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.

The intimate physiology of sleep is a difficult subject, and the difficulties of its explanations have been the topics of much controversy, and such controversy appears to have issued from various combinations of the teachings of observation, of experiment, and of analogical and other reasoning, upon the phenomena of sleep. I do not propose to follow at length the details of this part of our subject. As a clinical teacher I must not overload your memories, but rather must I try to make easy your mental digestion. For our practical purposes I think we may understand that two distinct, but associated and related, vital changes occur in sleep. The one is some intrinsic change in those ultimate tissue elements of the brain which are concerned in consciousness; the other and “coarser” change is a diminished supply of blood to the brain, and especially to the blood vessels of the cortex of that organ. The former change is at present undemonstrable, excepting by inferential reasoning. Perhaps there is some essential and intrinsic change in the brain, and perhaps there also is some such change in the spinal cord and ganglionic nervous system, both of rhythmic occurrence, and both conditions of healthy sleep. Perhaps there is a functional depression of these parts in sleep, and especially of the cerebral cells, arising from “an accumulation in and around them,” as Sir Thomas Lauder Brunton puts the matter as to the cerebral cells in sleep, of some of the products of normal tissue waste. Perhaps for normal sleep an intrinsic change of this kind must gain the wide distribution I have mentioned. It is likely that there is in sleep a rhythmic change such as I have indicated, and that this change is sustained by the physiological effects of some of the issuants of those tissue changes, muscular and nervous, which especially occur in the active waking state of the body.

Perhaps for our sleep we must drown our cerebral cells in a kind of auto-intoxication with the ashes of our waking fires. We may usefully recall this view of the subject when we use exercise and fatigue as remedies for insomnia. The proof of the other broad change in sleep--namely, diminished blood supply to the brain, and especially to its cortex, rests on inference from physiological analogies, on various observations, and on the solid basis of direct experimental evidence. We must note, however, that the human brain, in its perceptive, cogitative, and volitional functions, in these great divisions of consciousness, is not the only part which sleeps. The whole living body sleeps. The changes which the event of sleep declares certainly extend beyond mere loss of consciousness; they extend to secretion, to the action of the heart and blood vessels in the general circulation of the blood, to respiration, to “reflexes,” and so extend to all the tissue modifications, and to all the other vital activities, upon which such manifold transitions depend. In order to complete your precognitions of the physiology of sleep, before we pass on to consider the several conditions of insomnia and their appropriate therapeutics, I may refer your attention to the admirable accounts of these subjects to be found in the text-books of Dr. Augustus Waller and of Sir Michael Foster. From each of these volumes I offer a brief quotation, which sufficiently illustrates our subject for my present purpose. On that part of his subject which is so important to us from a therapeutical standpoint--namely, the state of the cerebral circulation during sleep, Dr. Waller says:

“Although there is no doubt that in coma--a pathological state similar in some respects to physiological sleep--the cerebral vessels are congested, the observations of Durham on the exposed cerebrum of sleeping dogs, and of Jackson on the retinal vessels of sleeping infants, are to the effect that vessels shrink in sleep, and we may therefore feel reasonably assured that the sleeping brain, in common with other resting organs, receives less blood than in its state of activity. Moreover, Mosso’s investigations on exposed human brains afford evidence that the organ becomes more vascular during mental activity....”

That sleep concerns the whole body, and not the brain alone, is well put by Sir Michael Foster. He says:

“Though the phenomena of sleep are largely confined to the central nervous system, and especially to the cerebral hemispheres, the whole body shares in the condition. The pulse and breathing are slower; the intestine, the bladder, and other internal muscular mechanisms are more or less at rest, and the secreting organs are less active, some apparently being wholly quiescent; the secretion of mucus attending a nasal catarrh is largely diminished during slumber, and the sleeper on waking rubs his eyes to bring back to his conjunctiva the needed moisture. The output of carbonic acid, and the intake of oxygen, especially the former, is lessened; the urine is less abundant, and the urea falls. Indeed, the whole metabolism and the dependent temperature of the body are lowered; but we cannot say at present how far these are the indirect results of the condition of the nervous system, or how far they indicate a partial slumbering of the several tissues.”