Some Troubles Of Sleep





Certain annoying incidents in connection with sleep annoy those

affected by them so much as to arouse them very completely from sleep

and make them wakeful for a time. Nothing disturbs most people so much

as the thought that some passing incident, a little out of the common,

is quite individual and peculiar to them. If they are at all nervous

they are likely to think that it portends some serious ailment, either

present or about to develop. Nothing reassures them more than to

learn that these incidents are not so uncommon as they imagine, indeed

that many of them are quite frequent, and, above all, that many people

who have had them are still alive and well beyond threescore and ten,

and laughing at the fears of their earlier years.





Starting.--Perhaps one of the most annoying of these incidental

troubles is starting in sleep. It occasionally happens that just about

the time a person is dozing off he suddenly starts and, almost before

he realizes it, is fully awake, his heart beating emphatically and

there may even be a little feeling of oppression on the chest. The

cause is not the same in all cases and individual differences are

worth investigating. In most people this starting means that there is,

for the moment, some mechanical interference with the action of the

heart and that a systole has been delayed and has been pushed through

with more force than usual because of this delay. A full stomach will

occasionally cause this, especially if patients lie on their left

sides. In some people even a drink of water taken just before retiring

will be sufficient weight to cause this interference with heart

action. An accumulation of gas in the stomach will do it by pushing up

against the diaphragm. Where there is a distinct tendency to the

accumulation of gas in the stomach I have sometimes been sure that the

expansion of the gas consequent upon the cozy warmth of the patient in

bed, or its greater effect upon the stomach because the relaxation of

sleep affected even the stomach walls slightly, was the cause of it.

It happens more frequently in the old than it does in the young, but

it is observed at all ages and patients are usually quite disturbed

about it, as, indeed, they are likely to be with regard to anything

that affects their hearts.



The thought that this forcible beat must mean some serious

pathological condition will obtrude itself on many people, and if it

does sleep is sure to be disturbed. Even though there may be no

discoverable lesion of the heart, these patients often, though they

are physicians, will worry lest some underlying condition should be

developing. The first patient who ever described this symptom to me

told me of it while I was a medical student and he is still alive and

in good health, though he is past seventy. At the time I went over him

rather carefully with the idea that there might be an organic heart

lesion, but found none. The prognosis of these cases is always

favorable, for there are many who suffer yet live long. I have found

if to occur particularly in elderly people when they were a little

overtired on going to bed, or in anemic young people when they had had

somewhat more exertion than usual during the day. Unless there is

really some demonstrable heart lesion the start does not mean anything

and patients can be reassured at once. They should be counselled

against lying on the left side, though in some of them it will occur

even while lying on the right side and then the mechanism of its

production seems to be the gaseous over-distention of the stomach.

Patients may be told at once that it occurs in a large number of

people and then, instead of lying awake and worrying about it as they

often do, they learn simply to place themselves in a more comfortable

position and go to sleep again without solicitude. They would learn

this for themselves in the course of time, but the physician's

reassurance will enable them to anticipate the lessons of experience

and they will thus be saved worrying.



At times this starting from sleep seems due to some unusual noise. In

certain nervous states even slight noises produce an exaggerated

reaction and there seems to be a surprising, almost hypnotic, acuity

of hearing just at the moment when all the other senses are going to

sleep. Any of the small noises that sound so loud in the stillness of

the night may serve to wake the patient so thoroughly after a

preliminary doze that sleep is disturbed for some time. As a rule,

however, such noises would not disturb people if they were in normal

healthy condition, or at least the disturbance would be only

momentary. The solicitous effort that some people make to get away

from every possible noise is an attempt in the wrong direction. We

have heard of people building special houses, or noise-proof rooms in

the center of houses where they hoped it would be impossible to be

disturbed. What is needed is not so much an effort to secure

absolutely noiseless surroundings, which is almost impossible in any

circumstances, be it city or country, but to change the patient's

physical condition so that slight noises are not reacted to so

explosively. There are many general directions for this and certain

drugs, as the bromides, are of distinct service. On the other hand,

the taking of cinchona products seems often to emphasize it.



