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Insomnia





To the minds of many people insomnia is one of the most serious ills
to which human nature is heir. Most of this quite false impression is
due to the sensational cultivation of dreads with regard to insomnia
by newspapers and in general conversation. If we were to credit such
impressions, there is a certain number of unfortunates who, for some
unknown reason, find it impossible to sleep and who, night after
night, drag out the weary hours wooing sleep that does not come, until
when daylight dawns they are in despair, distracted by lack of rest.
This is presumed to occur night after night, until finally the
worn-out mind succumbs to the intolerable anguish of being kept
constantly on the rack of wakefulness and the patient becomes insane
or saves himself from that by suicide. No wonder, then, that many a
one of these patients takes to the use of habit-forming drugs to
produce sleep. These, though effective only to a small degree, soothe
him for the time, but finally render him such a wreck that there is
not even will power enough for him to take his own life and end his
intolerable suffering.

Such gruesome pictures of the awful effects of insomnia run rife and
produce dreads in the community until just as soon as the ordinary
nervous supersensitive person loses an hour or two of sleep two or
three nights in a month, he begins to conjure up the specter of
insomnia with its awful terrors and still more awful possibilities,
and begins to bewail the fate that has chosen him as an unfortunate
victim. This exaggerated dread that slight losses of sleep, for which
there are often excellent reasons, will develop into an incurable
condition of persistent wakefulness has more to do than any other
single factor with the production of the state called insomnia which
is, however, never half as bad as it is pictured.


Absolute Sleeplessness.--A certain number of patients insist that they
sleep very little at night and some tell their friends and even their
physicians quite ingenuously that they sleep none at all, and that
this has been the case with them for a prolonged period. Practically
every physician has heard such stories, and at the beginning of his
professional career has usually wondered how the patients continued to
live and enjoy reasonably good health in spite of the lack of
absolutely necessary brain cell rest. After the physician has the
opportunity to investigate some of these stories he understands them
better. Patients in hospital, who insist that they are wakeful all the
night, prove usually when faithfully watched by a nurse to be wakeful
for an hour or two at the beginning of the night and then to sleep for
hours at a time, and all of them sleep for intervals more or less
prolonged, though they may wake a number of times during the night and
may think that they have not been asleep because they hear the clock
regularly or some other recurring noise. It is improbable that
patients ever spend several nights in succession without sleep and
their story is only an index of the persuasion that they are under
that they do not sleep, though they are having so many thoroughly
restful intervals that their brain cells suffer but little from
the need of sleep. Indeed, the principle source of nervous wear and
tear for them consists in their persuasion that they do not sleep and
the resultant impelling suggestion that a breakdown must before long
be inevitable.


Individual Differences.--There are too many safeguards in nature's
ordinary dealings with human beings for us to think that people can
pass many nights absolutely without rest. Brain cells may apparently
be very wakeful, they may be quite ready to take up at once and
seemingly without a break trains of thought interrupted sometime
before, yet somehow they succeed in obtaining their needed rest. In
this matter, as is well known, though it needs to be emphasized again
for the benefit of nervous individuals, different people have very
different needs. Some require many continuous hours of sleep or they
soon begin to have symptoms of nervous exhaustion. Others live on only
with snatches of sleep at intervals, or with interrupted sleep during
a limited portion of the twenty-four hours, yet enjoy good health for
many years. A few seem to be able to live in health and strength with
but a few hours of sleep. It may possibly be thought that those who
are living their lives with a small amount of sleep are drawing drafts
on their future vital powers, and that what they make up in intensity
of activity now by shortening sleep, they will discount by shortness
of life. How utterly untrue this impression is, however, will be best
understood from the fact that many of the men who have worked hardest
and slept the least number of hours in the day, have lived to be
eighty or even ninety years of age and some of them have even been
centenarians.


Cell Rest.--The great differences in the brain cells of different
individuals in what concerns sleep becomes more readily intelligible
when we recall the extreme differences as regards the need of rest of
the various cells in the same individual. While the brain cells seem
to require for healthy life, as a rule, nearly one-third of the time,
and a man who is constantly taking much less than eight hours of sleep
is probably hindering rather than helping his productiveness,
especially if his work is intellectual, there are cells in the body
that need no such amount of rest as this. Peristaltic movements occur
in the digestive tract almost constantly, with only short intervals,
and these cells get their rest between their movements. Pulmonary
cells and tissues must do the same thing, and are able to do it
without any special strain being put on them. The extreme example of
the lack of need for prolonged rest is found in the heart. Two-fifths
of every second the cells of this organ have a rest during the
diastole, but during the remaining three-fifths of every second for
all of life they must not only be ready to work but actually engaged
in it or serious symptoms ensue. The cells in the brain that subtend
cardiac and respiratory activity must be even more able to do without
rest, since their action is ceaseless during life. By analogy with
these it is not difficult to understand that the brain cells which are
involved in consciousness should on occasion be able to stand
prolonged periods of activity, or at least of wakefulness. Persistent
wakefulness does not appeal to us as so surely destructive after this
consideration.


