Insomnia

No “rule of thumb” cure.—Hypnotic drugs.—Risks from hypnotics.—Causal treatment.—Bromide of potassium.—Cure of anæmia.—Alcohol.—Carminatives.—Adjuvant remedies.—Popular remedies.—Rhythmic sleep.—Physical exercise.—Sunshine.—Monotonous impressions.—Bedclothes.—Ventilation.—Food.—Cold.—Toxic insomnia.—Senile insomnia.

There is no “rule of thumb” cure for insomnia. Each case must be separately studied; the details of its cure can only be decided under competent medical advice. I will help you all I can now in this part of our subject; but many remedial details are only suggested in practice by the exigencies of particular cases, and are only developed as the fruit of long experience in the treatment of persons suffering from sleeplessness. I shall tell you something of the use of hypnotic drugs, and of the dangers of some of them; I shall try to impress upon you the importance of stopping overwork, when overwork is a cause of insomnia; and I shall point out to you many hygienic considerations which bear upon the cure of insomnia, and some useful therapeutic adjuvants which I have found helpful to that end in my practice, and which may suggest to you many other successful remedial procedures.

In the treatment of insomnia you may find it necessary to exhibit some of the drugs which are known to you as hypnotics or soporifics; these are remedies that induce sleep. When you have to deal with a case of insomnia do not assume that you must of necessity give a hypnotic drug. I advise you rather to assume that you can cure a given case of insomnia by understanding its particular causation and by remedying the same, rather than by attacking the effect by dosing the patient with some hypnotic. Prescribe hypnotics only in exceptional cases; only administer such drugs when you cannot help it. Your experience in practice will enable you to decide, with increasing precision, when such an exceptional case is before you. Rely, whenever you can, upon an intelligent causal treatment of insomnia, combining such treatment with a judicious employment of some of the non-medicinal helpers of sleep which I am about to describe to you, if such addition to a strictly causal treatment be needed in any particular case. As a rule, the successful treatment of a case of sleeplessness follows from the discovery of its cause. In the severer forms of psychic insomnia, however, it often happens in practice that we must at once secure sleep by the action of some efficient hypnotic. I prefer opium or chloral. By the use alone of one of these drugs we can often quickly cure acute insomnia depending upon some sudden mental shock or strain. You will find that a few nights of sound and sufficient sleep, artificially induced by the exhibition of a reliable hypnotic, will do more than anything else to restore to the brain the power of sleeping without further aid from drugs. Besides chloral hydrate, opium, morphine, and the other soporific derivatives of opium, the chief hypnotic drugs are sulphonal, trional, paraldehyde, amylene hydrate, and the bromides, to which may be added alcohol and affusion of the head with cold water. For details concerning the comparative merits and demerits of chloral hydrate, paraldehyde, amylene hydrate, sulphonal, and trional, I must refer you to the admirable writings of Professor Binz.⁠[9]

Sir T. Lauder Brunton insists upon a well-recognised and valuable therapeutic consideration, namely, that a combination of hypnotics is sometimes more successful than any of them singly. He recommends a combination of “small quantities, such as 5 or 10 minims, of solution of opium or morphine, with 5 grains of chloral and 10 to 30 of potassium bromide.”⁠[10] These and other hypnotics may be variously combined to meet the indications of each particular case, according to the judgment of a skilful adviser.

Here I must warn you very plainly and very seriously of the risks which attach to the administration of powerful hypnotic drugs. Many human lives are yearly lost as the consequence of the taking by sufferers from insomnia of overdoses of hypnotics. All drugs which produce sleep as a physiological effect, and the relief of insomnia as a therapeutic action, with the exception, perhaps, of the bromides, produce stupor rather than sleep in overdoses, which deepens into the sleep which knows no waking when they are ingested or injected in larger doses still. So never allow a patient to dose himself with hypnotics. Keep the matter quite within your own secure hands, upon well-recognised limits of safety. In the less acute and more chronic forms of psychic insomnia, where the sleeplessness or wakefulness usually depends upon prolonged worry or overwork, I employ chloral or other powerful dormitives sparingly. They should only be used as temporary remedies, when it is necessary to secure at once a fair amount of sleep. A patient should never be allowed to swallow chloral or any other of the dangerous but valuable hypnotics whenever he feels so disposed, neither should he apportion their doses for himself; he can only safely take them under direct medical control and observation.

