Psychotherapy Part 77

He lived to the age of eighty-five. I know one of our most distinguished workers in medicine here in America who was so busy and so tired at the end of his day that he could not write his book. He would fall asleep on his chair at his desk to wake up only when the milkman came in the morning. He had constructed for himself a special stool without back or sides, shaped like a bench, so that whenever he fell asleep on it he fell off. The fall would wake him up and he would then go on with his work for some hours. He did this sort of thing for many years, and yet he is alive and in the full possession of intellectual health at the age of eighty-three. He learned this expedient from a German professor of medicine who told him of it and at the same time told him that it was no uncommon practice among German professors. Indeed, most of the famous long-livers of the nineteenth century were also well known for the small amount of sleep they required, and apparently there is no need of being anxious lest loss of sleep should prove serious, unless one is adding to whatever detriment to health it may be by worrying about it find so setting two damaging factors at work.

TREATMENT

Probably the most important immediate a.s.surance that can be given to those who come complaining of insomnia is that practically no one has ever {654} been seriously hurt by the wakefulness called insomnia.

Patients suffering from brain tumors, from serious disturbance's of cerebral circulation that give objective signs, from various organic diseases, as of the heart or liver, or certain const.i.tutional diseases, have been made worse by the wakefulness induced by their affections. In the cases where there were no definite objective signs and wakefulness was the only symptom we have no cases on record of serious injury resulting. Men have come complaining of wakefulness for days or weeks and sometimes, though it is strange to understand it, for months or even years, and yet have lived their lives without serious developments and have neither gone into insanity nor into any premature loss of vitality, much less a fatal termination. It is not subjective symptoms but objective signs that are of value for the diagnosis of the serious organic conditions. This rea.s.surance lifts a load from patients' minds at once and does more than anything else to relieve them of the burden of solicitude which is the main factor in the continuance of their insomnia.

Suggestive Treatment.--The psychotherapy of sleep consists in changing the patient's att.i.tude of mind toward his sleep. It is quite impossible for him to sleep normally and regularly if he worries much about it and if the afternoon and evening hours are mainly spent in wondering whether he will sleep, anxious as to when he is going to sleep like other people, marvelling how long he will last in health and sanity if his tendency to wakefulness continues. There is no factor so strong in insomnia as getting one's self on one's mind. It weighs as an intolerable burden, an incubus that is sure to keep its subject awake. Insomnia is a mental and not a physical ailment in much more than nine out of every ten cases. It is not the brain but the mind that is at fault. Patients must be made to realize that if they go quietly to bed, confident that if they do not sleep the early part of the night they will sleep later, and that in case they should lose considerable sleep, so long as they lie quietly for eight hours in bed, their physical organism is not likely to come to any serious trouble. They must be quiet, peaceful and unworried. They must not begin to toss at the first sign of not going promptly to sleep for by so doing they may put off completely the possibility of falling to sleep. Finally they must prepare for sleep by pa.s.sing a quiet evening, as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at least obviated. These are very different in different individuals and the suggestion of getting them out of the way helps a great deal in making people realize that they are better prepared for sleep than before. They have been keeping themselves awake by contrary unfavorable suggestions. They must be taught to aid themselves in going to sleep by a series of favorable suggestions attached to the doing of certain things that are helpful and, above all, avoiding acts of various kinds that have an unfavorable suggestive influence. In this way an acc.u.mulation of suggestions can be secured that will prove helpful.

Drugs.--Of course, patients must be warned with regard to the taking of drugs. Certain drugs may be taken for an occasional loss of a night's sleep, where the loss of sleep is regular and frequent, however, drugs are sure to do more harm than good. Opium leads to a serious habit, chloral is dangerous because it must be increased, most of the coal-tar somnifacients produce {655} serious after results and their physical effect is in the end probably more deleterious than would be the loss of the sleep which they are supposed to counteract.

This is true for even the vauntedly least harmful of them, and it is important to make patients understand it.

External Conditions to be Inhibited.--In the treatment of insomnia two sets of inhibitory conditions are particularly to be looked to, those external to the patient, and those internal. Unless every possible obstacle is removed there can be no a.s.surance of the relief of sleeplessness, while very often the careful regulation of a few conditions that are disturbing the patient will bring sleep fully and promptly. It is curious what small annoyances will sometimes prove disturbing.

