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SAFEGUARDING SLEEP

THE LANCETLONDON: : ST ITRD9_Y, OCTOBEI? 19, 1940

THE insomnia from which many people in bombedareas are suffering may be a symptom of a moregeneral disturbance, but it can lead to an intensifica-tion of fatigue and anxiety-a vicious circle. Shouldthe circle be broken by sedative drugs, as advocatedby Dr. TAYLOR HARRIS in our correspondence columnslast week ? Sleeplessness among these people is theresult of experience of the effects of immediate orremote bombing which has induced an emotionalattitude towards certain stimuli, specially certain

auditory stimuli. Noise alone does not keep peopleawake, once they have had a little time to recognisethat it has no importance for them ; the classical

example is that of the mother who sleeps tranquillynext door to a goods yard but who wakes the momentthe baby whimpers in the next room. She respondsto the emotionally important noise but not to theimpersonal loud noise. If a Londoner regards the gunsas noises which do not concern him, he can sleep ; ifhe has come to regard them as signals that his life isin danger, it is another story. It is the same withsirens warbling, German -aeroplanes humming,shrapnel whistling ; give them personal meaning forJohn Doe or Richard Roe, make them agents ofdread, signals of descending death, and they will wakehim from his sleep all right. Noises, however, are notthe only things that keep people from sleepingsoundly ; discomfort, cold, hunger, unaccustomedcompany or unaccustomed loneliness, misery of everysort may do this, but the remedies for these are chieflysocial. As far as noxious noises are concerned, themeasures for safeguarding sleep are ear-plugs, deepand therefore sound-proof shelters, and sedative

drugs. Ear-plugs are very well in their way, butthere are many people who would prefer to hear thewhistle or the whoosh of the bomb that was makingfor them ; they believe, or feel, that they would thendo something about it. Deep shelters are as yetluxuries for the few. There remain drugs.As sedatives the bromides stood almost alone for

seventy-five years, and large doses can be safelygiven for short periods. But unfortunately theircumulative effects are too serious to justify their pro-longed use. For the past 25 years their pre-eminencehas been challenged by the barbiturates, which weremade available as long ago as 1898 by the work ofNEBELTHAU. PURVES-STEWART and WILLCOX havewarned us of the toxic effects of these drugs, butwhen they are used in the comparatively small dosesneeded to allay anxiety alarming effects are rarelyencountered. The manifestations of idiosyncrasy,especially morbilliform rashes, are seen from time totime, but they are exceptional. Most physicians havehad under their care epileptics who have takenfour or five grains of phenobarbitone daily for ayear or more without showing signs of poisoning. Itis true that these people seem to be more tolerant tothe drug than non-epileptics, but the observationsuggests that the liver can cope w-ith substantialamounts of barbituric-acid derivatives. Our timid

use of these valuable hypnotics is largely attributableto that bogy of therapeutics, drug-addiction. Addic-tion is, in fact, a rare event when considered in relationto the enormous consumption of barbiturates all overthe world.The barbiturates of choice for the present purpose

are those in which the side-chain is oxidised slowly sothat a mild but sustained effect is produced. Pheno-barbitone in doses of gr. 2 twice or thrice daily isparticularly useful, but gr. 2 of sodium barbitone(Medinal) three times a day may be equally satis-factory. Apart from their portability-an importantpoint when they are taken at work-a furtheradvantage of barbiturates over bromides is their

greater selective action on the centres controllingemotional tone; if the dose is carefully adjusted,general depression of the higher centres and associa.tion fibres is slight or absent, and the mental slownessand lethargy, the hangover common after thera-

peutic doses of bromides, are not seen. Experiencein the treatment of peace-time anxiety associated withthe struggle for existence and happiness gives groundsfor the belief that the intelligent use of the barbi-turates in war-time will help the many millions nowfacing the challenge from the air. They will take theedge off anxiety, give the highly strung tranquillityand self-confidence, and will send the weary to bedmore hopeful that sleep will not be awaited in vain.