Another important point must not escape from view. It is this: an overworked man or woman must never be permitted to go on with his or her overwork and habitually secure sleep by chloral or by any other hypnotic. In such a case we must relentlessly aim at preventing the sleeplessness by removing its cause, instead of pursuing the illogical and precarious course, into which often a wilful and impatient patient would persuade us, of permitting that cause to continue, and of trusting to counteract or suppress the resulting insomnia, a troublesome effect of that cause, by medicine. Remember that work which prevents due sleep is dangerous work. When a man cannot sleep because he works his brain too much, we must make as a condition of our help that he stop or greatly lessen his labour. Especially should he abstain from mental work for some hours before going to bed. In many persons the cerebral hyperæmia of severe mental toil does not fall down to the circulatory limits required for healthy sleep for several hours after the cessation of such work. But I advise you to be wisely suspicious in practice as to accepting work as a cause of insomnia. Nature provides that disposition to rest shall follow work. It is mostly worry, not overwork, or it is work under wrong conditions, which makes sleep difficult.

Whatever the cause of the insomnia, a holiday, with complete change of scene and with distinct change of activities, will often do much to cure. Great as is the curative influence of new surroundings and of new outlets for energy, in many cases of psychic insomnia we cannot, however, do without drugs. Potassium bromide is by far the best hypnotic in well-nourished patients, and in the slighter cases generally. It is marvellously powerful in producing nervous calm; it is a direct brain sedative, and quite a safe one. But it must be given properly, and in full doses; after getting into bed, 30 to 60 grains, dissolved in water, should be the dose. Sometimes you may usefully combine with it some drug which will favour the contraction of the weakened cerebral blood vessels. For this indication we may give tincture of ergot or tincture of digitalis, one or both.

In many cases of chronic wakefulness arising from prolonged mental strain, the patient is distinctly anæmic. The insomnia cannot be cured unless the anæmia be cured. The pallor of the patient’s face, the lightened tints of his visible mucous surfaces, and his soft and small pulse, declare the condition of his blood. Such a person mostly feels drowsy when he is up and wakeful when he lies down. He needs hæmatinics, of which the best are iron and arsenic, singly or combined. His diet must be generous, containing plenty of fish, meat, and eggs. For such a patient alcohol is often the best hypnotic; its form and dosage need peculiarly precise prescription and careful supervision.

The prescription of alcohol as a remedy in disease is often difficult and sometimes dangerous. To many people a “nightcap” of toddy is a superfluous, perhaps hurtful, luxury. It gives, however, perhaps better than anything else, rest and sleep to the worried brain of feeble persons whose blood is poor. I find that alcohol is the best hypnotic in many cases of chronic psychic insomnia, when the patient is worried and weakly, sorrowful and anæmic. We need not exaggerate our responsibility in the prescription of alcohol; but we should never forget it. I have been accustomed to insist that when we use alcohol, in the form of any of the fluids which contain it, in the treatment of insomnia, we should explain to our patient the reasons for the employment of the remedy, and that we should discontinue this remedy as we discontinue the use of other drugs, when the conditions which called for its exhibition shall have disappeared.

I have found in practice that a carminative, best taken just after the patient be entered into bed for a night’s sleep, is an efficient remedy in some cases of intrinsic insomnia. Such a remedy is indicated when a sense of gastro-intestinal discomfort, often described by a patient as a feeling of “sinking” in the stomach, with or without flatulence, appears in any particular case to prevent sleep. A carminative is a cheering and comforting remedy, which relieves gastro-intestinal discomfort, stomach-ache, or belly-ache, disperses and prevents flatulence, and promotes speedily a feeling of local well-being, and all this so markedly that its name may be justified either by the song of joy which it almost inspires or by a carmen meaning a charm as well as a tune. Oil of cajuput is a reliable remedy of this kind. In its action it is a carminative, an antispasmodic, and a diffusible stimulant. It may be given in a dose of five drops, or a little less or a little more, dropped upon a piece of lump sugar, or crumb of bread. Hot water, as a beverage, is also a carminative, diffusible stimulant, and antispasmodic, promotive of gastro-intestinal peristalsis. I have read that a well-known English statesman, now living, cured himself of sleeplessness by drinking a tumblerful of hot water, “as hot as could be drunk,” before going to bed.

In slighter cases of intrinsic insomnia some of our dormitives which are milder than the ordinary hypnotics are useful. We may now consider these, which may be regarded as adjuvant remedies, of tried adoption. Many of these remedies are what may be called popular remedies, and a remedy, like a person, is not always the worse for being popular; they are “understanded of the people,” and you should understand them too, for it is scarcely convenient that you should run risks of being beaten in your therapeutics of insomnia by a non-professional prescription of a remedy of this class. A drachm of the officinal tincture of hop is a good dormitive. The slumberous repute of hop attaches to its aroma. King George the Third, by the advice of his physician, slept with his head upon a hop pillow, pulvinar lupuli, a pillow stuffed with newly-dried hop catkins. It is recorded that such a pillow was used successfully by our present King in his severe enteric fever in 1871. Dr. Berkeley, Lord Bishop of Cloyne, records: “I have known tar-water procure sleep and compose the spirits in cruel vigils, occasioned either by sickness or by too intense application of the mind.”⁠[11] Tar water, made according to the formula of this prescribing prelate, is still to be bought from pharmacists. Amongst popular remedies for sleeplessness there are: clove-tea; cowslip wine; nutmeg-tea (nutmeg may be narcotic in large dose); fennel stalks, eaten as celery; lettuce, as food, or in some of its medicinal preparations; onions, as food. What may be called the lore of these popular remedies is very interesting; you may pursue it as an instructive diversion, and as one from which you may gather points of use in medical practice.

