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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 *** |