BIRTH OF A TRADITIONONE day in March, 1838, Mrs. James Crichton of

Friars’ Carse stepped into her C-spring coach, paintedyellow and black, and posted to Montrose. She was

going to see Dr. W. A. F. Browne, and if she liked thelook of him she meant to make him superintendent ofthe new Crichton Royal Institution, now almost com-plete. Her husband, Dr. James Crichton, had left alarge fortune to be applied to such charitable purposesas she and her co-trustees thought fit, and after dueconsideration his bequest had been used to found atDumfries a hospital for the humane treatment of theinsane. Stories of past ill-usage of the mentally sickevoke in us the same disgust as accounts of an earlierbarbarous penal code ; to Mrs. Crichton they werecommonplaces which many of her contemporaries con-trived to ignore. She was one of those, like ElizabethFry, who could not rest comfortably in the knowledgeof abuses ; in the new Crichton Royal Institution theinsane were to be regarded and used as sick people andthe superintendent of her choosing must be a manwho believed in that principle. Dr. Browne, residentphysician at Montrose Royal Asylum, was young, buthe had travelled and studied under Pinel and Esquiroland had written a book called " What asylums were,are and ought to be." She liked him on sight, gavehim the appointment, and posted back to Friars’Carse in her yellow C-spring coach.That was the beginning of a hundred years of sym-

pathetic work for the insane, now commemorated in" The Chronicle of Crichton Royal " (Courier Press,High Street, Dumfries), by Dr. C. C. Easterbrook,superintendent of the hospital from 1908 to 1937. Ina foreword, the late Sir James Crichton-Browne,whose astonishing longevity almost bridged the gapof a century, put down some memories of the hospitalin the days of his father, the first superintendent. Herecalls Mrs. Crichton " as a prim little lady in a black

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gown with a frilled collar and frilled widow’s cap, of asomewhat sombre manner, as was the fashion of thetime," but genial, kindly, well-informed and with asweet voice. Her portrait, reproduced in the book,frilled collar and all, shows her with a pleasing douce-ness and an inquiring eye. Dr. Browne is there, too,and it is not difficult to see in his plain and kindlycountenance the quality that assured Mrs. Crichtonthat his patients would be gently treated. Dr.Easterbrook has told the story of the hospital not asa connected narrative but as a collection of summariesunder the headings of successive years. This has the

advantage of making it easy to follow growth andchange in the hospital departments : and change atCrichton Royal has always been growth in the bestsense. The steady improvement in accommodationillustrates this very well; the hospital, as originallydesigned by Mr. William Burn, was to have been athree-story building carrying the stamp of a lingeringRegency tradition ; it was modified, however, and thebuilding when completed though pleasing and spacioushad lost much of the elegance and proportion of theoriginal design. As the years go by we see this earlybuilding changing, dissolving, spreading, like a plantin one of those nature films which show you a life

history in a few minutes. Here a piece of land isadded, there a new building is opened to receive"pauper lunatics " ; in 1852 new kitchens andbakeries are being built, in 1860 the heavy windowguards and shutters are being removed, in 1867 theinstitution buys its own farm, in 1882 an ornamentaltiled floor and Venetian blinds have found their wayin. And so it goes on. Nowadays Crichton Royalwith its many buildings and acres is what it alwayswas-a mental hospital in the forefront of its kind,leading, not following in the rapid advance of workfor the mentally sick.