_No Pillow_.--I have found patients who had heard somewhere the idea that it was natural for man to sleep without a pillow. The pillow in this theory was supposed to be an added refinement of men in a state of luxury, but a real degeneration opposed to nature, and the many presumed benefits of sleeping on a perfectly level mattress with the head no higher than the rest of the body was emphasized. While in ordinary health these patients had found that after the preliminary discomfort of getting used to sleeping without a pillow, they were apparently the better for it. People will feel better for almost anything if they are only persuaded that they ought to. After a certain length of time, however, worry or work had a tendency to keep them more or less wakeful and then insomnia came on, that is, for several hours at the beginning of the night they did not go to sleep and became very much worried about it.

In several of these cases I have found one of the most helpful adjuncts to more direct treatment of their wakefulness was the restoration of the pillow. Just how the hygienic theory of pillowless sleep originated, or on what it is supposed to be founded, I do not know. The only theory of sleep that seems to have many adherents at present is that it is due to brain anemia. With the head a little higher than the rest of the body the force of gravity tends to help in the production of this brain anemia. The experience of mankind seems to confirm this. Certainly, from the earliest records of history men have slept with something under their head, even though they could find nothing better than a log or a stone. To sleep without a pillow is, owing to the conformation of the head and neck and shoulders, almost inevitably to sleep mainly on the back. From the anatomical relations of the internal organs it is easy to understand that sleeping on the side is more comfortable and healthy than sleeping on the back and hence most people naturally take this position.

Relaxation is much more complete and comfort is greater. What the majority of men do is almost surely dictated by instinct, and instinct is the most precious guide we have in the natural functions of life.

We are not so differently formed from the animals that the a.n.a.logy from their habits should not have some weight for us. Patients should then be advised always to sleep with a reasonably firm pillow, not too low, so that the head is a little higher than the body and the lateral position perfectly comfortable.

_Too high Pillow_.--There is an abuse in the other direction of too high a pillow that deserves to be noted. Occasionally the physician hears complaints of waking up with tired feelings in the large muscles of the back of the neck near their insertion into the occiput. This is sometimes complained of {656} as an occipital headache. Not infrequently it will be found that these people are sleeping on pillows that are too large, or that they pile up several of them. Most physicians have found in their experience that having the head quite a little higher than the rest of the body materially aided sleep, especially in elderly people. This is true even when there is no distinct heart lesion, but this favorable position is best secured not by means of one or more high pillows, but by raising the head of the bed, or by the insertion of bolsters beneath the mattress, so that there is a gentle slope upward from the hips to the head. High pillows should, as a rule, be discouraged, especially in young folks where the a.s.sumption of the strained positions which they cause, may encourage various deformities in the anatomy of the head and shoulders so that stoop shoulders or a craned neck result. On the other hand, before attempting to give drugs to elderly people, the arrangement of the mattress so as to put the head a foot, or even more, higher than the body should be tried and will often be found to give relief where other things fail.

_Discomfort Due to Cold_.--In order to sleep well patients must be thoroughly comfortable in bed. In recent years as the very hygienic practice of having a window in the sleeping apartment open has become a rule among intelligent people, sleeping rooms have been much colder than they used to be. Care must be taken lest the active factor in causing wakefulness should be cold. Over and over again I have found that patients who complain of wakefulness, in the latter part of the night particularly, that is, in the early morning, were awakened by the increasing cold because they were insufficiently clothed. Whenever the sleeping room becomes very cold, then, the patient should not sleep between cotton or linen sheets which are likely to induce sensations of chilliness, but in a light woolen nightgown. It is curious what a difference in the patient's feelings is produced by the touch of wool to the skin in cold weather as compared with cotton.

Thin, anemic patients are especially likely to suffer from chilliness.

It must not be forgotten, however, that some stout people, in spite of an acc.u.mulation of fat, are really anemic. Their red blood corpuscles and hemoglobin are distinctly below normal. These const.i.tute some of that large cla.s.s of stout women in whom reduction cures fail because of the anemic tendency. They must be as carefully protected from cold as thinner persons, yet they need fresh air for their comfort and health almost as much as tuberculosis patients. The experience of sanatoria in the Adirondacks and at alt.i.tudes generally shows that for quiet, undisturbed sleep, if the room becomes distinctly cold during the night because of an open window, a hood or night-cap and gloves, as well as the wearing of woolen underclothing, even to stockings, is almost indispensable. In older times, when houses were not well heated, many persons very sensibly wore night caps. Now that a return to cold fresh air in the sleeping room has come many will have to resume the old night-cap habit in spite of cosmetic objections to it.

