Insomnia

Part 1

Transcriber’s Notes:

Text enclosed by underscores is in italics (italics).

Additional Transcriber’s Notes are at the end.

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INSOMNIA: ITS CAUSES AND CURE.

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INSOMNIA: ITS CAUSES AND CURE.

BY JAMES SAWYER, SENIOR CONSULTING PHYSICIAN TO THE QUEEN’S HOSPITAL, BIRMINGHAM.

Birmingham: CORNISH BROS., 1904.

PREFACE.

The following pages are the first two of the chapters of “Contributions to Practical Medicine,” as they stand in the fourth edition, 1904, of that book. They include my lectures on the causes and treatment of insomnia, in the necessarily colloquial style in which they were uttered. For the convenience of my professional brethren, these chapters now are offered to them in a separate form in this little book. Every word has been revised and many additions have been made, by the fruits of later experience, for the sake of clearness, completeness, and precision; this has been done with hope of usefulness in medical practice, and with the aim of accuracy in diagnosis and success in therapeutics.

31, TEMPLE ROW, BIRMINGHAM, 1904.

CONTENTS.

PAGE

I. THE CAUSES OF INSOMNIA.

The appetite of sleep.--The physiology of sleep.--Etiology of insomnia.--Symptoms of insomnia.--Intrinsic insomnia.--Varieties of intrinsic insomnia.--Psychic insomnia.--Emotional shock and prolonged mental strain as causes of insomnia.--The nervous temperament.--Symptoms of intrinsic insomnia.--Toxic insomnia.--Insomnia from tobacco.--Alcoholic insomnia.--Insomnia from tea or from coffee.--Gouty insomnia.--Senile insomnia. 9

II. THE CURE OF 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. 47

I. THE CAUSES OF INSOMNIA.

The appetite of sleep.--The Physiology of sleep.--Etiology of insomnia.--Symptomatic insomnia.--Intrinsic insomnia.--Varieties of intrinsic insomnia.--Psychic insomnia.--Emotional shock and prolonged mental strain as causes of insomnia.--The nervous temperament.--Symptoms of intrinsic insomnia.--Toxic insomnia.--Insomnia from tobacco.--Alcoholic insomnia.--Insomnia from tea or from coffee.--Gouty insomnia.--Senile insomnia.

The important subject of insomnia has engaged my attention for a long time. In 1878 I delivered a clinical lecture on the causes and cure of insomnia to the students of the Birmingham Medical School, in the Queen’s Hospital, and the matter of this discourse was afterwards further published in The Lancet, on June 15th and 22nd of that year. This lecture I revised and rewrote entirely afterwards, embodying in it some additions from my later experience in practice, and, so enlarged, it was included in each of the two editions, of 1886 and 1891, of my “Contributions to Practical Medicine.” In the autumn of the year 1900, I reviewed the subject again in two clinical lectures which I gave at my hospital, and these were issued in print in The British Medical Journal, on December 1st and 8th, 1900. These last lectures, in which I have tried to bring their subject up to a point at least abreast of our latest knowledge in the principles and practice of medicine, I have revised and rewritten; and I have amplified them, especially in their therapeutic parts. So rewrought, they form the contents of the following essay. This work, done as to the causes and cure of insomnia, that is, done as to particular diagnostic and therapeutic efforts in which the skill of the physician and the resources of our art are often taxed severely, in the intricacies of a difficult, delicate, and abstruse subject, I have tried to accomplish in the spirit of the Baconian philosophy, in the spirit of that aphorism of Bacon which Sydenham prefixed to his renowned “Tractatus de Podagra et Hydrope,” namely, “Non fingendum aut excogitandum, sed inveniendum, quid Natura faciat, aut ferat.” The result of my pleasant labours I venture now to offer to the judgment of my profession. My lectures on insomnia were delivered for the instruction of medical students in my clinical class; they are further published in these pages in the hope that they may help my medical readers in practice. In view of the conditions of the original delivery of these utterances, I have decided, in revising them, to preserve their colloquial style. Furthermore, in preparation for this present publication of these lectures, (1904,) I have revised them again, and made some additions to the therapeutics of my subject.

