Purchased for the
University of Toronto Library
from funds donated by
Hannah Institute
for the History of Medicine
iiSLEEP, ^
INSOMNIA, AND HYPNOTICS,
BY
E. P. 'hURdI M. D.,
Membei- of the Massachusetts Aledical Society; Member of the
Cliinatological Society; Member of the Soci^te lU Meeie-
cine Pratique {Paris, France); one of the
Physicians to the Anna Jaqties Hos-
pital, N'ewburyport, ]\fass.
^ 1891,
GEORGE S. DAVIS
DETROIT, MICH. -
1
OCT
IV
1983
y
v^'
Copyrighted by
GEORGE S. DA^^S.
1891.
TABLE OF CONTENTS.
CHAPTER I.
THE I'HYSIOLOGY OF SLEEP.
Page .
General Considerations on Sleep^The Necessity of
Sleep; Proximate Cause or Causes — Functions of
the Cerebrum — Registration of Impressions —
Partial Memories; Sensory and Motor Localiza-
tions — The Cerebrum as an Originator of Energy
— Fatigue under Exertion — Waste and Repair —
Antecedents of Sleep — State of the Circulation
During Sleep — The Sense of Fatigue — Predis-
posing Causes of Sleep— Amount of Sleep Nec-
essary — Dreams— Dreaming an Indication of Im-
perfect Sleep; often a Morbid Symptom 1-28
CHAPTER II.
INSOMNIA.
General Divisions: i, Psychical; 2, Physical Causes
— Pain as a Cause of Insomnia — Insomnia Due
to Overwork of the Brain— Treatment — Insomnia
Due to Morbid States of the Brain — Insomnia of
Respiratory Origin — Insomnia of Heart Disease
— Cardiac Dyspnoea — Insomnia of Gastro-intesti-
nal Origin — Insomnia of Cystitis — Insomnia
from Genital Irritation — Insomnia of Toxic
Origin — Insomnia of Continued Fevers and Its
Treatment 29-88
VI.
CHAPTER III.
HYPNOTICS.
Page.
Opium and Narcotics — Alcohol and Other Stimulants
— Bromide of Potassium and Bromides — Chloral
— Sulphonal — Paraldehyd — Urethan — Somnal
— Amylen hydrate — Chloralamid — Remedial
Measures not Medicinal: (a) Baths, (b) The Wet
Pack, (c) The Turkish Bath, (d) Shower and Jet-
baths, (e) Electricity 89-112
PREFACE.
This little treatise, though long advertised to be a trans-
lation of a recent monograph of Germain S^e in the MMecinc
Moderne, is in reality a product of my own pen, and whatever
merit may belong to it, and all the faults and mistakes, must
be credited to me. The monograph of Prof. See, with all its
excellences, was found to be too brief and too incomplete for
reproduction in the Leisure Library. A book on the subject
had been promised, and the title announced, and I felt con-
strained to make good the announcement by my own en-
deavors; and all that I can say in palliation of my pre-
sumption in attempting to write a treatise on a subject which
has been recently handled so ably by Macfarlane, is that the
topic is one that has intensely interested me, that I have
bestowed on it considerable independent thought, and that I
have endeavored concisely to state, in a common sense and
practical way, the questions presented. It will be found,
moreover, that as long as medical subjects continue to
attract the attention of mankind, so long will there be trea-
tises written on Sleep and its phenomena, and attempts,
scientifically, to explain these phenomena and remedy those
conditions which give rise to that distressing infirmity of our
modern life — Insomnia.
I desire in this place to state, once for all, that any
coincidences between parts of this treatise and articles which
have appeared during the past year in certain medical jour-
nals (the Therapeutic Gazette, the Boston Medical and Sur-
gical Journal, the Medical Age) are explained by the fact
that, in the preparation of this book, I have used material
which I had previously contributed to the columns of those
journals.
E. P. HuRD, M.D.
Newburyport, Mass., Dec. ist, 1891.