Solicitude Over Sleep.--For those who are much disturbed by the loss
of even slight amounts of sleep and who are prone to complain rather
bitterly if they are not able to get more than five or six hours a
night, I find it a useful preliminary to any more formal treatment of
their so-called insomnia to recall the examples of some of the
great workers who succeeded in accomplishing marvelously good work
though they took much less sleep than the amount the patient secures,
yet seems to think inadequate. In spite of such lack of sleep, these
workers lived to advanced old age. There are many well-authenticated
illustrations of this in recent times. Perhaps the most striking
testimony to the power of the human mind to continue work without
requiring the refreshment of sleep, except for very short periods, is
that of Humboldt, the great traveller, scientist writer and diplomat.
Max Mueller, in his autobiography tells the story. It was when he
himself was about forty. Humboldt said to him: "Ah! Max, when I was
your age I had time to accomplish something, now I find that I must
take at least five hours of sleep every night." At the moment
Humboldt was over eighty. Mueller said to him: "But, Your Excellency,
how much sleep, then, did you take when you were my age?" "Oh!" he
said, "I used to turn the light down, throw myself on the lounge for a
couple of hours, and then get up and go on with my work again."
Humboldt, after a life full of the hardest kind of work of many kinds,
lived well past ninety in the full vigor of his intellectual powers.

There are many other examples that might readily be quoted. The
traditions of the University of Berlin contain many illustrations of
men who did very little sleeping, yet succeeded in accomplishing an
immense amount of work and lived far beyond the Psalmist's limit.
Virchow, whom I knew very well, did not take more than four or five
hours of sleep on most nights in the year. He would be in the Lower
House of the Prussian Legislature, which, like the House of Commons,
holds its meetings late at night, until one A. M. or later and would
be at his laboratory shortly after seven. There was a tradition at the
University of Berlin in my time there of one of the older professors
in the theological department who went to bed only every alternate
night. He had a forty-eight-hour day for work with a seven-hour break.
He lived to the age of eighty-five. I know one of our most
distinguished workers in medicine here in America who was so busy and
so tired at the end of his day that he could not write his book. He
would fall asleep on his chair at his desk to wake up only when the
milkman came in the morning. He had constructed for himself a special
stool without back or sides, shaped like a bench, so that whenever he
fell asleep on it he fell off. The fall would wake him up and he would
then go on with his work for some hours. He did this sort of thing for
many years, and yet he is alive and in the full possession of
intellectual health at the age of eighty-three. He learned this
expedient from a German professor of medicine who told him of it and
at the same time told him that it was no uncommon practice among
German professors. Indeed, most of the famous long-livers of the
nineteenth century were also well known for the small amount of sleep
they required, and apparently there is no need of being anxious lest
loss of sleep should prove serious, unless one is adding to whatever
detriment to health it may be by worrying about it find so setting two
damaging factors at work.


TREATMENT

Probably the most important immediate assurance that can be given to
those who come complaining of insomnia is that practically no one has
ever been seriously hurt by the wakefulness called insomnia.
Patients suffering from brain tumors, from serious disturbance's of
cerebral circulation that give objective signs, from various organic
diseases, as of the heart or liver, or certain constitutional
diseases, have been made worse by the wakefulness induced by their
affections. In the cases where there were no definite objective signs
and wakefulness was the only symptom we have no cases on record of
serious injury resulting. Men have come complaining of wakefulness for
days or weeks and sometimes, though it is strange to understand it,
for months or even years, and yet have lived their lives without
serious developments and have neither gone into insanity nor into any
premature loss of vitality, much less a fatal termination. It is not
subjective symptoms but objective signs that are of value for the
diagnosis of the serious organic conditions. This reassurance lifts a
load from patients' minds at once and does more than anything else to
relieve them of the burden of solicitude which is the main factor in
the continuance of their insomnia.