These may seem little things, but they count very much in relieving disturbed sleep. The curious thing about them is that patients themselves seldom realize that certain common-sense regulations are more important for sleep than formal remedies. They want to be "cured"

of their insomnia, not relieved by suggestion.

_Cold Feet_.--A large number of people have their sleep at the beginning of the night seriously disturbed by cold feet. Some cannot get to sleep for {657} an hour or more, because their feet are cold.

If the patients become worried over this loss of sleep, a real insomnia may develop. It is for these people that the old-fashioned warming-pan was invented and it should not be forgotten that the symptom can be relieved very promptly by means of a hot-water bag or a hot brick wrapped in flannel at the foot of the bed. An excellent practice for very sensitive persons, is to have the sheets warmed thoroughly for a couple of hours before bedtime. This is especially important in damp weather.

The distinguished English surgeon. Sir Henry Thompson, who lived well beyond eighty years of age (when surely he would seem to have some right to do so), wrote a little book on how to be well and grow old and describes a habit which he had acquired and that I have often recommended to patients and friends as well as used myself with advantage when there is a tendency to cold feet, either habitually or occasionally. It is, moreover, useful whenever there is a tendency to insomnia because some exciting occupation has preceded going to bed.

Before retiring Sir Henry used to sit beside his bath tub and let the hot water flow into it over his feet, gradually becoming warmer and warmer, until he could no longer stand the heat. A temperature well above 120 degrees may be borne with comfort after a while, though at the beginning it would seem entirely too hot. The feet are kept in the hot water at least five minutes. When taken out they should be thoroughly red and show evidence of a good deal of blood having been attracted to them. If they are now carefully wiped and rubbed vigorously there will usually be no further tendency to cold feet that night and sleep will come naturally. Sir Henry said that when he had been out at meetings where he had to make an address or had to take part in business of any kind that inclined to make him wakeful, he found this an excellent method of preparing himself for immediate sleep.

It must not be forgotten that the worst forms of cold feet are found among those suffering from flatfoot. The dropping of the arch interferes with the return circulation and also with lymphatic circulation. These individuals feel very tired because of their foot condition, yet their cold feet often disturbs their sleep at the beginning of the night. The only effective relief for this is afforded by proper treatment of the feet. (See the chapter on Foot Troubles.)

_Lack of Air_.--On the other hand, occasionally it happens in spite of all that has been said in recent years about fresh air in sleeping rooms, windows are hermetically sealed and even then people cover themselves with many thicknesses of bed clothing and are too warm. I have found over and over again that where people could not be persuaded to leave a window open all night (and when they are old and deeply prejudiced in the matter I do not insist, for the suggestion of possibly catching cold would almost surely keep them awake), the thorough airing of rooms before retiring made a great difference in the sleep of elderly people. When patients are young, I simply insist on the window being wide open for some time before they go to bed and slightly during the night, except in extreme cold weather. Many a patient who complains of waking several times during the night and being awake for some time on each occasion will begin to have longer periods of sleep without a break if such a change in the ventilation of the room is effected. {658} Anyone who has seen fever patients who had been restless, disturbed and wakeful, sink into a quiet slumber after the room has been thoroughly aired and the temperature of it reduced ten or fifteen degrees, will realize how helpful this same method of treatment will be in nervous, wakeful irritability.

How important air is for the obtaining of the power to sleep for many hours every day can be best understood and appreciated from the habits insisted on for patients in tuberculosis sanatoria as a result of experience. When there is any tendency to a rise in temperature in these patients they are kept absolutely without exercise. They are either in bed or on a lounging chair all day, but they are out in the air or at least close to an open window. As a rule, they sleep some in the morning and then they sleep again in the afternoon. This would ordinarily be fatal to sleep at night in even healthy people taking considerable exercise and therefore presumably tired and more likely to sleep than these patients who had made no exertion during the twenty-four hours; but it is not often, after patients have been for ten days or two weeks at the sanatorium, that there is any complaint of lack of sleep at night. This is true in spite of the fact that patients are often wakened by coughing during the night, yet after a comparatively short interval they go to sleep again and sleep until morning. This is not true when patients do not pa.s.s most of their time in the open air and when their rooms are not well aired.

