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Insomnia
F e b r u a r y , 1929]
239
INSOMNIA
TUBERCLE. T'E.BR U A t ~ Y , 1929.
][n$omJlla. Sleep has been described as a " closing for repairs," and of all the many elaborate theories which have been evolved that of rest and recuperation has always been the most acceptable to the human mind. As the plant has its resting stage, so the animal has sleep. The brain becomes antemic, respiration thoracic in character, oxidation diminished, temperature lowered, and many other physiological processes are restricted to a minimum ; even red bloodcells diminish in size. Only those nerve centres which are essential to life appear to remain on duty, and even these are profoundly modified. It used to be claimed that there accumulates in the brain during waking hours a fatigue substance which eventually induces sleep--a " d r u g g i n g of the tissue by its own excreta." Recent researches have contributed not a little to our knowledge of the production of sleep, and they fail to support many of these older notions on this subjeer. Kleitman [1] has made a large number of physiological observations upon himself and upon normal students during periods of experimental insomnia and of subsequent sleep. In his experiments blood-sugar, alkaline reserve of blood, percentage of h0emoglobin, reel and white cell count, body weight, basal metabolic rate, appetite, temperature, all showed no variation from normal during experimental insomnia, but respiration, heart-rate and bloodpressure exhibited a marked decrease, whilst a positive Babinski reflex and other reflexes were present in the sleep which followed. There is, moreover, a greater excretion of phosphates and acids at night which can be reversed by sleeping during the day. Conversely, there is a greater excretion of chloride by day, again reversed by sleep. Further, Kleitmau found that there was some evidence that the diurnal temperature variation is due to alternation of sleep 16"
and wakefulness. Sleep, the author suggests, is due to tile inhibition of the higher levels in the central nervous system. Pavlov [2j, in his brilliant studies on conditioned reflexes in dogs, recently published, has developed the theory of inhibition. During a period, of twenty-five years' patient work on the cerebral hemispheres, he has accumulated a mass of evidence on sleep which cannot be reproduced here. His conclusion is that sleep and internal inhibition are one and the same process, and in some of his experiments he records that the quick transition from full alertness to true physiological sleep was amazing. Internal inhibition during the alert state is nothing but a scattered sleep of groups of cellular structures, and sleep is nothing but internal inhibition irradiated over the hemispheres and lower centres of the brain. Let us turn now to the clinical side of the picture. There is an old adage, " He who sleeps dines." I n tuberculosis insomnia is often an adverse symptom of real difficulty to the physician, and he hasless freedom in the choice of drugs for its relief than has the general physician. The mental tension of the patient's outlook in the early stages of the disease, with perhaps a year or more of enforced idleness in front of him, certain prominent symptoms, such as cough, incident in the disease, the more insidious symptoms associated with toxmmia, are a few of the causes of insomnia the treatment of which may confront the physician. The real lesson of the recent work on sleep and insomnia would appear to be the hope of getting away from the old r u l e - o f - thumb methods of treating insomnia in tuberculosis with drugs alone. The approach to this whole subject is now based on a wider front. No one can read Pavlov's chapter on sleep without realizing that the outlook is changing and that there is room for new clinical research to complete the work of the physiologists and psychologists. REFERENCES. [1] KLEITMAN,!'ft. Amer. Jour. of Phys., 1923, 66, 67.
[2] PAVLOV,I. P. " Conditioned Reflexes," London, 1927.
239
INSOMNIA
TUBERCLE. T'E.BR U A t ~ Y , 1929.
][n$omJlla. Sleep has been described as a " closing for repairs," and of all the many elaborate theories which have been evolved that of rest and recuperation has always been the most acceptable to the human mind. As the plant has its resting stage, so the animal has sleep. The brain becomes antemic, respiration thoracic in character, oxidation diminished, temperature lowered, and many other physiological processes are restricted to a minimum ; even red bloodcells diminish in size. Only those nerve centres which are essential to life appear to remain on duty, and even these are profoundly modified. It used to be claimed that there accumulates in the brain during waking hours a fatigue substance which eventually induces sleep--a " d r u g g i n g of the tissue by its own excreta." Recent researches have contributed not a little to our knowledge of the production of sleep, and they fail to support many of these older notions on this subjeer. Kleitman [1] has made a large number of physiological observations upon himself and upon normal students during periods of experimental insomnia and of subsequent sleep. In his experiments blood-sugar, alkaline reserve of blood, percentage of h0emoglobin, reel and white cell count, body weight, basal metabolic rate, appetite, temperature, all showed no variation from normal during experimental insomnia, but respiration, heart-rate and bloodpressure exhibited a marked decrease, whilst a positive Babinski reflex and other reflexes were present in the sleep which followed. There is, moreover, a greater excretion of phosphates and acids at night which can be reversed by sleeping during the day. Conversely, there is a greater excretion of chloride by day, again reversed by sleep. Further, Kleitmau found that there was some evidence that the diurnal temperature variation is due to alternation of sleep 16"
and wakefulness. Sleep, the author suggests, is due to tile inhibition of the higher levels in the central nervous system. Pavlov [2j, in his brilliant studies on conditioned reflexes in dogs, recently published, has developed the theory of inhibition. During a period, of twenty-five years' patient work on the cerebral hemispheres, he has accumulated a mass of evidence on sleep which cannot be reproduced here. His conclusion is that sleep and internal inhibition are one and the same process, and in some of his experiments he records that the quick transition from full alertness to true physiological sleep was amazing. Internal inhibition during the alert state is nothing but a scattered sleep of groups of cellular structures, and sleep is nothing but internal inhibition irradiated over the hemispheres and lower centres of the brain. Let us turn now to the clinical side of the picture. There is an old adage, " He who sleeps dines." I n tuberculosis insomnia is often an adverse symptom of real difficulty to the physician, and he hasless freedom in the choice of drugs for its relief than has the general physician. The mental tension of the patient's outlook in the early stages of the disease, with perhaps a year or more of enforced idleness in front of him, certain prominent symptoms, such as cough, incident in the disease, the more insidious symptoms associated with toxmmia, are a few of the causes of insomnia the treatment of which may confront the physician. The real lesson of the recent work on sleep and insomnia would appear to be the hope of getting away from the old r u l e - o f - thumb methods of treating insomnia in tuberculosis with drugs alone. The approach to this whole subject is now based on a wider front. No one can read Pavlov's chapter on sleep without realizing that the outlook is changing and that there is room for new clinical research to complete the work of the physiologists and psychologists. REFERENCES. [1] KLEITMAN,!'ft. Amer. Jour. of Phys., 1923, 66, 67.
[2] PAVLOV,I. P. " Conditioned Reflexes," London, 1927.