SURGERY OF DYSMENORRHŒADYSMENORRHCEA is an economic problem, wasting

many valuable hours of working time in youngwomen. How great this wastage may be is pointedout by MILLER,1 who calculates that 45% of all

menstruating women suffer some discomfort at themenstrual periods, while 17% are seriously incapaci-tated for at least an hour every month and manyfor a longer period, sometimes for a whole day. InCanada the working time lost by women as a resultof menstrual troubles amounts to 9000 days in theyear. A number of useful women are deterredfrom going to work because of their liability to thisrecurrent incapacity. The textbooks of gynaecologyoffer a dispiriting prospect for a woman sufferingfrom intractable dysmenorrhoea. She starts with

analgesic drugs, working up from aspirin to the bar-biturates, with perhaps a dash of belladonna thrownin, on the assumption that the pain is a visceral

spasmodic cramp. She graduates to a dilatation,which offers generously to relieve in 50% of casesand to cure in 25%. If unsuccessful this may be

repeated or she may be straightway promoted toa presacral neurectomy if her doctor is surgicallyminded ; if he is organotherapeutically minded sheundergoes a long and expensive course of cestrin orprogesterone therapy. Meanwhile she has beenadvised by the distaff members of her family to get

1. Miller, N. F. Canad. med. Ass. J. 1940, 42, 349.

married and have a child, but this is no certain cure.As a last resort she is seen by a psychiatrist or bya surgeon who performs a subtotal hysterectomy.It is not surprising that many of these women areultimately branded as neurotics.The true nature of the complaint is concealed

under a multiplicity of largely meaningless terms,which serve as a cloak for our real ignorance of thecause ; thus we have primary, true idiopathic, spas-modic, virginal and even intrinsic dysmenorrhoea;these are separated from secondary dysmenorrhcea.This last is a more reasonable term and includes allthose cases in which the pain first occurs in associa-tion with some definite organic lesion of the uterusor appendages, such as myoma, endometrioma andinflammatory diseases of the adnexa. The groupof organic dysmenorrhoeas is a separate entity andmust be excluded from consideration here since curefollows the ablation or correction of the cause. Thisleaves a large group of so-called functional dysmenor-rhceas in which a careful pelvic survey excludesuterine or adnexal abnormality. O’DoNEL BROWNE 2

makes a strong plea for the subdivision of this classinto uterine and ovarian dysmenorrhcea. He baseshis arguments first on clinical grounds and secondlyon a technique of exclusion by examination which hehas devised himself ; and he then correlates his con-clusions with the physiology of the nerve-supply tothe female genitalia. Clinically the uterus referspain to the midline of the abdomen and alwaysbelow the umbilicus. The character of this painis a sharp stabbing or cramp-hence the term spas-modic dysmenorrhoea. It may also be a dull ache,but subject to exacerbations. Though often pre-menstrual, it may coincide with the flow, to ceasean hour or two after its establishment ; rarely it

persists to the end of the menstrual loss. Ovarian

pain, in contrast to this, may be unilateral or

bilateral or even referred to a side opposite to thelesion ; it is menstrual but chiefly premenstrual,always subumbilical, but for some queer reason

chiefly on the left side and often radiating downthe thighs. Nausea, dyspareunia, dyschezia andeven fainting attacks are inconstant symptoms.Diffuse lower abdominal pain, central and lateral,suggests a mixed uterine and ovarian origin.O’DoEL BROWNE separates these two distinct typesof pain by compressing each ovary in turn betweenthe examining fingers. If this manoeuvre faithfullyreproduces by a deep-sensibility reflex the type ofpain that the patient knows as dysmenorrhcea, thenthe ovary is the origin. He then passes-withoutanaesthesia, but with full aseptic ritual-a uterinesound, and gently stimulates the endometrium ofthe uterus in all directions with its blunt point. Thenature of the pain evoked is carefully noted and if itmimics the pain of the patient’s dysmenorrhoea theuterus is concluded to be the origin. It is importantnot to grasp the cervix with a vulsellum but to con-duct the whole procedure with great gentleness.The sound can be passed blind if a small Cusco’sspeculum is impracticable. Any gynaecologist ofexperience will agree that this examination is quitefeasible. The origin of the pain can thus be attri-buted to uterus alone, ovaries alone, or both.

Surgical correction can be achieved by interrupting2. Browne, O’D. T. D. J. Obstet. Gynæc. 1939, 46, 962.