I have found that two classes of nervous patients particularly were

likely to be disturbed by these starts in their sleep. The first class

is perhaps the larger. They are the patients who do not eat enough.

They will usually be found to be underweight and to be nursing some

thought with regard to their digestion, or some supposed idiosyncrasy

towards food that is keeping them below the normal weight for their

height. Nothing makes sleep lighter than a certain amount of hunger.

This hunger may be disguised so completely, or so covered up by the

patient's persuasion that more food cannot be taken without serious

gastric disturbance, that it may pass utterly unnoticed. When such

patients are disturbed early in the night, it usually means that

besides taking a not quite sufficient amount of food they are taking

more tea or coffee or some stimulant than is good for them. I say some

stimulant because in several cases that I investigated rather

carefully the cause seemed to be the alcohol taken with one of the

largely advertised patent medicines, a supposed digestive tonic,

consisting mainly of dilute alcohol, and really about as strong as

whiskey. When the tendency to be startled occurs in the early

mornings, then people need to eat something simple just before they go

to bed.



The other class of cases who are likely to start at night in their

sleep are those who do not get out into the air enough during the day

or who sleep in rooms insufficiently ventilated. At the beginning of

the night the lack of ventilation makes the sleep light and easily

disturbed. After a certain number of hours have been spent in a badly

ventilated room the patient sinks into a rather deep sleep, which is

likely to be dreamy, however, and then he is rather hard to waken, but

wakes not feeling rested, but on the contrary often heavier and more

tired than on retiring. In these cases an investigation of the amount

of air the patient is allowing to enter his sleeping room or that his

circumstances provide him with is extremely important. As for those

who do not get out enough during the day, it is easy to understand

that their sleep may be light. To them, as a rule, it will be a

surprise to find how much depth is added to their sleep by an

additional hour or two in the air. Commonly, people who do not get out

much during the day are shivery and suffer from cold, especially

in the winter time, and so they are likely to keep their rooms rather

tightly closed. In this case they have two reasons for a tendency to

be wakeful, which is emphasized if there are noises near them or if

there is anything that disturbs their sleep.



In young children, of course, it must not be forgotten that starting

in sleep may be due to the twitching pains of a beginning tuberculous

joint disease. At times the children are so young, or the symptoms so

vague and the tenderness, if there is any, so deep, that the real

significance of this may not be recognized. The most successful

treatment for these starting pains in children that has thus far been

found, forms a striking commentary on what we have just been saying

with regard to fitful sleep when ventilation is insufficient or when

the patient has not been out of doors enough during the day. The

children from the New York hospitals who in recent years were taken

down to Sea Breeze during the autumn and winter and made to live in

wards, the windows of which were constantly open so that the

temperature was often below fifty, so that doctors and nurses had to

wrap themselves up warmly and sometimes cover their heads and their

hands, had all been sufferers from these starting pains before this

experience, but gradually they lessened in frequency until after a few

months the crying of a child at night because of these pains was

extremely rare. The lesson is evident, and abundance of air not only

cures tuberculous conditions, but also makes the nervous system so

much less irritable that starting pains do not so easily affect it.





Noise.--Slight noises often make it impossible for nervous people to

sleep. This is much more a question of personal sensitiveness and

anxious expectancy and over-irritability than anything else. One

distinguished physician whom I knew was extremely sensitive to noise

and would be awake for hours if wakened up early in the night by the

slamming of a door or a call in the street or anything of the kind. He

suffered from insomnia to a noteworthy degree and found to his

surprise that he could sleep better on a train than anywhere else.

After he had lost two or three nights of sleep he actually used to

make arrangements to take a berth on an express train going out of his

city, ride until the morning and then come back. He usually slept well

amidst all the noise and jar of the train, though he would be quite

sleepless at home as the result of even slight noises. I have known

people suffering from insomnia who took a long ocean trip on a slow

vessel and who slept well amidst all the noises of shipboard, but were

light sleepers after landing, and felt that they missed the noise and

bustle. Of course, in these cases the rocking movements sometimes

predispose to sleep. It is not the custom now to rock infants to sleep

and a very definite agreement seems to have been come to among

pediatrists to forbid the practice as harmful. It is probable,

however, that the instinct of the race in the matter was not at fault.