Suggestive Treatment.--The psychotherapy of sleep consists in changing
the patient's attitude of mind toward his sleep. It is quite
impossible for him to sleep normally and regularly if he worries much
about it and if the afternoon and evening hours are mainly spent in
wondering whether he will sleep, anxious as to when he is going to
sleep like other people, marvelling how long he will last in health
and sanity if his tendency to wakefulness continues. There is no
factor so strong in insomnia as getting one's self on one's mind. It
weighs as an intolerable burden, an incubus that is sure to keep its
subject awake. Insomnia is a mental and not a physical ailment in much
more than nine out of every ten cases. It is not the brain but the
mind that is at fault. Patients must be made to realize that if they
go quietly to bed, confident that if they do not sleep the early part
of the night they will sleep later, and that in case they should lose
considerable sleep, so long as they lie quietly for eight hours in
bed, their physical organism is not likely to come to any serious
trouble. They must be quiet, peaceful and unworried. They must not
begin to toss at the first sign of not going promptly to sleep for by
so doing they may put off completely the possibility of falling to
sleep. Finally they must prepare for sleep by passing a quiet evening,
as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at
least obviated. These are very different in different individuals and
the suggestion of getting them out of the way helps a great deal in
making people realize that they are better prepared for sleep than
before. They have been keeping themselves awake by contrary
unfavorable suggestions. They must be taught to aid themselves in
going to sleep by a series of favorable suggestions attached to the
doing of certain things that are helpful and, above all, avoiding acts
of various kinds that have an unfavorable suggestive influence. In
this way an accumulation of suggestions can be secured that will prove
helpful.


Drugs.--Of course, patients must be warned with regard to the taking
of drugs. Certain drugs may be taken for an occasional loss of a
night's sleep, where the loss of sleep is regular and frequent,
however, drugs are sure to do more harm than good. Opium leads to a
serious habit, chloral is dangerous because it must be increased, most
of the coal-tar somnifacients produce serious after results and
their physical effect is in the end probably more deleterious than
would be the loss of the sleep which they are supposed to counteract.
This is true for even the vauntedly least harmful of them, and it is
important to make patients understand it.


External Conditions to be Inhibited.--In the treatment of insomnia two
sets of inhibitory conditions are particularly to be looked to, those
external to the patient, and those internal. Unless every possible
obstacle is removed there can be no assurance of the relief of
sleeplessness, while very often the careful regulation of a few
conditions that are disturbing the patient will bring sleep fully and
promptly. It is curious what small annoyances will sometimes prove
disturbing.


No Pillow.--I have found patients who had heard somewhere the idea
that it was natural for man to sleep without a pillow. The pillow in
this theory was supposed to be an added refinement of men in a state
of luxury, but a real degeneration opposed to nature, and the many
presumed benefits of sleeping on a perfectly level mattress with the
head no higher than the rest of the body was emphasized. While in
ordinary health these patients had found that after the preliminary
discomfort of getting used to sleeping without a pillow, they were
apparently the better for it. People will feel better for almost
anything if they are only persuaded that they ought to. After a
certain length of time, however, worry or work had a tendency to keep
them more or less wakeful and then insomnia came on, that is, for
several hours at the beginning of the night they did not go to sleep
and became very much worried about it.

In several of these cases I have found one of the most helpful
adjuncts to more direct treatment of their wakefulness was the
restoration of the pillow. Just how the hygienic theory of pillowless
sleep originated, or on what it is supposed to be founded, I do not
know. The only theory of sleep that seems to have many adherents at
present is that it is due to brain anemia. With the head a little
higher than the rest of the body the force of gravity tends to help in
the production of this brain anemia. The experience of mankind seems
to confirm this. Certainly, from the earliest records of history men
have slept with something under their head, even though they could
find nothing better than a log or a stone. To sleep without a pillow
is, owing to the conformation of the head and neck and shoulders,
almost inevitably to sleep mainly on the back. From the anatomical
relations of the internal organs it is easy to understand that
sleeping on the side is more comfortable and healthy than sleeping on
the back and hence most people naturally take this position.
Relaxation is much more complete and comfort is greater. What the
majority of men do is almost surely dictated by instinct, and instinct
is the most precious guide we have in the natural functions of life.
We are not so differently formed from the animals that the analogy
from their habits should not have some weight for us. Patients should
then be advised always to sleep with a reasonably firm pillow, not too
low, so that the head is a little higher than the body and the lateral
position perfectly comfortable.


