by a +<em>carmen</em> meaning a charm as well as a tune. Oil +of cajuput is a reliable remedy of this kind. In +its action it is a carminative, an antispasmodic, +and a diffusible stimulant. It may be given +in a dose of five drops, or a little less or a +little more, dropped upon a piece of lump +sugar, or crumb of bread. Hot water, as a +beverage, is also a carminative, diffusible +stimulant, and antispasmodic, promotive of +gastro-intestinal peristalsis. I have read that +a well-known English statesman, now living, +cured himself of sleeplessness by drinking a +tumblerful of hot water, “as hot as could be +drunk,” before going to bed.</p> + +<p>In slighter cases of intrinsic insomnia +some of our dormitives which are milder than +the ordinary hypnotics are useful. We may +now consider these, which may be regarded as +adjuvant remedies, of tried adoption. Many of +these remedies are what may be called popular +remedies, and a remedy, like a person, is not +always the worse for being popular; they are +<span class="pagenum">[56]</span>“understanded of the people,” and you should +understand them too, for it is scarcely convenient +that you should run risks of being +beaten in your therapeutics of insomnia by a +non-professional prescription of a remedy of +this class. A drachm of the officinal tincture +of hop is a good dormitive. The slumberous +repute of hop attaches to its aroma. King +George the Third, by the advice of his +physician, slept with his head upon a hop +pillow, <i lang="la">pulvinar lupuli</i>, a pillow stuffed with +newly-dried hop catkins. It is recorded that +such a pillow was used successfully by our +present King in his severe enteric fever in 1871. +Dr. Berkeley, Lord Bishop of Cloyne, records: +“I have known tar-water procure sleep and +compose the spirits in cruel vigils, occasioned +either by sickness or by too intense application +of the mind.”⁠<a id="FNanchor_11_11" href="#Footnote_11_11" class="fnanchor">[11]</a> Tar water, made according to +the formula of this prescribing prelate, is still +to be bought from pharmacists. Amongst +popular remedies for sleeplessness there are: +clove-tea; cowslip wine; nutmeg-tea (nutmeg +may be narcotic in large dose); fennel stalks, +eaten as celery; lettuce, as food, or in some of +<span class="pagenum">[57]</span>its medicinal preparations; onions, as food. +What may be called the lore of these popular +remedies is very interesting; you may pursue +it as an instructive diversion, and as one from +which you may gather points of use in medical +practice.</p> + +<p>There are many other matters to which +you must give attention in the treatment of +chronic psychic insomnia, if you would follow +my advice that you should only give hypnotics +in exceptional cases, and only when you really +cannot obtain a successful result without them. +I can now do little more than mention the +more important of such details to you.</p> + +<p>Some of them you will find useful in +some cases, in other cases others. How best to +combine them in any given case experience will +teach you. Firstly, whether he sleep well or ill, +the patient ought from day to day to go to bed +and to get up at fixed and regular times. +“Lying in bed in the morning” is not a remedy +for insomnia. Healthy sleep is a rhythmic +act, and rhythmic sleep must be cultivated. +The conditions for the periodic recurrence of +sleep must be supplied. An afternoon nap for +half an hour or so after a meal, with the feet +kept warm before a fire, is helpful, and I have +found in practice that it conduces to, rather +<span class="pagenum">[58]</span>than hinders, better sleeping in bed at night.</p> + +<p>Again, daily bodily exercise in the open +air, but always short of great fatigue, must be +enjoined. What is called carriage exercise is +better than no outdoor change at all, but walking +is a far better exercise, and cycling better +still, and riding on horseback the best of all. +A worn and worrying man, habitually wrapt up +in an absorbing torture of self-consciousness, +exaggerating his subjectivities, and sleeping +badly, must perforce come out of himself, and +blot out his self-consciousness with the saving +graces of objectivities when he mounts a cycle +or a horse’s back. Gardening, in the open air, +not in conservatories nor in hothouses, affords +good exercise, and it is very efficient in keeping +up objective