There are many other matters to which you must give attention in the treatment of chronic psychic insomnia, if you would follow my advice that you should only give hypnotics in exceptional cases, and only when you really cannot obtain a successful result without them. I can now do little more than mention the more important of such details to you.

Some of them you will find useful in some cases, in other cases others. How best to combine them in any given case experience will teach you. Firstly, whether he sleep well or ill, the patient ought from day to day to go to bed and to get up at fixed and regular times. “Lying in bed in the morning” is not a remedy for insomnia. Healthy sleep is a rhythmic act, and rhythmic sleep must be cultivated. The conditions for the periodic recurrence of sleep must be supplied. An afternoon nap for half an hour or so after a meal, with the feet kept warm before a fire, is helpful, and I have found in practice that it conduces to, rather than hinders, better sleeping in bed at night.

Again, daily bodily exercise in the open air, but always short of great fatigue, must be enjoined. What is called carriage exercise is better than no outdoor change at all, but walking is a far better exercise, and cycling better still, and riding on horseback the best of all. A worn and worrying man, habitually wrapt up in an absorbing torture of self-consciousness, exaggerating his subjectivities, and sleeping badly, must perforce come out of himself, and blot out his self-consciousness with the saving graces of objectivities when he mounts a cycle or a horse’s back. Gardening, in the open air, not in conservatories nor in hothouses, affords good exercise, and it is very efficient in keeping up objective attention. Dwellers in towns may find good objective employment, of a kind counteractive of insomnia, in various physical exercises and drills, in fencing with foils, and in other similar recreations, all of which you, as medical advisers, must learn to understand in their several details, so that you may prescribe them intelligently to suit the particular needs and aptitudes of individual patients; many may at least copy Archbishop Whately, who remedied the strain of his logic by splitting his logs, and give their minds a refreshing and recreative objective bent, and their muscles healthy work, by cutting up firewood. As to sunshine, we healers welcome the present therapeutic worship of the sun. Certainly sunshine is a natural tonic and calmative. In practice you may be sure you will find free and long daily exposure to sunshine a valuable adjuvant in the cure of insomnia.

Again, many people have acquired more or less insomnia in the acquisition of the bad habit of thinking out their affairs upon getting into bed. Some patients pursue this bad practice for years, and they often conceal it or disregard it when they seek medical help for sleeplessness. In such a case you must find out this bad habit, and break your patient of it, for the cure of insomnia. Evoke the patient’s self-control in this regard. In such cases especially, and in the cure of insomnia generally, people who find it difficult to get off to sleep have been advised to count monotonously, one, two, three, up to a thousand or more, until they fall asleep; to picture some familiar scene and keep the mind fixed upon it; to repeat the letters of the alphabet over and over again. The late Dr. Pereira gave some interesting illustrations of the well-known fact that a continued repetition of monotonous impressions on the senses of hearing, seeing, or touch, are provocative of sleep. One passage from his monumental work on remedies I may quote to you. Speaking of monotonous impressions in the therapeutics of insomnia, he wrote: “This is the principle of ‘the method of procuring sound and refreshing slumber at will’ recommended by the late Mr. Gardner, who called himself the hypnologist. His method was for some time kept secret, and was first made public by Dr. Binns. It is as follows: Let the patient ‘turn on his right side, place his head comfortably on the pillow, so that it exactly occupies the angle a line drawn from the head to the shoulder would form, and then, slightly closing the lips, take rather a full inspiration, breathing as much as he possibly can through the nostrils. This, however, is not absolutely necessary, as some persons always breathe through their mouths during sleep, and rest as sound as those who do not. Having taken a full inspiration, the lungs are then to be left to their own action; that is, the respiration is neither to be accelerated nor retarded too much; but a very full inspiration must be taken. The attention must now be fixed upon the action in which the patient is engaged. He must depict to himself that he sees the breath passing from his nostrils in a continuous stream, and the very instant he brings his mind to conceive this apart from all other ideas,’ he sleeps. ‘The instant the mind is brought to the contemplation of a single sensation, that instant the sensorium abdicates the throne, and the hypnotic faculty steeps it in oblivion.’”⁠[12]

These various methods seem to be devices for changing the current of conscious cerebration. Amongst my patients I have found the plan of taking deep inspirations commended by many of them. But for the most part these expedients succeed for a night or two only, and they can scarcely be relied upon either exclusively or long. These sundry practices may even keep up wakefulness; when the mind attends to them too closely, they may sustain the self-consciousness which keeps the brain from slipping into slumber. To try hard to go to sleep is often the surest way to keep awake. We do many things best when we forget ourselves, and going to sleep is no exception to the rule.