CHAPTER I.
THE PHYSIOLOGY OF SLEEP.
It has been sufficiently demonstrated that during
sleep the brain is relatively anaemic. The observa-
tions of Durham, of Hammond, of Mosso, and others,
have proved this. During sleep, all the encephalic
blood-vessels are under a diminished pressure, as
shown by the manometer. And this lessening of the
active flow corresponds with a diminution of cerebral
function. This is in accordance with the facts of
physiology generally: the performance of function is
characterized by vascular fulness and activity; the
cessation of function is attended with decrease of the
vascularity and volume of a part.
The immediate cause of sleep, however, is not
simply the shutting off of a portion of the blood-current
from the brain. The lessening of the blood-supply is
rather the accompaniment than the cause of sleep.
The true cause is the torpor — engourdisse7nent—oi the
cerebral cells. This torpor may be the result of
waste, unbalanced by repair, of the hemispherical
ganglia, which become functionally inactive^ owing
to diminution of oxidizing material, as well as to
clogging of the venous and lymphatic channels by the
accumulated debris of organic combustions.
But this is not all. As the effete products of cell
function have a paralyzing action on the cells them-
selves — a truth exemplified even in the protoplasmic
life of microbes, which are now known to generate by
their activity ptomaines that are microbicide — so
the toxic theory of sleep, first propounded by
Preyer, has much probability in its favor. Preyer
thinks that lactic acid is one of the principal waste
products whose retention in the blood causes sleep,
and refers to experiments of his own where lactic acid
was injected in the veins of animals and produced a
deep somnolent condition which was undistinguish-
able from actual sleep. But lactic acid is only one of
the toxic products of the living economy; the urinary
salts are also destructive of cell life, and every cell
is a laboratory of poisons, — leucomaines — which exer-
cise their injurious effects on the organism as soon as
the emunctories are incompetent thoroughly to per-
form their task of elimination. Bouchard, who has
performed many interesting experiments on animals
by injecting the urine of various physiological and
pathological states, finds that the urine of the day pos-
sesses a toxicity twice as great as that of the night,
and that the former produces narcosis, while the latter
possesses convulsivant properties.*
From these experiments the inference is drawn
that during the period of waking activity the processes
of disassimilation give rise to products which by their
accumulation cause sleep. And this accumulation
takes place because the elimination of these sub-
stances by the urine goes on the more slowly the
* La Midecine Moderne, 1890, p. 183.
— 3 —
nearer we approach the usual period of sleep. On
the other hand, during sleep, the convulsivant sub-
stances which result from denutrition cooperate in
bringing about awakening, f
In accordance with this theory, it might be expected
that there would be a definite relationship between the labor
done and the amount of sleep required — that hard brain
work would necessitate more sleep than muscular work, and
that those who toil little would sleep little. Unfortunately,
theories, like parables, do not always "go on all fours."
The relationship above spoken of is not mathematically
established; the coal-heavers and diggers of the soil are the
best, while the brain-workers are the poorest sleepers, and
those that do little or no work of brain or muscle sometimes
sleep with extraordinary soundness, and even have no diffi-
culty in going to sleep in the daytime.
There is reason to believe that sleep often ensues frcJm
simple torpor or lethargy of the cerebral cells, a state into
which some persons are constitutionally prone to lapse.
The state of. the foetus in utero may be regarded as one of
continuous sleep, and it has been remarked that idiots and
feeble-minded persons sleep much more than active-minded
men.
The Necessity of Sleep. — It is a law of
nature that every kind of force or energy emanat-
ing from the organic or inorganic world shall be
the exact equivalent of some pre-existent kind of
force. This is the doctrine of the correlation and
equivalence and persistence of force now universally
admitted. The power that drives the piston rod of
f G. S6e, loc cit.
— 4 —
the steam engine existed latent in the coal as static
force, originally coming in the form of dynamic force
— light and heat — from the sun, that great primal
source of power.