attention. Dwellers in towns may +find good objective employment, of a kind +counteractive of insomnia, in various physical +exercises and drills, in fencing with foils, and +in other similar recreations, all of which you, +as medical advisers, must learn to understand +in their several details, so that you may +prescribe them intelligently to suit the particular +needs and aptitudes of individual +patients; many may at least copy Archbishop +Whately, who remedied the strain of his logic +by splitting his logs, and give their minds a +<span class="pagenum">[59]</span>refreshing and recreative objective bent, and +their muscles healthy work, by cutting up firewood. +As to sunshine, we healers welcome the +present therapeutic worship of the sun. Certainly +sunshine is a natural tonic and calmative. +In practice you may be sure you will find free +and long daily exposure to sunshine a valuable +adjuvant in the cure of insomnia.</p> + +<p>Again, many people have acquired more +or less insomnia in the acquisition of the bad +habit of thinking out their affairs upon getting +into bed. Some patients pursue this bad practice +for years, and they often conceal it or +disregard it when they seek medical help for +sleeplessness. In such a case you must find +out this bad habit, and break your patient of +it, for the cure of insomnia. Evoke the +patient’s self-control in this regard. In such +cases especially, and in the cure of insomnia +generally, people who find it difficult to get +off to sleep have been advised to count +monotonously, one, two, three, up to a +thousand or more, until they fall asleep; to +picture some familiar scene and keep the mind +fixed upon it; to repeat the letters of the +alphabet over and over again. The late Dr. +Pereira gave some interesting illustrations of +the well-known fact that a continued repetition +<span class="pagenum">[60]</span>of monotonous impressions on the senses of +hearing, seeing, or touch, are provocative of +sleep. One passage from his monumental work +on remedies I may quote to you. Speaking of +monotonous impressions in the therapeutics of +insomnia, he wrote: “This is the principle of +‘the method of procuring sound and refreshing +slumber at will’ recommended by the late Mr. +Gardner, who called himself the hypnologist. +His method was for some time kept secret, and +was first made public by Dr. Binns. It is as +follows: Let the patient ‘turn on his right +side, place his head comfortably on the pillow, +so that it exactly occupies the angle a line +drawn from the head to the shoulder would +form, and then, slightly closing the lips, take +rather a full inspiration, breathing as much +as he possibly can through the nostrils. This, +however, is not absolutely necessary, as some +persons always breathe through their mouths +during sleep, and rest as sound as those who do +not. Having taken a full inspiration, the lungs +are then to be left to their own action; that is, +the respiration is neither to be accelerated nor +retarded too much; but a very full inspiration +must be taken. The attention must now be +fixed upon the action in which the patient is +engaged. He must depict to himself that he +<span class="pagenum">[61]</span>sees the breath passing from his nostrils in a +continuous stream, and the very instant he +brings his mind to conceive this apart from all +other ideas,’ he sleeps. ‘The instant the mind +is brought to the contemplation of a single +sensation, that instant the sensorium abdicates +the throne, and the hypnotic faculty steeps it +in oblivion.’”⁠<a id="FNanchor_12_12" href="#Footnote_12_12" class="fnanchor">[12]</a></p> + +<p>These various methods seem to be devices +for changing the current of conscious cerebration. +Amongst my patients I have found the +plan of taking deep inspirations commended by +many of them. But for the most part these +expedients succeed for a night or two only, and +they can scarcely be relied upon either exclusively +or long. These sundry practices may even +keep up wakefulness; when the mind attends +to them too closely, they may sustain the self-consciousness +which keeps the brain from slipping +into slumber. To try hard to go to sleep +is often the surest way to keep awake. We do +many things best when we forget ourselves, +and going to sleep is no exception to the rule.