Too high Pillow.--There is an abuse in the other direction of too
high a pillow that deserves to be noted. Occasionally the physician
hears complaints of waking up with tired feelings in the large muscles
of the back of the neck near their insertion into the occiput. This is
sometimes complained of as an occipital headache. Not
infrequently it will be found that these people are sleeping on
pillows that are too large, or that they pile up several of them. Most
physicians have found in their experience that having the head quite a
little higher than the rest of the body materially aided sleep,
especially in elderly people. This is true even when there is no
distinct heart lesion, but this favorable position is best secured not
by means of one or more high pillows, but by raising the head of the
bed, or by the insertion of bolsters beneath the mattress, so that
there is a gentle slope upward from the hips to the head. High pillows
should, as a rule, be discouraged, especially in young folks where the
assumption of the strained positions which they cause, may encourage
various deformities in the anatomy of the head and shoulders so that
stoop shoulders or a craned neck result. On the other hand, before
attempting to give drugs to elderly people, the arrangement of the
mattress so as to put the head a foot, or even more, higher than the
body should be tried and will often be found to give relief where
other things fail.


Discomfort Due to Cold.--In order to sleep well patients must be
thoroughly comfortable in bed. In recent years as the very hygienic
practice of having a window in the sleeping apartment open has become
a rule among intelligent people, sleeping rooms have been much colder
than they used to be. Care must be taken lest the active factor in
causing wakefulness should be cold. Over and over again I have found
that patients who complain of wakefulness, in the latter part of the
night particularly, that is, in the early morning, were awakened by
the increasing cold because they were insufficiently clothed. Whenever
the sleeping room becomes very cold, then, the patient should not
sleep between cotton or linen sheets which are likely to induce
sensations of chilliness, but in a light woolen nightgown. It is
curious what a difference in the patient's feelings is produced by the
touch of wool to the skin in cold weather as compared with cotton.
Thin, anemic patients are especially likely to suffer from chilliness.
It must not be forgotten, however, that some stout people, in spite of
an accumulation of fat, are really anemic. Their red blood corpuscles
and hemoglobin are distinctly below normal. These constitute some of
that large class of stout women in whom reduction cures fail because
of the anemic tendency. They must be as carefully protected from cold
as thinner persons, yet they need fresh air for their comfort and
health almost as much as tuberculosis patients. The experience of
sanatoria in the Adirondacks and at altitudes generally shows that for
quiet, undisturbed sleep, if the room becomes distinctly cold during
the night because of an open window, a hood or night-cap and gloves,
as well as the wearing of woolen underclothing, even to stockings, is
almost indispensable. In older times, when houses were not well
heated, many persons very sensibly wore night caps. Now that a return
to cold fresh air in the sleeping room has come many will have to
resume the old night-cap habit in spite of cosmetic objections to it.
These may seem little things, but they count very much in relieving
disturbed sleep. The curious thing about them is that patients
themselves seldom realize that certain common-sense regulations are
more important for sleep than formal remedies. They want to be "cured"
of their insomnia, not relieved by suggestion.


Cold Feet.--A large number of people have their sleep at the
beginning of the night seriously disturbed by cold feet. Some cannot
get to sleep for an hour or more, because their feet are cold.
If the patients become worried over this loss of sleep, a real
insomnia may develop. It is for these people that the old-fashioned
warming-pan was invented and it should not be forgotten that the
symptom can be relieved very promptly by means of a hot-water bag or a
hot brick wrapped in flannel at the foot of the bed. An excellent
practice for very sensitive persons, is to have the sheets warmed
thoroughly for a couple of hours before bedtime. This is especially
important in damp weather.

The distinguished English surgeon. Sir Henry Thompson, who lived well
beyond eighty years of age (when surely he would seem to have some
right to do so), wrote a little book on how to be well and grow old
and describes a habit which he had acquired and that I have often
recommended to patients and friends as well as used myself with
advantage when there is a tendency to cold feet, either habitually or
occasionally. It is, moreover, useful whenever there is a tendency to
insomnia because some exciting occupation has preceded going to bed.
Before retiring Sir Henry used to sit beside his bath tub and let the
hot water flow into it over his feet, gradually becoming warmer and
warmer, until he could no longer stand the heat. A temperature well
above 120 degrees may be borne with comfort after a while, though at
the beginning it would seem entirely too hot. The feet are kept in the
hot water at least five minutes. When taken out they should be
thoroughly red and show evidence of a good deal of blood having been
attracted to them. If they are now carefully wiped and rubbed
vigorously there will usually be no further tendency to cold feet that
night and sleep will come naturally. Sir Henry said that when he had
been out at meetings where he had to make an address or had to take
part in business of any kind that inclined to make him wakeful, he
found this an excellent method of preparing himself for immediate
sleep.