In the galvanic battery we see chemical force
converted into electricity, and in the conducting wire
we have the transformation of electric force into heat.
In the organic world we witness the metamorphosis
of light, heat and chemism into those forces which are
called vital.*
* " It is now an admitted doctrine that the nervous power
is generated from the action of nutriment supplied to the
body, and is therefore of the class of forces having a com-
mon origin and capable of being mutually converted, in-
cluding mechanical momentum, heat, electricity, magnetism,
and chemical decomposition. * * * * What is called
vitality is not a peculiar force, but a collection of the forces
of inorganic matter in such a way as to keep up a living
structure. * * * * The nerve force that is drawn from
the waste of a given amount of food is capable of being
transmitted into any other form of animal life. Poured into
the muscles during violent conscious effort, it increases their
activity; passing to the alimentary canal, it aids in the force
of digestion; at other points, it is converted into sensible heat;
while the same power is found capable of yielding true elec-
trical currents. The evidence that establishes the common
basis of mechanical and chemical force, heat and electricity,
namely, their mutual convertibility and common origin,
establishes the nerve force as a member of the same group."
— [Bain; Senses and Intellect, p. 65.
The life of the highest as well as the lowest organisms
is characterized by the manifestation of certain activities
— 5 —
It is a truism to say that all organs that
are exercised must have rest. After every con-
siderable effort of the muscular system, a greater
or less incapacity for further exertion results, and
the subjective expression of this incapacity we
call fatigue. The tired muscles obtain a meas-
ure of repair during the intervals of work, and
such intervals may be frequent during the working
hours. We often rest one set of muscles when we are
working another set. Even those actions which are
derivable from the cosmic environment; the energy which
we expend as nerve-force, muscular contraction, thought and
will is but the expression of destructive changes taking place
within our bodies. How much of nerve and muscular activity
is the direct product of the breaking up of ternary compounds
in the organism — fats, carbo-hydrates and glycogen, which are
stored up as " reserves" in the tissues — how much is due to
direct tissue metabolism, it is impossible to say; it is certain,
however, that parts of the body that undergo exercise waste
pari passu with that exercise, and that in undergoing disinte-
gration, the static force that gave them structural form and
function is set free as dynamical energy,' and in accordance
with the substratum throughout which it is liberated, mani-
fests itself as some form of vital force.
Plants expend little motion, and consequently their waste
is inappreciable. Actiniae kept in an aquarium diminish
little in bulk from prolonged abstinence. Even fish, which
are much more active than other aquatic creatures, suffer
little loss of substance when kept long unfed. The same
remark applies with greater pertinency to cold-blooded animals
and to hibernating animals. On the contrary, warm-blooded
animals in a state of normal activity expend much energy and
_ 6 —
most continuous, as respiration and the pulsations of
the heart, have distinct periods of suspension. It is a
mistake to suppose that the heart and lungs never
rest. After each contraction and dilatation of the
heart, as Hammond reminds us, there is a pause of
one-fourth the time of a beat in which the heart rests
and is repaired. Hence the heart may be said to rest
six hours out of the twenty-four. After each respira-
tory act, there is a pause equal to one-third of the
whole time; thus the lungs rest eight hours out of the
twenty-four. But for the busy brain, there are no
sufficient seasons for rest during the working hours.
The latest, most elaborate, most noble product of
evolution, superadded to the spinal and sensory
ganglia of the animal economy ages after the auto-
matic action of these centres had been established by
waste much substance. f This waste must be made good by
repair,and the conditions of repair are a normal supply of food,
a normal circulation, and opportunity for appropriation of
pabulum. If this opportunity be not afforded from moment to
moment; if synchronous with waste, repair cannot go on,
suitable seasons must ensue when the equilibrium may be re-
stored. If the system cannot in its entirety be refected while
work is going on, work must stop while the system is being
refected. The machine is out of repair, and business must
be suspended while it is having an overhauling. These
considerations give hints as to the true meaning of sleep.
t Vide Herbert Spencer's Principles of Biology, Vol. i, p. 170, from
which I have borrowed several illustrations of the law stated. Tlie only
satisfactory explanation of the phenomenon of sleep is furnished by such
biological inductions.
organization, and superadded for the greater elabora-
tion of faculty and for the more complete co-ordina-
tion of faculty with the conditions of existence, the
cerebrum is still the latest development in the evolu-
tion of the individual, and perhaps the most hetero-
geneous and unstable in its molecular constitution.