</p> + +<p>Again, to promote the sleep of a person +in bed, you should make sure that the bedclothes +which cover him are sufficient and not +<span class="pagenum">[62]</span>excessive. If the covering bedclothes be +especially arranged in quantity each night by +thermometric guidance, according to the temperature +of the air in the patient’s bedroom, +so as to secure that the thickness of the upper +bedclothes will give to the occupant of the bed +a general feeling of sleep-inducing and sleep-sustaining +comfort, and not of sleep-preventing +discomfort, either from local or from +general chilliness or from local or from general +over-heating, sleep will be powerfully promoted. +And, further, if such arrangements be made +with the knowledge and with the interested +approval of the patient, or by himself, we gain +the valuable adjuvant of his self-confidence as +to his sleeping well, and establish in his mind +for the particular night before him a happy +expectation which is likely to be realised. For +your guidance as to the details of practice +arising from this indication of treatment, I +may tell you that, from observations I have +made, I have found that in a large bedroom +in the middle of a large house, with a window +of the room always kept open, a Fahrenheit +thermometer indicated a temperature of 70°, +or upwards, in the hottest weather, and of 40°, +or less, in the coldest weather, in the country, +at an elevation of about 300 feet above the +<span class="pagenum">[63]</span>sea-level, in mid-England. At a temperature +of 44°, the upper bedclothing should consist +of a sheet, three blankets, a light counterpane, +and a light small blanket, this last not “turned +over” at the upper edge of the bedclothing and +not “turned in at the bottom”; at a temperature +of 70°, it should be a sheet only. Between +these extremes of temperature the changes in +the thickness of the covering bedclothes should +be gradual. These extremes should be the ends +of a series of gradations passing through about +nine terms. With a little care you can make a +serviceable thermometric register, marking the +suitable bedclothing for a given external temperature +of the bedroom in any particular case, +and so you may cure intrinsic insomnia, and +prevent its recurrence.</p> + +<p>In all cases, the bedroom window should +be open all night and all the year round, and +arranged so that it may be so without draught. +The head of the bed should be away from a wall. +The best bed on which to lie is a hair mattress, +covered with a sheet and a blanket, and supported +upon a chain stretcher.</p> + +<p>In some cases a little food taken just at +the time for sleeping is an efficient soporific. +You may often observe that the good effects of +a little nourishment—a cup of cocoa or a small +<span class="pagenum">[64]</span>piece of dry bread, taken upon getting into bed +or upon awakening after a slumber which is +too short for a night’s rest, are most happy.</p> + +<p>You may usefully remember that sleep +may often be induced by the temporary application +of cold to the head or to the general +surface of the body. A person who has been +lying awake will often fall asleep at once upon +regaining his bed after getting out of bed and +sousing his head, neck, and hands in cold +water, or after following Charles Dickens’s plan +of standing at his bedside until he feels chilly, +and thereupon shaking up and cooling his pillows +and bedclothes, and then getting into bed.</p> + +<p>In the toxic kinds of insomnia we must +especially endeavour, as I have already suggested +to you, to act upon the maxim, “<i lang="la">Cessante +causâ cessat et effectus.</i>” We must stop or lessen +the consumption of tobacco, alcohol, tea, etc., +as the case may be. The sufferer from toxic +insomnia will ask you what must be done for +sleep. This is not quite the question; the +question is not what the patient must do, but +rather what the patient must not do. The consumption +of something must be left off. When +you have found out the what and when of that +something, the patient’s self-control, loyal coöperation, +and obedience to your directions are +<span class="pagenum">[65]</span>essential to your curing the case. A discussion +of the treatment of gouty insomnia, and of the +sleeplessness arising in some chronic kidney +diseases, would involve a consideration of the +whole question of the therapeutics of the +maladies upon which these forms of wakefulness +depend. If you find evidence of copræmia +in a case of insomnia, you must, in any case, +treat the underlying fæcal retention. Such +fæcal retention may be the whole cause, or an +active part of the cause, of the insomnia. Senile +insomnia is very obstinate. Perhaps in the +bromides, with full doses of hop or henbane, +we have the most efficient and least harmful +medicinal means of relief; while the promotion +of sleep may be accomplished by an intelligent +combination of some of the non-medicinal +measures to which I have referred.