It must not be forgotten that the worst forms of cold feet are found
among those suffering from flatfoot. The dropping of the arch
interferes with the return circulation and also with lymphatic
circulation. These individuals feel very tired because of their foot
condition, yet their cold feet often disturbs their sleep at the
beginning of the night. The only effective relief for this is afforded
by proper treatment of the feet. (See the chapter on Foot Troubles.)


Lack of Air.--On the other hand, occasionally it happens in spite of
all that has been said in recent years about fresh air in sleeping
rooms, windows are hermetically sealed and even then people cover
themselves with many thicknesses of bed clothing and are too warm. I
have found over and over again that where people could not be
persuaded to leave a window open all night (and when they are old and
deeply prejudiced in the matter I do not insist, for the suggestion of
possibly catching cold would almost surely keep them awake), the
thorough airing of rooms before retiring made a great difference in
the sleep of elderly people. When patients are young, I simply insist
on the window being wide open for some time before they go to bed and
slightly during the night, except in extreme cold weather. Many a
patient who complains of waking several times during the night and
being awake for some time on each occasion will begin to have longer
periods of sleep without a break if such a change in the ventilation
of the room is effected. Anyone who has seen fever patients who
had been restless, disturbed and wakeful, sink into a quiet slumber
after the room has been thoroughly aired and the temperature of it
reduced ten or fifteen degrees, will realize how helpful this same
method of treatment will be in nervous, wakeful irritability.

How important air is for the obtaining of the power to sleep for many
hours every day can be best understood and appreciated from the habits
insisted on for patients in tuberculosis sanatoria as a result of
experience. When there is any tendency to a rise in temperature in
these patients they are kept absolutely without exercise. They are
either in bed or on a lounging chair all day, but they are out in the
air or at least close to an open window. As a rule, they sleep some in
the morning and then they sleep again in the afternoon. This would
ordinarily be fatal to sleep at night in even healthy people taking
considerable exercise and therefore presumably tired and more likely
to sleep than these patients who had made no exertion during the
twenty-four hours; but it is not often, after patients have been for
ten days or two weeks at the sanatorium, that there is any complaint
of lack of sleep at night. This is true in spite of the fact that
patients are often wakened by coughing during the night, yet after a
comparatively short interval they go to sleep again and sleep until
morning. This is not true when patients do not pass most of their time
in the open air and when their rooms are not well aired.


Sleep at Sea.--I know nothing that is more effective in doing away
with insomnia than a sea voyage. The passengers sit on their lounging
chairs all the morning in the open air, usually sleeping for some
time, often for several hours. During the afternoon this is repeated.
In spite of this extra sleep they turn in, not long after ten, and
sleep well until morning. There is practically no exercise and the air
usually excites such an appetite that five and even six meals a day
are consumed. There is no disturbance of digestion unless some special
excess is indulged in, and, above all, sleep is rather favored than
impaired by the large amount of food taken. This experience which is
so common, is very valuable as indicating just what is the best
pre-requisite for sleep. It is not exercise and tiredness to such a
degree that one fairly drops from fatigue, but such an oxidation of
all tissues by the breathing of pure air that there are no toxic waste
products left in the system to act as excitants for disturbance of
sleep.


Cold Water.--In summer, when wakefulness is due to heat, a cool bath,
or at least a rub down with cold water and going to bed without drying
is an excellent method of inviting sleep. Under these circumstances
the sheet acts as a soothing cool pack and people who have been
wakeful for hours before, or at least have found considerable
difficulty in getting to sleep, sleep promptly. The mechanism of
sleep-production is easy to understand. There is less blood to go to
the brain when the little capillaries at the surface are pretty well
extended and after the application of cool water the reaction which
follows the closing of the capillaries in response to cold leaves them
of sufficient size to accommodate a large amount of the blood of the
body. Of course, in both cases there is the suggestive value of a
proceeding of this kind so well calculated to predispose the patient's
mind to go to sleep without solicitude.