I do not propose to go into any lengthy con-
sideration of the functions of the brain. I
assume the cerebrum to be the seat of sensa-
tion, thought, volition. The psycho-motor centres
are located in the post-frontal and parietal regions.
No such precise localization for the purely psychical
centres is yet possible. "The endless variety
in the character and complexity of our cerebral
activities," says Macfarlane, " implies the exist-
ence of a like multiplicity of centres." Localization
we do indeed know in part. Ferrier's teachings with
regard to the motor centres for the muscular group-
ings of the face, upper and lower extremities, etc.
(which are mostly located along the fissure of
Rolando), are generally accepted. The visual centre
is in the occipito-angular region; the auditory is in the
temporo-sphenoidal convolutions. The seat of smell
is probably in the tip of the temporo-sphenoidal lobe,
that of taste is in the region of the suMculum cornu
ammonis.
The seat of cutaneous sensation — tactile, thermic,
pathic — located by Ferrier in the gyrus hippocampi
and gyrus fornicatus, seems the rather, in accordance
— 8 —
with a multitude of facts collected by Dana,* to be in
the motor areas of the cortex. A study of cases
shows that the the sensory centres for special parts of
the body, /. ^., face, arm, or leg, are in general iden-
tical with the motor centres for those parts, but are
larger and more diffuse. The tactile sensation seems
to be more strictly confined to the motor areas, f
The centres of the psychical operations are
known to be somewhere in the cortex, but apart from
the general vague division of mind into feeling, intel-
lect, and volition, and the recognition of the fact that
these three aspects of mind are so dependent among
themselves, although characteristic in their manifesta-
tions that no one could exist alone, no further division
of mind is possible in the present state of science.
There is, however, a sort of psychical differentia-
tion with definite localization of which we are war-
ranted in speaking, and as the subject is of import-
ance in connection with the physiology of sleep, I
may be pardoned such digression as may be neces-
sary to set forth views which may now be considered
as data of science.
Ribot, in his "Diseases of Memory," remarks
that in physiology the distinction of partial memories
is now currently received. "Memory resolves itself
into memories, just as the life of an organism resolves
*" The Cortical Localization of the Cutaneous Sensa-
tions," Journal of Mental Diseases, Oct., 1888.
f Dana, loc cit.
— 9 —
itself into the life of the organs, tissues, and anatom-
ical elements that compose it."
As memory is only the sum of partial mem-
ories, and all our knowledge (based on memory) is
primarily derived through the senses, and as all the
sense-organs have their centres in the cerebrum where
the residua of sensations (to use Maudsley's expres-
sion) constitute the memories of each special sense,
so certain diseased conditions may obliterate one set
of sense-memories by destroying their anatomical
substrata, leaving, it may be, intact the memories of
other senses.
Charcot, in a recent lecture, has given us a good
instance of this suppression of certain groups of
memories. It was a case of loss of the mental vision
of objects — forms and colors — coming on suddenly in
a subject noted for great intellectual activity, but
especially for the strength of his visual memory.