Sleep at Sea.--I know nothing that is more effective in doing away with insomnia than a sea voyage. The pa.s.sengers sit on their lounging chairs all the morning in the open air, usually sleeping for some time, often for several hours. During the afternoon this is repeated.

In spite of this extra sleep they turn in, not long after ten, and sleep well until morning. There is practically no exercise and the air usually excites such an appet.i.te that five and even six meals a day are consumed. There is no disturbance of digestion unless some special excess is indulged in, and, above all, sleep is rather favored than impaired by the large amount of food taken. This experience which is so common, is very valuable as indicating just what is the best pre-requisite for sleep. It is not exercise and tiredness to such a degree that one fairly drops from fatigue, but such an oxidation of all tissues by the breathing of pure air that there are no toxic waste products left in the system to act as excitants for disturbance of sleep.

Cold Water.--In summer, when wakefulness is due to heat, a cool bath, or at least a rub down with cold water and going to bed without drying is an excellent method of inviting sleep. Under these circ.u.mstances the sheet acts as a soothing cool pack and people who have been wakeful for hours before, or at least have found considerable difficulty in getting to sleep, sleep promptly. The mechanism of sleep-production is easy to understand. There is less blood to go to the brain when the little capillaries at the surface are pretty well extended and after the application of cool water the reaction which follows the closing of the capillaries in response to cold leaves them of sufficient size to accommodate a large amount of the blood of the body. Of course, in both cases there is the suggestive value of a proceeding of this kind so well calculated to predispose the patient's mind to go to sleep without solicitude.

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Diet.--As has already been outlined in the hints that precede, the first thing in the treatment of insomnia is to remove any causes that may be at work in producing wakefulness. Among the most common of these in our modern life is the taking of coffee or tea, important in the order mentioned. Every physician has frequent experiences of people who complain of insomnia, yet who take a cup of coffee late at night. A large proportion of humanity cannot do this with impunity and expect to go to sleep promptly. Occasionally one finds that patients complaining of sleeplessness are taking three to five cups of coffee a day. This must be stopped. A physician may be told by such patients that they cannot get along without their coffee. I have only one answer for this and it is meant to show patients that if they want to sleep they must take the means to secure it and, above all, must remove all disturbing factors. I tell them that if they cannot do without coffee they may continue to do without sleep. If they want to sleep they must give up coffee or at least must limit the amount. I have found it comparatively easy to get people to limit coffee-taking by the suggestion that there should be one tablespoonful of strong coffee taken to a cup of hot milk. This gives the taste, or rather the aroma of coffee, for coffee has properly no taste to speak of, and while, at first, patients crave the stimulation they have been accustomed to, it takes but a few days to overcome this craving entirely.

Usually it is easy to get people to confess that they are taking too much coffee. For some reason not easy to understand it is harder to get them to acknowledge that they are taking too much tea. Coffee is taken with a certain amount of deliberation. Tea may be and often is taken at odd intervals for friendliness' sake and sometimes patients do not know how much they are taking. Six or seven cups a day may be their usual quota, yet they do not realize it and at first are inclined to answer that they take it only two or three times a day, forgetting the little potations between meals. Tea is not so p.r.o.ne to cause wakefulness as coffee, yet the toxic irritant principle in both is the same and when the amount of tea and its strength are sufficient, the same results follow. The tea habit must always be given up if there is complaint of lack of sleep, especially early in the night.

There is a very common persuasion that the eating of food in any quant.i.ty shortly before going to bed, and especially the eating of certain materials, will keep people awake. It is well known, however, that there are a great many people who can eat anything and sleep well after it and young children sleep best when their stomachs are full.

There are undoubtedly idiosyncrasies in this matter that must be respected, but many patients are deceiving themselves. They are eating too little and their wakefulness is more due to the mental state than to anything else. As this contradicts a very prevalent impression, I may say that it is said deliberately and only after much experience with people inclined to be over-solicitous about their diet and their health generally and who were actually producing wakefulness or at least very light dreamful sleep, by their elimination from their diet, and especially from their evening meal, of many nutritious substances.