Rocking seems to relax a certain tension of muscles that of itself

prevents the brain anemia which is the physiological basis of sleep.

It is extremely difficult for nervous people to relax themselves

completely, and the rocking movements, by tending to help them in this

matter, are excellent predisposing factors. A rocking chair or a

hammock furnish abundant proof of this.



Noise in general, as regards its relation to sleep, is an extremely

individual matter. Habit plays the largest role in the matter. We all

know the stories of men who have gone to great expense in order

to build noise-proof rooms and yet have found afterwards that they did

not sleep well. The rustle of the bedclothes as their thoraxes rose

and fell in respiration was enough to disturb them when they allowed

themselves to become over-sensitive about noise. We all know how

impossible sleep becomes with a rustle of a mouse in the wastepaper

basket, or the scratching of one on the wainscoting. On the other

hand, anyone who has lived in a large city where past hundreds of

thousands of homes the elevated trains thunder every few minutes all

during the night, or the trolley goes rolling by within a few feet of

the bed, knows, too, that a great many people become accustomed to

noises so as to be utterly undisturbed by them, though at the

beginning any such insensitiveness to noise seemed out of the

question.



I remember having a patient who insisted that he could not sleep so

near the elevated. At the end of a week he had lost so many nights of

sleep that he was almost in despair. If he did get sound asleep he

said he used to hear the thunder of the elevated train coming toward

him in his dreams and he would begin to pull his feet up so as to get

them out of the way of the train, yet always with the feeling that he

could not get them quite far enough, until his knees were almost to

his chin. Under the influence of a little bromides, two hours more of

outdoor air than he had been accustomed to before, and some

reassurance that noise need not disturb sleep at all if taken

philosophically, he learned in the course of two weeks to sleep quite

peacefully and now has lived for ten years where the elevated passes

within ten feet of his window, which is wide open for seven months in

the year and always at least slightly open, except in the most stormy

weather. It is a question, then, of the individual much more than his

surroundings. The problem is to predispose the mind to sleep and then

the senses will not disturb it except under special circumstances.



As a matter of fact, noises usually disturb people very little at

night. The most surprising things can happen between 12 and 3 o'clock

and attract no attention. Burglars calmly blow up a safe in a hotel

confident that if there is no one awake when the explosion occurs

there will be no investigation, because even though people wake up at

the noise, they will wait for its repetition in order to see what it

means, will not get up to investigate, especially in cold weather, and

usually promptly go to sleep again.





Lying Awake.--There are many people to whom lying awake carries with

it a sense of discouragement and dread. They seem to forget that lying

awake and occupation with pleasant thoughts may be made a very

agreeable pastime by those who are not over-anxious to sleep and who

let the pleasant thoughts that may be suggested by the environment or

the noises that are heard flow through consciousness. Everyone knows

how pleasant it is or may be to listen to the rain patter on the roof

of a country house, or to hear the murmur of the ocean or of the wind

through the trees when there is not too much anxiety about to-morrow

and to-morrow's occupations and the necessity for sleep to be ready

for them. Stewart Edward White, in his series of essays on "The

Forest," has a chapter on Lying Awake at Night that can well be

recommended to the attention of those who complain bitterly of an hour

of sleeplessness. Of course, in his case the lying awake is in the

midst of the forest with all the witchery of wind in the trees and the

unusual sounds of forest life, while ordinary lying awake is in

the rather monotonous environment at home, but still there is much

that can be said for his insistence that in peaceful brooding,

faculties revive while soft velvet fingers are laid on the drowsy

imagination and you feel that in their caressing vaster spaces of

thought are opened up. The impatience that comes to so many almost at

once if they fail to go to sleep promptly only serves to keep them

awake just that much more surely.