Diet.--As has already been outlined in the hints that precede, the
first thing in the treatment of insomnia is to remove any causes that
may be at work in producing wakefulness. Among the most common of
these in our modern life is the taking of coffee or tea, important in
the order mentioned. Every physician has frequent experiences of
people who complain of insomnia, yet who take a cup of coffee late at
night. A large proportion of humanity cannot do this with impunity and
expect to go to sleep promptly. Occasionally one finds that patients
complaining of sleeplessness are taking three to five cups of coffee a
day. This must be stopped. A physician may be told by such patients
that they cannot get along without their coffee. I have only one
answer for this and it is meant to show patients that if they want to
sleep they must take the means to secure it and, above all, must
remove all disturbing factors. I tell them that if they cannot do
without coffee they may continue to do without sleep. If they want to
sleep they must give up coffee or at least must limit the amount. I
have found it comparatively easy to get people to limit coffee-taking
by the suggestion that there should be one tablespoonful of strong
coffee taken to a cup of hot milk. This gives the taste, or rather the
aroma of coffee, for coffee has properly no taste to speak of, and
while, at first, patients crave the stimulation they have been
accustomed to, it takes but a few days to overcome this craving
entirely.

Usually it is easy to get people to confess that they are taking too
much coffee. For some reason not easy to understand it is harder to
get them to acknowledge that they are taking too much tea. Coffee is
taken with a certain amount of deliberation. Tea may be and often is
taken at odd intervals for friendliness' sake and sometimes patients
do not know how much they are taking. Six or seven cups a day may be
their usual quota, yet they do not realize it and at first are
inclined to answer that they take it only two or three times a day,
forgetting the little potations between meals. Tea is not so prone to
cause wakefulness as coffee, yet the toxic irritant principle in both
is the same and when the amount of tea and its strength are
sufficient, the same results follow. The tea habit must always be
given up if there is complaint of lack of sleep, especially early in
the night.

There is a very common persuasion that the eating of food in any
quantity shortly before going to bed, and especially the eating of
certain materials, will keep people awake. It is well known, however,
that there are a great many people who can eat anything and sleep well
after it and young children sleep best when their stomachs are full.
There are undoubtedly idiosyncrasies in this matter that must be
respected, but many patients are deceiving themselves. They are eating
too little and their wakefulness is more due to the mental state than
to anything else. As this contradicts a very prevalent impression, I
may say that it is said deliberately and only after much experience
with people inclined to be over-solicitous about their diet and their
health generally and who were actually producing wakefulness or at
least very light dreamful sleep, by their elimination from their diet,
and especially from their evening meal, of many nutritious substances.
I make it a rule to insist with patients that if it is more than five
hours since their last meal they must take a glass of milk and some
crackers or a cup of cocoa and something to eat before going to bed.
This is particularly important if they have been out in the air much
between their last meal and bedtime.



The Evening Hours.--The use of the hours after the evening meal is an
extremely important factor with regard to insomnia. If the patient
tries to read the paper or some conventionally interesting magazine or
book, thoughts of the possibility of his not sleeping will surely
obtrude themselves and he will fail to get to sleep when he lies down.
As a matter of fact, he will have so disturbed himself as to
predispose to insomnia. Some quiet occupation, interesting yet not too
interesting, that diverts the mind from the thoughts about itself and
about sleep possibilities, yet does not excite it, is the best
possible auxiliary and preparation for sleep. Prof. Oppenheim has, as
usual, said this very well in his "Letters to Nervous Patients," to
which we have turned so often:

A great deal depends upon the right use of the evening hours. On no
account let yourself occupy them with anxious forebodings about the
night. But, on the other hand. It is not at present wise to take up
your mind with too exciting thoughts, as the strong after-impression
of feeling and fancy may counteract the tendency to sleep. You must
find out for yourself whether a quiet game (cards, halma, chess, or
patience), the reading of a serious or an amusing book, the perusal
of an illustrated paper, or a chat with a friend will be most
certain to give you that tranquillity of mind through the vestibule
of which you will pass into the temple of sleep.


Direct Sleep Suggestions.--Many plans are suggested by which people
are supposed to be able to get to sleep. A favorite and very old
suggestion is that of counting sheep go over a fence or something of
that kind that is merely mechanical, yet takes the mind from other
thoughts. As a rule, any plan involving mental occupation that is
meant to produce sleep is likely to react and do harm rather than
good. Sleep must not be wooed deliberately but must be allowed to come
of its own sweet will. It is extremely important that exciting
thoughts and bothering interests be put aside, not at the moment when
we want to go to sleep, but some considerable time before. This is not
always an easy matter and often requires careful planning. It is worth
while doing it, however, in order to secure sleep promptly and not
allow a prolonged period to pass while one is lying awake, for if
nervous irritability ensues wakefulness is still further prolonged and
the patient may begin to toss and so disarrange the bedclothing and
disturb himself as to prepare for several hours of sleeplessness which
would not have occurred if there had been an appropriate interval
given to preparing the mind for sleep.