This individual would recall the principal features of
a landscape, a painting, a play, with extraordinary ex-
actness and vividness; his imagination was keen, and
he excelled in perspective. He could readily recall
what he had read by the mental images of words,
lines, sentences, etc., presenting themselves. His
memory of persons and places was wonderful. After
the accident to which allusion has been made, and
which seems to have been of the nature of a limited
embolism, he lost his visual memory of forms and
-colors, and was obliged in the management of his
commercial affairs to have recourse to other forms of
memory (the auditive, tactual, etc.), which were un-
impaired. The city where he lived, his very home,
and the faces and forms of the members of his family
were at first strange to him; he recognized nobody
•except by the voice; he could only find his place of
business by inquiry. Little by little his visual mem-
ories returned, but never completely. He had lost
the faculty of drawing; could no longer sketch the
form of any object which he had once seen. His
memory of colors was gone; he could not form the
mental image of black, white, red, etc., and when any-
thing of a bright hue was presented to him, he could
not recognize the color. The larger part of what he-
had learned by reading was forgotten, while the
memory of what had been acquired by the auditory
sense was as vivid as ever.
This gentleman wrote to Charcot that his "in-
terior vision," once so active and perfect, "had com-
pletely disappeared." He could no longer represent
to himself the forms and features of his wife and
children, or any other person or object with which
he had been familiar. His dreams were completely
changed; he now no longer dreamed of persons and
places, but of voices and words. A remarkable con-
sequence of the loss of this mental faculty was the-
change of character which he had experienced. He
found himself much less prone to sorrow, sympathy
and moral emotion than formerly. Having recently
lost a valued relative, he felt much less poignant grief
than we would have felt could he have represented to
himself by the interior vision the physiognomy of this
relative, the phases of the disease through which he
had passed, and especially, if he could have pictured
to himself the external effect produced by this death-
on the members of his family. He concludes his let-
ter by the remark that he is now obliged to say to-
himself the things which he wishes to retain in his
memory, whereas, before the occurrence of his cere-
bral lesion, he had only to photograph them by sight inr
order to remember them.
Charcot concludes some very judicious and in-
structive comments on this interesting case, of whose
details we have given but an imperfect idea, by the
following observations: " It cannot now be denied
that the possible and actual suppression, in numerous
instances, of an entire group of memories, of a whole
category of commemorative images, without the par-
ticipation of other groups, of other categories, is a
capital fact in pathology as well as in cerebral physi-
ology; it leads necessarily to the admission that these
divers groups of memories have their seat in certain
determined regions of the encephalon, and adds an-
other proof to those already existing that the hemi-
spheres of the cerebrum consist of a certain number of
differentiated organs, of which each possesses its proper
function, while remaining in the most intimate con-
nection with the others. This last proposition is,
moreover, to-day generally admitted by those who
study the functions of the brain, not only in animals,
in the laboratory, but also, and especially, in man, by
the procedures of the anatomo-clinical method."
To sum up, then, the cerebrum is the great
centre of sensation, perception, and ideation, of con-
scious, emotional, voluntary activity. Pulses of mole-
cular motion from the brain are being continually
diffused throughout the body, and the healthy per-
formance of its office by every part of the body de-
pends largely on these gushes of nervous energy.
There are differences in molecular activity between
nerve fibres and nerve cells. " While the matter com-
posing a cell is built up of enormously complex ag-
gregates of molecules, wholly unshielded from ex-
ternal disturbance, the nerve matter of a fibre is pro-
tected throughout its entire length by a membranous
sheath. And while it is probable that the action go-
ing on in a cell consists in the continual fall of un-
stably arranged molecules into a state of more stable
equilibrium, from which a fresh rush of blood is con-
tinually raising them to their unstable state, it is
probable that the action going on in a fibre consists in
the successive isomeric transformation and retrans-
formation of the system of molecules which make up
the fibre." '^ The cell is the place where nervous
energy is liberated, while the fibre is a path along
which nervous energy is transmitted."*
The amount of molecular energy locked up in a
nerve centre is proportionate to the amount of unsta-
ble nerve matter awaiting decomposition; and the
* This view is well brought out by Virchow. He be-
lieves that all function (or activity of all kinds in tissues) is
due to changes of place in the minute particles of the cell
contents. This change of place is almost instantaneously
transmitted through all the cells in proximity. A change in
the electrical state of the part is connected with it. Vir-
chow's view that restitution of function does not always de-
pend on a fresh absorption of nutritive material may per-
haps seem novel. Rest alone, he says, is often sufficient to
enable the cells in a very short space of time to renew their
activity. The molecules which had quitted their usual posi-
tion gradually revert to it, and hence are ready for function
again. Virchow seems to have proved this by experiments
on nerves which have been cut out of the body. — [Cellular
Pathology, p. 327.