I make it a rule to insist with patients that if it is more than five hours since their last meal they must take a gla.s.s of milk and some crackers or a cup of cocoa and something to eat before going to bed.

This is particularly important if they have been out in the air much between their last meal and bedtime.

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The Evening Hours.--The use of the hours after the evening meal is an extremely important factor with regard to insomnia. If the patient tries to read the paper or some conventionally interesting magazine or book, thoughts of the possibility of his not sleeping will surely obtrude themselves and he will fail to get to sleep when he lies down.

As a matter of fact, he will have so disturbed himself as to predispose to insomnia. Some quiet occupation, interesting yet not too interesting, that diverts the mind from the thoughts about itself and about sleep possibilities, yet does not excite it, is the best possible auxiliary and preparation for sleep. Prof. Oppenheim has, as usual, said this very well in his "Letters to Nervous Patients," to which we have turned so often:

A great deal depends upon the right use of the evening hours. On no account let yourself occupy them with anxious forebodings about the night. But, on the other hand. It is not at present wise to take up your mind with too exciting thoughts, as the strong after-impression of feeling and fancy may counteract the tendency to sleep. You must find out for yourself whether a quiet game (cards, halma, chess, or patience), the reading of a serious or an amusing book, the perusal of an ill.u.s.trated paper, or a chat with a friend will be most certain to give you that tranquillity of mind through the vestibule of which you will pa.s.s into the temple of sleep.

Direct Sleep Suggestions.--Many plans are suggested by which people are supposed to be able to get to sleep. A favorite and very old suggestion is that of counting sheep go over a fence or something of that kind that is merely mechanical, yet takes the mind from other thoughts. As a rule, any plan involving mental occupation that is meant to produce sleep is likely to react and do harm rather than good. Sleep must not be wooed deliberately but must be allowed to come of its own sweet will. It is extremely important that exciting thoughts and bothering interests be put aside, not at the moment when we want to go to sleep, but some considerable time before. This is not always an easy matter and often requires careful planning. It is worth while doing it, however, in order to secure sleep promptly and not allow a prolonged period to pa.s.s while one is lying awake, for if nervous irritability ensues wakefulness is still further prolonged and the patient may begin to toss and so disarrange the bedclothing and disturb himself as to prepare for several hours of sleeplessness which would not have occurred if there had been an appropriate interval given to preparing the mind for sleep.

Diminishing Solicitude.--Patients must not be too anxious for sleep.

If they worry themselves over the possibility of not sleeping then they will almost surely disturb their sleep, or at least delay its coming. The ideal state of mind is not to bother one's head about it, to lie down habitually at a given hour, compose one's self to sleep with a.s.surance and then wait its coming without solicitude. Many people will say this is not easy to do, but habit makes it easy. Most of our animal life is lived by habit. We are hungry at certain times by habit. Our bowels move at a particular time by habit. We can sleep by habit. If we try to use our intellect solicitously with regard to any of these habitual functions we do much more harm than good. The more anxiety there is about sleep the more likely it is to be disturbed. When the habit of sleep at a particular hour has been broken the best way to regain it is to lie down at that particular hour and then wait patiently for {661} the advent of sleep. If impatience gets the better of us sleep is kept off and will not come for hours. If the patient can lie down feeling "Well, if I do not sleep now I will to-morrow morning" then there is usually little difficulty about sleep.

_Dread of Consequences_.--Many people who suffer from insomnia fear that their loss of sleep will injure their intellectual capacity or make them prematurely aged, or drain their vitality so that they will not have health and strength of mind and body when they grow old. This adds to their solicitude about themselves and inveterates their condition. There is only one answer to this dread, which has no foundation in what we know of actualities, and that is, to tell them the experience of certain persons which absolutely contradicts such a notion. One distinguished physician who, at the age of seventy-five, is writing books that are attracting widespread attention and is doing an amount of work that many a younger man might envy, has told me of all that he suffered from insomnia between the ages of thirty and fifty-five. His mental productivity was much hampered at that time by his wakefulness and anxiety with regard to it. He feared the worst as regards advancing years, yet he is in the full possession of mental and bodily strength well beyond the Psalmist's limit. His is not an exceptional case, for there are many others in my own personal knowledge. Virchow once told me of years when he suffered from insomnia, yet he lived to be well past eighty and then died, not from natural causes, but from an injury. A man who accomplished an immense amount of work in his day in the organization of a great university suffered from insomnia in his younger years to such a degree that his friends and even he himself feared for his mental stability, eventually overcame this symptom completely and went on to years of great active work, dying in the end, not from his head, but his heart.

