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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

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

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

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

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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