Psychotherapy

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 accumulation of fat, are really anemic. Their red blood corpuscles and hemoglobin are distinctly below normal. These constitute some of that large class 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 altitudes 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 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 Troubles3.)

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. 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 pass 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 passengers 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 appetite 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 circumstances 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.

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 prone 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 quantity 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 glass 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.

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 illustrated 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 pass 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 pass 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 assurance 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 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 classic 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.

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 passed 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 pronounced 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 glass 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 circumstance. 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 reassert 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.

Habits.—In the correction of troubles of sleep one of the difficulties that the physician has to contend with when patients have grown accustomed to staying up late and finally have so disturbed their sleep mechanism that symptoms of insomnia develop, is the declaration that there is no use for them going to bed early since they cannot sleep. If a man has been accustomed for a long period to go to bed between midnight and 2 a. m. and his habits are suddenly changed so that he goes to bed at ten or even eleven, it is very likely that for some time after retiring he will not sleep. If he grows over-anxious he may toss and become somewhat feverish and then, even when the accustomed time for sleep comes, he may not secure it. Besides, the depression consequent upon failure to sleep when he has fulfilled his physician's directions and when he knows that this is considered an important adjuvant in his treatment, acts as a distinctly discouraging factor. Under these circumstances it is important to recall to him that one habit can only be removed by the making of another. It may be necessary to send him to bed for awhile only an hour earlier than before until he has grown accustomed to going to sleep somewhat sooner, and then this habit, in turn, be changed to an earlier hour so as to secure all the sleep that is necessary.