— 13 —
greater the quantity of motion liberated, the less of
material remains for the liberation of motion.* Hence
the diminished readiness with which the nervous cen-
tres respond to stimuli after a few repetitions of the
disturbance. The amount of explosive material is
lessened with each explosion. The enfeeblement of
nerve-centres when caused by moderate action is in-
conspicuous, for the disintegrated mass speedily re-
integrates itself from the materials brought in the
blood.f But if the stimulation and consequent dis-
charge are violent, or very often repeated, then repair
falls so far in arrear of waste that the nerve centres
become partially or completely incapacitated. ''All the
unstable substance within easy reach of the incoming
disturbance has been decomposed, leaving only such
part as is most removed from ordinary disturbances
and can be affected only by excessive ones." As ex-
amples we need only to be reminded of the tired
horse that needs persistent urging and the continued
and often excessive use of the lash to make him con-
tinue his pace. Also of the effect of friction of the
skin in causing paralysis of the vaso-motor nerves and
cutaneous congestion. The familiar experiment of
the effect of irritating the web of the frog's foot is to
the point. The arteries are at first contracted under
the stimulus; "the strong impression conveyed to the
vaso-motor centres there liberates an excessive dis-
* Spencer's Psychology, vol, i, p.
f Herbert Spencer, loc. cit., p. 89.
— 14 —
charge along the fibres supplying those arteries, caus-
ing spasmodic contraction of their muscular coats.
The second result is that these arteries dilate, losing
their normal contractility; they become distended
with blood, and the part is congested. That this is
due to extreme prostration or temporary paralysis of
the vaso-motor centre has been clearly proved, for if
the nerve-trunk containing the vaso-motor fibres be
dissected out and artificially irritated, the dilated ar-
teries instantly contract."*
Mr. Herbert Spencer, from whom I have bor-
rowed these illustrations respecting the vaso-motor
nerves, has hardly done more than gather up into a
complete whole the generalizations of his leading sci-
entific contemporaries. Virchow, for example, in his
Cellular Pathology, p. 149, has said substantially the
same respecting the action of vaso-motor nerves
under stimulation, and the readiness with which they
are exhausted. In the smaller vessels, with few mus-
cular fibres, the exhaustion follows so speedily the
stimulation that it seems as if the irritant had pro-
duced no contraction, so soon does relaxation follow.
These familiar truths explain why the brain
needs the rest of the night. Repair and waste are
not evenly balanced during the waking hours. Waste
has got in excess of repair. Not that no repair has
been going on during the working hours — nutrition is
actively going on at all times, and in the spinal cord
* Loc. cit., p. 87.;
— 15 —
and medulla oblongata it is probable that repair ever
keeps pace with waste, or falls but little in arrear,
equilibrium being quickly restored. The peculiar
functions of these lower centres are of an automatic
kind, stimuli always producing responsive discharges
along established lines. It would certainly be for the
•advantage of every species in the struggle for exist-
tence that those automatic functions should be per-
formed at such an even, uniform rate that repair and
waste should be in equilibrium. Such is the condi-
tion of these nerve centres. From minute to minute
brief pauses occur, when waste is made good by re-
pair. This was shown to be true in respect to respira-
tion, the pause after each respiratory act giving the
bulb sufficient time for repose and repair.
With the cerebrum the case is somewhat different.