Diminishing Solicitude.--Patients must not be too anxious for sleep.
If they worry themselves over the possibility of not sleeping then
they will almost surely disturb their sleep, or at least delay its
coming. The ideal state of mind is not to bother one's head about it,
to lie down habitually at a given hour, compose one's self to sleep
with assurance and then wait its coming without solicitude. Many
people will say this is not easy to do, but habit makes it easy. Most
of our animal life is lived by habit. We are hungry at certain times
by habit. Our bowels move at a particular time by habit. We can sleep
by habit. If we try to use our intellect solicitously with regard to
any of these habitual functions we do much more harm than good. The
more anxiety there is about sleep the more likely it is to be
disturbed. When the habit of sleep at a particular hour has been
broken the best way to regain it is to lie down at that particular
hour and then wait patiently for the advent of sleep. If
impatience gets the better of us sleep is kept off and will not come
for hours. If the patient can lie down feeling "Well, if I do not
sleep now I will to-morrow morning" then there is usually little
difficulty about sleep.


Dread of Consequences.--Many people who suffer from insomnia fear
that their loss of sleep will injure their intellectual capacity or
make them prematurely aged, or drain their vitality so that they will
not have health and strength of mind and body when they grow old. This
adds to their solicitude about themselves and inveterates their
condition. There is only one answer to this dread, which has no
foundation in what we know of actualities, and that is, to tell them
the experience of certain persons which absolutely contradicts such a
notion. One distinguished physician who, at the age of seventy-five,
is writing books that are attracting widespread attention and is doing
an amount of work that many a younger man might envy, has told me of
all that he suffered from insomnia between the ages of thirty and
fifty-five. His mental productivity was much hampered at that time by
his wakefulness and anxiety with regard to it. He feared the worst as
regards advancing years, yet he is in the full possession of mental
and bodily strength well beyond the Psalmist's limit. His is not an
exceptional case, for there are many others in my own personal
knowledge. Virchow once told me of years when he suffered from
insomnia, yet he lived to be well past eighty and then died, not from
natural causes, but from an injury. A man who accomplished an immense
amount of work in his day in the organization of a great university
suffered from insomnia in his younger years to such a degree that his
friends and even he himself feared for his mental stability,
eventually overcame this symptom completely and went on to years of
great active work, dying in the end, not from his head, but his heart.
We have records of a number of such cases. Few of the hard students of
the world went through life without having some bother from insomnia.
It is well-known, however, that many of the great thinkers,
investigators and discoverers in philosophy and in science have lived
long lives well beyond the age of the generality of mankind.


Mental Diversion.--The main thing is to banish the thoughts of one's
ordinary occupation as far as that can be accomplished without
laboring so intently at this as to give the mind another bothersome
occupation. Many people find that a game of cards just before going to
bed takes their thoughts off business and worry almost better than
anything else. Something like this is needed in many people. Most
people must not write for some time before retiring, because writing
proves so absorbing an occupation, as a rule, that the mind becomes
thoroughly awake and then remains so for some time afterwards. Reading
is better, but the reading must be chosen with proper care. An
exciting story, for instance, may serve to keep one awake for hours,
as everyone knows who has tried and found himself still reading at
three in the morning after having begun an interesting book. The
reading of works of general information, of travels, of description of
places, where it is comparatively easy to stop at any place, of short
stories which do not hold the interest beyond a brief period, is much
better. Osler's recommendation to have a classic author beside one's
bed to be read for a few minutes every night after retiring as a
preparation for sleep is an excellent remedy for the milder forms of
insomnia, as well as a stepping-stone to scholarship.



William Black in one of his books has a description of an old man who
had suffered from insomnia very severely until he discovered a plan of
his own to enable him to get to sleep. This consisted in reading the
Encyclopedia Britannica. He began at the beginning and read straight
ahead, article after article, and volume after volume. He never even
by any chance departed from this routine either to look up cross
references, or read anything further about men who were mentioned in
the article he was going through at the moment and whose names
occurred in another volume. He read straight on until his eyes got
heavy and then he went to sleep. At the time he was introduced into
the story he had already read the whole work through twice and was, I
think, at "D" on the third reading. He had had considerable bother
about getting to sleep before he adopted this plan, but it proved an
always efficient somnifacients. There is a story about an old American
farmer who said that he read the dictionary over and over again for
the same purpose. The stories were short and disconnected, but they
never bothered his sleep, while his wife and daughters were sometimes
kept up more than he thought was good for them by their interest in
the story paper.


