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.





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