We have records of a number of such cases. Few of the hard students of the world went through life without having some bother from insomnia.

It is well-known, however, that many of the great thinkers, investigators and discoverers in philosophy and in science have lived long lives well beyond the age of the generality of mankind.

Mental Diversion.--The main thing is to banish the thoughts of one's ordinary occupation as far as that can be accomplished without laboring so intently at this as to give the mind another bothersome occupation. Many people find that a game of cards just before going to bed takes their thoughts off business and worry almost better than anything else. Something like this is needed in many people. Most people must not write for some time before retiring, because writing proves so absorbing an occupation, as a rule, that the mind becomes thoroughly awake and then remains so for some time afterwards. Reading is better, but the reading must be chosen with proper care. An exciting story, for instance, may serve to keep one awake for hours, as everyone knows who has tried and found himself still reading at three in the morning after having begun an interesting book. The reading of works of general information, of travels, of description of places, where it is comparatively easy to stop at any place, of short stories which do not hold the interest beyond a brief period, is much better. Osler's recommendation to have a cla.s.sic author beside one's bed to be read for a few minutes every night after retiring as a preparation for sleep is an excellent remedy for the milder forms of insomnia, as well as a stepping-stone to scholarship.

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William Black in one of his books has a description of an old man who had suffered from insomnia very severely until he discovered a plan of his own to enable him to get to sleep. This consisted in reading the Encyclopedia Britannica. He began at the beginning and read straight ahead, article after article, and volume after volume. He never even by any chance departed from this routine either to look up cross references, or read anything further about men who were mentioned in the article he was going through at the moment and whose names occurred in another volume. He read straight on until his eyes got heavy and then he went to sleep. At the time he was introduced into the story he had already read the whole work through twice and was, I think, at "D" on the third reading. He had had considerable bother about getting to sleep before he adopted this plan, but it proved an always efficient somnifacients. There is a story about an old American farmer who said that he read the dictionary over and over again for the same purpose. The stories were short and disconnected, but they never bothered his sleep, while his wife and daughters were sometimes kept up more than he thought was good for them by their interest in the story paper.

Treatment of Early Morning Wakefulness.--With regard to the disturbance of sleep in the early morning hours there are certain instructions to patients that have always seemed to me extremely important. Most of the patients who complain of wakefulness in the early morning hours are really suffering from hunger at that time.

This is especially true with regard to those who stay up rather late at night. They have their last regular meal about seven or a little earlier, they get to bed at eleven or even later, and some of them, following the old maxim that eating before sleep is likely to disturb it, go to bed on an empty stomach. Whenever more than four hours have pa.s.sed since the last meal the stomach is quite empty, and after the preliminary fatigue has worn off and the sleep has become lighter and the lack of nourishment more p.r.o.nounced a vague sense of discomfort in the abdominal region wakes them, though most of them do not realize that they are disturbed by a craving for food. In a large number of these cases I have found that the recommendation of a gla.s.s of milk and some crackers, or some simple cake, just before retiring does more than anything else to lengthen sleep and prevent what has been learnedly called matutinal vigilance.

After emptiness of the digestive tract, the most prominent cause of wakefulness in the early morning is anxiety about the hour of rising or about some engagement that has to be kept in the early morning. I have known patients who worked themselves up so much thinking over the necessity for rising at a particular hour to catch a train, that they were awake for several hours before they needed to be. Some are much more inclined to this over-anxiety than others. If they move to the country where trains have to be caught regularly, their sleep may be seriously disturbed by this circ.u.mstance. If the trouble becomes acute they must simply change their residence. If it is absolutely necessary that they stay, then they must have someone to wake them at a definite time. This must be someone on whom they can absolutely depend, otherwise the old solicitude will rea.s.sert itself. This seems a small matter, yet I have known serious cases of neurasthenia with annoying digestive symptoms due to nothing else than this morning wakefulness consequent upon overanxiety with regard to trains and other morning engagements.