" Its substance is consumed by every thought, by
every action of the will, by every sound that is heard,
by every object that is seen, by every substance that
is touched, by every odor that is smelled, by every
painful or pleasurable sensation, and so on. Each
instant of our lives witnesses the decay of some por-
tion of its mass, and the formation of new material
to take its place."*
Hence the need of that periodical repose we call
sleep. Sleep becomes emphatically "tired Nature's
sweet restorer," "balm of hurt minds," "chief nour-
Hammond, "Sleep and its Derangements," p. 12.
— i6 —
isher in life's feast." In this adaptation of organisms
to the waste of the day and the repair of the night,
Herbert Spencer sees an example of the principle of
survival of the fittest. **An animal so constituted
that waste and repair were balanced from moment ta
moment throughout the twenty-four hours, would,
other things being equal, be overcome by an enemy
or competitor that would evolve greater energy dur-
ing the hours when light facilitates action, at the ex-
pense of being less energetic during the hours of
darkness and concealment. Hence there has neces-
sarily established itself that rhythmical variation in
nervous activity which we see in sleep and waking.'^
(Principles of Psychology, vol. i, p. 88).
Antecedents of Sleep. — There is every reason to
believe that one of the antecedents of sleep is a cer-
tain change in the composition of the blood circulat-
ing in the capillaries of the pia mater, where by the nutri-
tion of the cortical cells is diminished. This change
may be regarded as an accumulation of waste extrac-
tives. There is also doubtless another factor, as
stated by Pflugger; the brain is extremely sensitive
to the want of oxygen, e.g.^ when frogs are deprived
of this element for any length of time, they fall into
a condition resembling sleep. Some experiments of
Pettenkofer and Voit make it apparent that oxygen
accumulates in the blood during sleep to be utilized
during the waking hours; deficiency or absence of
this "change-compelling" element may well cause
— -17 —
that lethargy of function whose full expression is
sleep.*
Another antecedent of sleep is lethargy of the
circulation. There are probably several factors in
this change. Less blood is attracted to the cortex
by the cells becoming functionally inactive, and the
tired brain sends diminished energy to the heart, and
there is a slowing of the circulation. With a diminu-
tion of vaso-dilator influence in the higher ganglia '
there may be an augmentation of vaso-dilator in-
fluence in automatic ganglia lower down (the inhib i-
tory agency of the hemispheres being withdrawn),
hence a narrowing of the calibre of the cerebral
arterioles and a lessened blood supply. During
sleep, then, it is believed that the proper functions
of the cerebrum are mostly suspended, nutrition
only being active; the constricted arterioles supply-
ing just enough blood to the nerve cells that the
requisite reparative processes may be performed.
* These experimenters, by an ingenious laboratory con-
trivance, were enabled to measure the amount of oxygen
inhaled and of carbonic acid exhaled during the 24 hours.
A healthy man was put into the test chambers with the light
occupation of taking to pieces the works of a watch. Of the
total quantity of oxygen inhaled by him, 33 per cent, was
absorbed during the day, and about double, 67 per cent.,
during the night. This goes far to prove that night is the
time for storing up oxygen to be used during the day in the
production of work. — [North British Review, June, 1868, p.
269.
This relatively anaemic condition of the cerebrum
during sleep has been proved by numerous well at-
tested observations, as those of Sir Astley Cooper,
Pierquin, Bonders, Durham, Hammond, Mosso, and
others. The experiments of Hammond were made
on dogs from whose crania portions of bone were
trephined, exposing the brain and its membranes.
The details of these experiments are now sufficiently
known since their publication in his book on "Sleep
and its Derangements." Durham's observations,
which were several years prior to Hammond's, also
pertained to dogs.
Pierquin's case is recorded by Dendy in his "Philo-
sophy of Mystery," and elsewhere.* A girl in Montpellier
had lost a large portion of her scalp and skull. The brain
could be seen for a considerable extent of surface. When
she was in dreamless sleep, her brain was motionless and
low within the cranium; but when her sleep was imperfect
and she was agitated with dreams the cerebrum moved and
beat; more blood coursed through the vessels of the pia
mater, and the brain protruded through the holes in the
skull. * * * When she was awake and in vigorous
thought, the brain swelled, and protrusion was very observ-
able.