Again, to promote the sleep of a person in bed, you should make sure that the bedclothes which cover him are sufficient and not excessive. If the covering bedclothes be especially arranged in quantity each night by thermometric guidance, according to the temperature of the air in the patient’s bedroom, so as to secure that the thickness of the upper bedclothes will give to the occupant of the bed a general feeling of sleep-inducing and sleep-sustaining comfort, and not of sleep-preventing discomfort, either from local or from general chilliness or from local or from general over-heating, sleep will be powerfully promoted. And, further, if such arrangements be made with the knowledge and with the interested approval of the patient, or by himself, we gain the valuable adjuvant of his self-confidence as to his sleeping well, and establish in his mind for the particular night before him a happy expectation which is likely to be realised. For your guidance as to the details of practice arising from this indication of treatment, I may tell you that, from observations I have made, I have found that in a large bedroom in the middle of a large house, with a window of the room always kept open, a Fahrenheit thermometer indicated a temperature of 70°, or upwards, in the hottest weather, and of 40°, or less, in the coldest weather, in the country, at an elevation of about 300 feet above the sea-level, in mid-England. At a temperature of 44°, the upper bedclothing should consist of a sheet, three blankets, a light counterpane, and a light small blanket, this last not “turned over” at the upper edge of the bedclothing and not “turned in at the bottom”; at a temperature of 70°, it should be a sheet only. Between these extremes of temperature the changes in the thickness of the covering bedclothes should be gradual. These extremes should be the ends of a series of gradations passing through about nine terms. With a little care you can make a serviceable thermometric register, marking the suitable bedclothing for a given external temperature of the bedroom in any particular case, and so you may cure intrinsic insomnia, and prevent its recurrence.

In all cases, the bedroom window should be open all night and all the year round, and arranged so that it may be so without draught. The head of the bed should be away from a wall. The best bed on which to lie is a hair mattress, covered with a sheet and a blanket, and supported upon a chain stretcher.

In some cases a little food taken just at the time for sleeping is an efficient soporific. You may often observe that the good effects of a little nourishment—a cup of cocoa or a small piece of dry bread, taken upon getting into bed or upon awakening after a slumber which is too short for a night’s rest, are most happy.

You may usefully remember that sleep may often be induced by the temporary application of cold to the head or to the general surface of the body. A person who has been lying awake will often fall asleep at once upon regaining his bed after getting out of bed and sousing his head, neck, and hands in cold water, or after following Charles Dickens’s plan of standing at his bedside until he feels chilly, and thereupon shaking up and cooling his pillows and bedclothes, and then getting into bed.

In the toxic kinds of insomnia we must especially endeavour, as I have already suggested to you, to act upon the maxim, “Cessante causâ cessat et effectus.” We must stop or lessen the consumption of tobacco, alcohol, tea, etc., as the case may be. The sufferer from toxic insomnia will ask you what must be done for sleep. This is not quite the question; the question is not what the patient must do, but rather what the patient must not do. The consumption of something must be left off. When you have found out the what and when of that something, the patient’s self-control, loyal coöperation, and obedience to your directions are essential to your curing the case. A discussion of the treatment of gouty insomnia, and of the sleeplessness arising in some chronic kidney diseases, would involve a consideration of the whole question of the therapeutics of the maladies upon which these forms of wakefulness depend. If you find evidence of copræmia in a case of insomnia, you must, in any case, treat the underlying fæcal retention. Such fæcal retention may be the whole cause, or an active part of the cause, of the insomnia. Senile insomnia is very obstinate. Perhaps in the bromides, with full doses of hop or henbane, we have the most efficient and least harmful medicinal means of relief; while the promotion of sleep may be accomplished by an intelligent combination of some of the non-medicinal measures to which I have referred.

Now I must close our consideration of this interesting subject of the therapeutics of intrinsic insomnia. I have sketched broad outlines for your guidance, which will suggest to you many other details in your practice. That the best physician is the physician who is the best inspirer of hope, Coleridge it was, I think, who so declared. He was largely right. Of course, truthful hope. Certainly is this largely true in nervous maladies. In the cure of intrinsic insomnia, especially, the best physician is one who is a master of his art and withal the most ingenious inspirer of his patient’s desire of cure and belief that it is obtainable.