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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/77326-0.txt b/77326-0.txt new file mode 100644 index 0000000..b76526a --- /dev/null +++ b/77326-0.txt @@ -0,0 +1,1216 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 77326 *** + +Transcriber’s Notes: + +Text enclosed by underscores is in italics (_italics_). + +Additional Transcriber’s Notes are at the end. + + * * * * * + +INSOMNIA: ITS CAUSES AND CURE. + + * * * * * + + + + +INSOMNIA: ITS CAUSES AND CURE. + + + BY + JAMES SAWYER, + SENIOR CONSULTING PHYSICIAN TO THE QUEEN’S + HOSPITAL, BIRMINGHAM. + + Birmingham: + CORNISH BROS., + 1904. + + + + +PREFACE. + + +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. + + 31, TEMPLE ROW, + BIRMINGHAM, 1904. + + + + +CONTENTS. + + + PAGE + + I. THE CAUSES OF INSOMNIA. + + 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. 9 + + II. THE CURE OF INSOMNIA. + + 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. 47 + + + + +I. THE CAUSES OF INSOMNIA.[1] + + + _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._ + +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 +further published in _The Lancet_, 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 _The British Medical +Journal_, 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 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. + +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 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 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. + +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 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, _cessante causâ cessat et effectus_, +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.[2] 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 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.”[3] 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. + +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 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 of some +of the issuants of those tissue changes, muscular and nervous, which +especially occur in the active waking state of the body. + +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 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[4] and of Sir Michael +Foster.[5] 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: + +“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 evidence that the organ becomes more vascular during mental +activity....” + +That sleep concerns the whole body, and not the brain alone, is well +put by Sir Michael Foster. He says: + +“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.” + +You may find an interesting and instructive employment if you follow +Sir Michael Foster 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. + +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 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 _symptomatic insomnia_, and of cases of +what may be called _intrinsic insomnia_. 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. + +As to symptomatic insomnia, pain, if severe enough, and from +whatever cause arising; pyrexial elevation of temperature; 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 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 +_indicatio causalis_, of the _indicatio morbi_, and of the _indicatio +symptomatica_. 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. + +Now let us consider the details of intrinsic 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, _insomnia per se_. 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. + +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, 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 _psychic_, the _toxic_, +and the _senile_. Let us see how these divisions work out in detail. + +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. 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. + +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 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. + +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 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. + +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 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 +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 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. + +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 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.[6] 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 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.[7] 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 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. _Ars medici est in +observationibus_ 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. + +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 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 +catch their words. He may also complain of seeing spots before his +eyes--little cobwebby black lines, _muscæ volitantes_, 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, 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. + +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, 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. + +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 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. + +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 cerebral vasomotor debility, with a consequent tendency to +persistent conscious thought, and so to wakefulness. + +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 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. + +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. 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. + +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 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 +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. + +As I have already told you, there is a senile form of intrinsic +insomnia. Remember that 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, 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. + + +FOOTNOTES: + +[1] A Clinical Lecture: published in _The British Medical Journal_, +December 1st, 1900; lately revised, rewritten, and extended. + +[2] The Senses and the Intellect. + +[3] Mental and Moral Science. + +[4] An Introduction to Human Physiology. By Augustus D. Waller, M.D., +F.R.S., 2nd Edition. London, 1893. + +[5] A Text-Book of Physiology. By M. Foster, M.A., M.D., LL.D., F.R.S., +5th Edition, Part IV. London, 1891. + +[6] A Medical Lexicon. Published by the New Sydenham Society. + +[7] Clinically, the most marked temperaments are those known +respectively by the names of bilious, lymphatic, nervous, and +sanguineous. + + + + +II. THE CURE OF INSOMNIA.[8] + + + _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._ + +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 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. + +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 +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.[9] + +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.”[10] These and other hypnotics may be variously +combined to meet the indications of each particular case, according to +the judgment of a skilful adviser. + +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 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. + +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. 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. + +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 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. + +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. + +The prescription of alcohol as a remedy in disease is often difficult +and sometimes dangerous. To many people a “nightcap” of 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. + +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, 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 _carmen_ 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. + +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 “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, _pulvinar lupuli_, 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.”[11] +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 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. + +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. + +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 +than hinders, better sleeping in bed at night. + +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 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. + +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 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 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.’”[12] + +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. + +Again, to promote the sleep of a person in bed, you should make sure +that the bedclothes which cover him are sufficient and not 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 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. + +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. + +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 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. + +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. + +In the toxic kinds of insomnia we must especially endeavour, as I +have already suggested to you, to act upon the maxim, “_Cessante +causâ cessat et effectus._” 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 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. + +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 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. + + +FOOTNOTES: + +[8] A Clinical Lecture: published in _The British Medical Journal_, +December 8th, 1900; since revised and extended. + +[9] Lectures on Pharmacology. New Sydenham Society’s Translation. + +[10] A Text-Book of Pharmacology, &c. + +[11] Siris: ... concerning the virtues of Tar water. By the Right Rev. +Dr. George Berkeley, &c., 2nd Edition. Dublin, 1744. + +[12] Elements of Materia Medica. + + * * * * * + +Transcriber’s Notes: + +Footnotes have been moved to the end of each chapter and relabeled +consecutively through the document. + +Punctuation has been made consistent. + +Obvious typographical errors have been corrected. + +*** END OF THE PROJECT GUTENBERG EBOOK 77326 *** 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%; 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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 diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6c72794 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This book, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. 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