</p> + +<p>Now I must close our consideration of this +interesting subject of the therapeutics of +intrinsic insomnia. I have sketched broad outlines +for your guidance, which will suggest +to you many other details in your practice. +That the best physician is the physician who is +the best inspirer of hope, Coleridge it was, I +think, who so declared. He was largely right. +Of course, truthful hope. Certainly is this +largely true in nervous maladies. In the cure +<span class="pagenum">[66]</span>of intrinsic insomnia, especially, the best physician +is one who is a master of his art and +withal the most ingenious inspirer of his +patient’s desire of cure and belief that it is +obtainable.</p> + +<div class="footnotes"> +<h3>FOOTNOTES:</h3> + +<div class="footnote"><p><a id="Footnote_1_1" href="#FNanchor_1_1" class="label">[1]</a> A Clinical Lecture: published in <cite>The British Medical +Journal</cite>, December 1st, 1900; lately revised, rewritten, and +extended.</p></div> + +<div class="footnote"><p><a id="Footnote_2_2" href="#FNanchor_2_2" class="label">[2]</a> The Senses and the Intellect.</p></div> + +<div class="footnote"><p><a id="Footnote_3_3" href="#FNanchor_3_3" class="label">[3]</a> Mental and Moral Science.</p></div> + +<div class="footnote"><p><a id="Footnote_4_4" href="#FNanchor_4_4" class="label">[4]</a> An Introduction to Human Physiology. By Augustus +D. Waller, M.D., F.R.S., 2nd Edition. London, 1893.</p></div> + +<div class="footnote"><p><a id="Footnote_5_5" href="#FNanchor_5_5" class="label">[5]</a> A Text-Book of Physiology. By M. Foster, M.A., +M.D., LL.D., F.R.S., 5th Edition, Part IV. London, 1891.</p></div> + +<div class="footnote"><p><a id="Footnote_6_6" href="#FNanchor_6_6" class="label">[6]</a> A Medical Lexicon. Published by the New Sydenham +Society.</p></div> + +<div class="footnote"><p><a id="Footnote_7_7" href="#FNanchor_7_7" class="label">[7]</a> Clinically, the most marked temperaments are those +known respectively by the names of bilious, lymphatic, +nervous, and sanguineous.</p></div> + +<div class="footnote"><p><a id="Footnote_8_8" href="#FNanchor_8_8" class="label">[8]</a> A Clinical Lecture: published in <cite>The British Medical +Journal</cite>, December 8th, 1900; since revised and extended.</p></div> + +<div class="footnote"><p><a id="Footnote_9_9" href="#FNanchor_9_9" class="label">[9]</a> Lectures on Pharmacology. New Sydenham Society’s +Translation.</p></div> + +<div class="footnote"><p><a id="Footnote_10_10" href="#FNanchor_10_10" class="label">[10]</a> A Text-Book of Pharmacology, &c.</p></div> + +<div class="footnote"><p><a id="Footnote_11_11" href="#FNanchor_11_11" class="label">[11]</a> Siris: ... concerning the virtues of Tar water. +By the Right Rev. Dr. George Berkeley, &c., 2nd Edition. +Dublin, 1744.</p></div> + +<div class="footnote"><p><a id="Footnote_12_12" href="#FNanchor_12_12" class="label">[12]</a> Elements of Materia Medica.</p></div> +</div> + +<hr class="tb x-ebookmaker-drop"> + +<div class="chapter"> +<div class="transnote"> +<h2 style="margin-top: 0em">Transcriber’s Notes:</h2> + +<p>New original cover art included with this eBook is granted to the public domain.</p> + +<p>Footnotes have been moved to the end of the text and relabeled +consecutively through the document.</p> + +<p>Punctuation has been made consistent.</p> + +<p>Obvious typographical errors have been corrected.</p> +</div></div> + +<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 77326 ***</div> +</body> +</html> diff --git a/77326-h/images/cover.jpg b/77326-h/images/cover.jpg Binary files differnew file mode 100644 index 0000000..2094833 --- /dev/null +++ b/77326-h/images/cover.jpg diff --git a/77326-h/images/title.jpg b/77326-h/images/title.jpg Binary files differnew file mode 100644 index 0000000..cc69a97 --- /dev/null +++ b/77326-h/images/title.jpg |