Very often, as suggested by Mr. White, this wakefulness occurs just

when a good night's rest is surely expected. There is sometimes even a

preliminary period of drowsiness. Then some little noise that

ordinarily would not be noticed at all floats into the consciousness

with a vigor that indicates that one sense is thoroughly awake. The

very surprise of it wakes up the other senses with a start and then

comes the thought that there is to be no sleep for some time. If this

is resented, the period of wakefulness will be all the longer. If,

when it has proved to be inevitable, one sits up quietly, reads a book

for a time, plays a quiet game of solitaire, it may be on a board kept

beside the bed for such purposes, or in some quiet way succeeds in

bothering away the thought of insomnia, then almost surely sleep will

come after a time, quietly and restfully, and the lost period will not

prove harmful. If nature does not want to sleep she must not be forced

into it, but gently led and after a time the wakefulness will

disappear.





Night Terrors.--One of the troubles of sleep that is more often called

to the attention of the physician than almost any other, is the

so-called "night terrors" of children. Little ones wake with a scream,

sit up in bed, evidently terrified, usually trembling, and ready to

seek refuge from something that has seriously disturbed them. Under

Dreams we have called attention to the fact that usually these terrors

are due to a dream. Sometimes the dreams are the ordinary experience

of supposed falling in sleep, from which the patients wake very much

startled, or they are repetitions of exciting scenes through which

they have passed, or of stories that they have heard, or, above all,

plays that they have seen. Ghost stories, for instance, told shortly

before they go to bed will often disturb children. Fairy stories and

the ordinary myths of childhood, usually with a happy ending and

without any serious terrors in them, are not so likely to disturb

them. Melodramatic theatrical performances to which children lend

themselves and their attention with great concentration of mind, have

nearly as much effect on them as if they passed through the actual

scenes. Every physician knows how much a fright is likely to disturb a

child and cause it to wake many a night afterwards in a state of

terror.





Respiratory Interference.--It is particularly important to remember

that any interference with breathing will almost surely wake the child

in a seriously startled condition. Adults are often affected by this

same sort of dream, due very often to some pathological condition in

the throat around which a series of dream ideas collect with somewhat

poignant results. I have known a man suffering from elongated uvula

wake up thinking that he was suffocating because, as he thought, he

had nearly swallowed his tongue, or at least had been trying to do so.

The sensation was so startling that it brought him to his feet at

once. I have known a patient traveling a long five-days' railroad

journey and suffering severely from train catarrh, come to the

persuasion that he might suffocate during sleep because his nose was

completely stopped up and he had not the habit of sleeping with his

mouth open. As a result his sleep was as much disturbed by his mind as

his breathing. If these affect adults so strongly, it is easy to

understand why children should be so frightened by them. Children who

are mouth-breathers from adenoids or nasal obstruction, and still more

those whose nasal breathing apparatus is not completely stopped up,

but who are frequent intermittent mouth-breathers, are especially

likely to be troubled in this way. The neurosis known as nervous

croup, due to a spasm of the vocal cords, occurs oftenest in this

class of children and is an associated phenomenon to that of night

terrors.





Sleeping in the Light.--The habit of accustoming children to sleep

with a light in the room nearly always lessens the depth of their

sleep. They are more easily wakened and their sleep is not so

refreshing. Besides, if they do not grow accustomed to the dark when

they are young, they may always retain a dread of the dark and will

require some light in the room where they sleep. Nature intended that

the eyes and the optic nerve should have as complete a rest as

possible and even with the lids lowered some light stimulus, if it is

present, finds its way to the nerve fibers. Hence the desirability of

having as far as possible an absolutely dark room. For some very

timorous children, this may seem impossible. Many mothers will recall

how awful the dark seemed to them and what shadowy shapes loomed up in

it. It will usually be found on inquiry, however, that in these cases

the children, after having been accustomed to sleep with some light

and after having had all sorts of exciting pictures shown them and

stories told them, were asked to sleep in the dark. From the very

beginning they should be accustomed to sleeping in the dark and then

it has none of the terrors thus pictured.





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