Sleep is a function of life, and life, in some sense, may be said to be a function of sleep, in man, in the animals which are a little lower than he is, in some sort in plants, in everything which lives. The living organism which cannot sleep cannot live. For all beings endowed with the crowning mercy of consciousness sleep is a pleasure as well as an appetite, and it is a necessity as well as both. For these conscious beings, strung as they are in their sentience to the most exquisite responses in the world’s vast chorus of living harmonies, sleep is indeed and in truth “tired nature’s sweet restorer.” For man, at the head of such beings, and perhaps the only of them which knows the cark of a mind’s unrepose, or the wear of “that unrest which men miscall delight,” sleep it is indeed which smoothes out life’s fretting creases and “knits up the ravelled sleeve of care.” That you may become practitioners of medicine you are students in this place of the manifold sciences of medicine in some of their chief practical bearings, mingled with the inexorable simplicities and with the endless intricacies of the art of healing. You are clinical students here of that cherished art of ours, an art which is of men philanthropic and of time perennial, as its lovely figure stands revealed in all its subtle and splendid details, firm and broad based upon the blended foundations of its great constituent sciences. You are students in this hospital I love of that great art of ours in clinical medicine, in its concrete application to individual cases of human suffering, no two of them indeed ever quite identical, no more than are identical a tree’s waving leaves or the billows of the rolling sea. Let us press forward together, in all the absorbing zest of the pursuit which is ours, to the brightest understanding which yet there may be of the intimate nature of sleep. Let us collect, discriminate and sort the causes which make for insomnia. Let us sift and sum up all which our sciences and our art, our experience, and even our empiricism, of which last I am not ashamed, have of tried adoption for its cure. In this work your physiological training, your clinical insight, your utilitarian aim, and even your poetic fancy and your literary culture, may all find coördinated play, in the comprehension and in the verbal depiction of functions and maladies which are intricate with our lives, associate with our highest attributes, and woven in woof and warp into the very texture of all our pains and of all our pleasures.

Favoured by your kind attention, I purpose to offer you some considerations upon the vital function of sleep, and upon the conditions, causes, and cure of insomnia, based upon a somewhat long and successful experience of those subjects in practice, as a physician. These subjects are certainly of first-rate importance in relation to our knowledge of the science and our practice of the art of medicine. Possibly you may scarcely be able to appreciate their relative importance while you are, as yet, only hospital students. Later in your careers, when you become engaged in actual practice among the sick, and especially when you take part in what is called private practice, often will you be confronted by the perplexities of insomnia, and often will your pleasant duty lie in successfully unravelling the causes of sleeplessness, on that soundest principle of causation and of therapeutics, cessante causâ cessat et effectus, and in curing insomnia by counteracting those causes, and by making their tiresome and diresome effects to cease. I hope to be able to show you that in such happy results the science and the art of the physician may play a successful part. Like thirst and like hunger, sleep is an appetite. We may define an appetite, in the words of the philosopher Bain, to be a craving produced by the recurring wants and necessities of our bodily or organic life. An appetite, strictly so-called, has two characteristic marks, and these marks are strikingly characteristic of sleep; these marks are two conditions which are true to sleep--namely, its periodic recurrence and its organic necessity. We know that the natural course of a human life brings on sleep without the volition of the individual willing the event. The true character of sleep as a veritable appetite appears when it is resisted. Under such resistance the individual person experiences what is called, in metaphysical parlance, a “massive” form of uneasiness, discomfort, and pain. The will of the individual, in the presence of this uneasiness, is energetically urged to remove such discomfort and unrest, and is urged from pain towards pleasure, is urged to obtain the gratification of relief in what Bain called “the corresponding voluminous pleasure of falling asleep.” In this imperatively urgent volitional impulse is the appetite of sleep. Sleep is a desire; with the further characteristics of its organic necessity, and its periodic recurrence, it ranks as one of our appetites.

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