Treatment of Early Morning Wakefulness.--With regard to the
disturbance of sleep in the early morning hours there are certain
instructions to patients that have always seemed to me extremely
important. Most of the patients who complain of wakefulness in the
early morning hours are really suffering from hunger at that time.
This is especially true with regard to those who stay up rather late
at night. They have their last regular meal about seven or a little
earlier, they get to bed at eleven or even later, and some of them,
following the old maxim that eating before sleep is likely to disturb
it, go to bed on an empty stomach. Whenever more than four hours have
passed since the last meal the stomach is quite empty, and after the
preliminary fatigue has worn off and the sleep has become lighter and
the lack of nourishment more pronounced a vague sense of discomfort in
the abdominal region wakes them, though most of them do not realize
that they are disturbed by a craving for food. In a large number of
these cases I have found that the recommendation of a glass of milk
and some crackers, or some simple cake, just before retiring does more
than anything else to lengthen sleep and prevent what has been
learnedly called matutinal vigilance.

After emptiness of the digestive tract, the most prominent cause of
wakefulness in the early morning is anxiety about the hour of rising
or about some engagement that has to be kept in the early morning. I
have known patients who worked themselves up so much thinking over the
necessity for rising at a particular hour to catch a train, that they
were awake for several hours before they needed to be. Some are much
more inclined to this over-anxiety than others. If they move to the
country where trains have to be caught regularly, their sleep may be
seriously disturbed by this circumstance. If the trouble becomes acute
they must simply change their residence. If it is absolutely necessary
that they stay, then they must have someone to wake them at a definite
time. This must be someone on whom they can absolutely depend,
otherwise the old solicitude will reassert itself. This seems a small
matter, yet I have known serious cases of neurasthenia with annoying
digestive symptoms due to nothing else than this morning wakefulness
consequent upon overanxiety with regard to trains and other morning
engagements.



Habits.--In the correction of troubles of sleep one of the
difficulties that the physician has to contend with when patients have
grown accustomed to staying up late and finally have so disturbed
their sleep mechanism that symptoms of insomnia develop, is the
declaration that there is no use for them going to bed early since
they cannot sleep. If a man has been accustomed for a long period to
go to bed between midnight and 2 a. m. and his habits are suddenly
changed so that he goes to bed at ten or even eleven, it is very
likely that for some time after retiring he will not sleep. If he
grows over-anxious he may toss and become somewhat feverish and then,
even when the accustomed time for sleep comes, he may not secure it.
Besides, the depression consequent upon failure to sleep when he has
fulfilled his physician's directions and when he knows that this is
considered an important adjuvant in his treatment, acts as a
distinctly discouraging factor. Under these circumstances it is
important to recall to him that one habit can only be removed by the
making of another. It may be necessary to send him to bed for awhile
only an hour earlier than before until he has grown accustomed to
going to sleep somewhat sooner, and then this habit, in turn, be
changed to an earlier hour so as to secure all the sleep that is
necessary.

In a word, insomnia is not a definite affection to be treated by
giving one or the other of one's favorite drugs, or if these should
fail trying still others, but it is a condition of mind very often
predisposed to by certain conditions of body. If this condition of
mind can be adjusted by careful attention to the correction of
whatever may be physically out of order, then there is every reason to
look for definite improvement very soon and complete cure without any
delay. Insomnia is not the awful ailment that it is sometimes
pictured, nor all that it appears to the excited imagination of the
young person who loses a few hours' sleep; but a manifold condition to
be dealt with very differently in different individuals, according to
the indications of the case. If the patient's confidence can be
secured that means more than almost anything else that can be done. If
a little patience is exercised in obtaining such definite details of
the mental state and of certain physical factors as may seem quite
trivial to the patient yet are really predisposing elements for his
affection, the therapeutics become comparatively simple. It is the use
of tact and judgment in this matter that means most, however, and then
very few drugs will be required. Between the habits consequent upon
the opiates and certain of the serious hemolytic conditions due to the
abuse of coal-tar products, this is a consummation that may well be
worked for assiduously.





Next: Some Troubles Of Sleep

Previous: Mental States Of Disappointment



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