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.
In a word, insomnia is not a definite affection to be treated by giving one or the other of one's favorite drugs, or if these should fail trying still others, but it is a condition of mind very often predisposed to by certain conditions of body. If this condition of mind can be adjusted by careful attention to the correction of whatever may be physically out of order, then there is every reason to look for definite improvement very soon and complete cure without any delay. Insomnia is not the awful ailment that it is sometimes pictured, nor all that it appears to the excited imagination of the young person who loses a few hours' sleep; but a manifold condition to be dealt with very differently in different individuals, according to the indications of the case. If the patient's confidence can be secured that means more than almost anything else that can be done. If a little patience is exercised in obtaining such definite details of the mental state and of certain physical factors as may seem quite trivial to the patient yet are really predisposing elements for his affection, the therapeutics become comparatively simple. It is the use of tact and judgment in this matter that means most, however, and then very few drugs will be required. Between the habits consequent upon the opiates and certain of the serious hemolytic conditions due to the abuse of coal-tar products, this is a consummation that may well be worked for assiduously.
CHAPTER VIII
SOME TROUBLES OF SLEEP
Certain annoying incidents in connection with sleep annoy those affected by them so much as to arouse them very completely from sleep and make them wakeful for a time. Nothing disturbs most people so much as the thought that some passing incident, a little out of the common, is quite individual and peculiar to them. If they are at all nervous they are likely to think that it portends some serious ailment, either present or about to [{664}] develop. Nothing reassures them more than to learn that these incidents are not so uncommon as they imagine, indeed that many of them are quite frequent, and, above all, that many people who have had them are still alive and well beyond threescore and ten, and laughing at the fears of their earlier years.
Starting.—Perhaps one of the most annoying of these incidental troubles is starting in sleep. It occasionally happens that just about the time a person is dozing off he suddenly starts and, almost before he realizes it, is fully awake, his heart beating emphatically and there may even be a little feeling of oppression on the chest. The cause is not the same in all cases and individual differences are worth investigating. In most people this starting means that there is, for the moment, some mechanical interference with the action of the heart and that a systole has been delayed and has been pushed through with more force than usual because of this delay. A full stomach will occasionally cause this, especially if patients lie on their left sides. In some people even a drink of water taken just before retiring will be sufficient weight to cause this interference with heart action. An accumulation of gas in the stomach will do it by pushing up against the diaphragm. Where there is a distinct tendency to the accumulation of gas in the stomach I have sometimes been sure that the expansion of the gas consequent upon the cozy warmth of the patient in bed, or its greater effect upon the stomach because the relaxation of sleep affected even the stomach walls slightly, was the cause of it. It happens more frequently in the old than it does in the young, but it is observed at all ages and patients are usually quite disturbed about it, as, indeed, they are likely to be with regard to anything that affects their hearts.
The thought that this forcible beat must mean some serious pathological condition will obtrude itself on many people, and if it does sleep is sure to be disturbed. Even though there may be no discoverable lesion of the heart, these patients often, though they are physicians, will worry lest some underlying condition should be developing. The first patient who ever described this symptom to me told me of it while I was a medical student and he is still alive and in good health, though he is past seventy. At the time I went over him rather carefully with the idea that there might be an organic heart lesion, but found none. The prognosis of these cases is always favorable, for there are many who suffer yet live long. I have found if to occur particularly in elderly people when they were a little overtired on going to bed, or in anemic young people when they had had somewhat more exertion than usual during the day. Unless there is really some demonstrable heart lesion the start does not mean anything and patients can be reassured at once. They should be counselled against lying on the left side, though in some of them it will occur even while lying on the right side and then the mechanism of its production seems to be the gaseous over-distention of the stomach. Patients may be told at once that it occurs in a large number of people and then, instead of lying awake and worrying about it as they often do, they learn simply to place themselves in a more comfortable position and go to sleep again without solicitude. They would learn this for themselves in the course of time, but the physician's reassurance will enable them to anticipate the lessons of experience and they will thus be saved worrying.
At times this starting from sleep seems due to some unusual noise. In [{665}] certain nervous states even slight noises produce an exaggerated reaction and there seems to be a surprising, almost hypnotic, acuity of hearing just at the moment when all the other senses are going to sleep. Any of the small noises that sound so loud in the stillness of the night may serve to wake the patient so thoroughly after a preliminary doze that sleep is disturbed for some time. As a rule, however, such noises would not disturb people if they were in normal healthy condition, or at least the disturbance would be only momentary. The solicitous effort that some people make to get away from every possible noise is an attempt in the wrong direction. We have heard of people building special houses, or noise-proof rooms in the center of houses where they hoped it would be impossible to be disturbed. What is needed is not so much an effort to secure absolutely noiseless surroundings, which is almost impossible in any circumstances, be it city or country, but to change the patient's physical condition so that slight noises are not reacted to so explosively. There are many general directions for this and certain drugs, as the bromides, are of distinct service. On the other hand, the taking of cinchona products seems often to emphasize it.
I have found that two classes of nervous patients particularly were likely to be disturbed by these starts in their sleep. The first class is perhaps the larger. They are the patients who do not eat enough. They will usually be found to be underweight and to be nursing some thought with regard to their digestion, or some supposed idiosyncrasy towards food that is keeping them below the normal weight for their height. Nothing makes sleep lighter than a certain amount of hunger. This hunger may be disguised so completely, or so covered up by the patient's persuasion that more food cannot be taken without serious gastric disturbance, that it may pass utterly unnoticed. When such patients are disturbed early in the night, it usually means that besides taking a not quite sufficient amount of food they are taking more tea or coffee or some stimulant than is good for them. I say some stimulant because in several cases that I investigated rather carefully the cause seemed to be the alcohol taken with one of the largely advertised patent medicines, a supposed digestive tonic, consisting mainly of dilute alcohol, and really about as strong as whiskey. When the tendency to be startled occurs in the early mornings, then people need to eat something simple just before they go to bed.