Professor Mosso, of Turin, had the rare oppor-
tunity of making similar observations on three per-
sons, each of whom had lost a portion of the skull.
His studies of the cerebral circulation during sleep
* Combe's Physiology, p. 143. Jarvis' Physiology, p.
432. American Annals of Phrenology, No. i, p. 37.
— 19 —
and during the waking moments have been the most
thorough, and go to show: " i. That in the act of
going to sleep a dilatation and relaxation of the ves-
sels of the forearm occur, with a corresponding con-
traction in the vessels of the brain, this change be-
coming most pronounced during deep sleep. 2. That
all external stimulation, however slight, such as a ray
of light falling upon the eye, a noise, etc., is attended
by contraction of the vessels of the forearm, greater
blood pressure, and an increased flow of blood to the
brain. 3. That tjiese changes are accompanied by a
modification of the respiratory rhythm, and an ac-
celeration of the pulsations of the heart. 4. That
during sleep, the quantity of blood in the brain is sub-
ject to fluctuation without any apparent cause. 5.
That all mental activity is attended by an increased
quantity of blood in the brain." *
These facts seem to teach that the sleep state is
attended with relative anaemia of the brain, and that
the amount of blood supply to that organ is in ratio
with the mental activity.
Hammond regards this diminution of the quantity
of blood circulating in the brain as the immediate
cause of sleep, and affirms that whatever cause is
*" Insomnia and its Therapeutics," Macfarlane, p. 16.
Mosso devised special instruments by which he took tracings
of the movements of the brain, the pulsations of the heart,
etc.; he also invented the Plethysmograph, for estimating
the quantity of blood in the forearm and hand.
20
capable of lessening the quantity of blood in the
brain is also capable of inducing sleep.
To this view has been opposed the fact that pa-
tients suffering from general anaemia (from haemor-
rhage, chlorosis, cachexia, etc.), are often the victims
of insomnia, and that conditions of plethora are often
attended with troublesome somnolence. Ligature of
the carotids in animals does not produce a state re-
sembling true sleep, and faradization of the cephalic
ends of the two divided cervical sympathetic cords in
animals, while it produces considerable cerebral an-
aemia, does not bring about the least tendency to
somnolence.*
These objections appear to me to be well taken,
and it seems probable that the vascular and cardiac
modifications are, as Vulpian says, ''only accessory
and adjuvant," " concomitant or consecutive, play-
ing no essential role in the physiology of sleep."
At the same time, there is no doubt that " slight
and gradual anaemia of the brain is conducive to
sleep," and therefore we see the utility, in some cases
of insomnia, of hot pediluvia, cold, wet cloths to the
head, etc.
The Sense of Fatigue. — Subjectively, sleep is pre-
ceded by a sense of fatigue, which is the more pro-
nounced the greater the labor which has produced it.
Fatigue may be regarded as an expression of waste
* See these objections forcibly stated by Vulpian in his
Lemons sur I'Appareil Vaso-Moteur^ t. i, p. 150.
21
unbalanced by repair; according to Preyer, lactic acid
and creatine accumulating in the blood cause this
sensation by their paralyzing action on the cells of
the cortex.
"Fatigue," says Benedikt,* **is a property inher-
ent in all the nervous and muscular tissues; but the
almost unlimited duration of certain automatic move-
ments of pathological nature proves that the fatigue
which supervenes after voluntary movements has its
origin in the motor centers of the cortex. =»=***
The sensation of fatigue is in a certain sense a guar-
anty of safety for the muscular apparatus. In certain
pathological states, often even by the energy of the
will alone it may be overcome. But there then fol-
lows a still greater realization of fatigue, which may
be the result of complete exhaustion."
Normal fatigue easily leads on to a condition of
sluggishness and languor known as sleepiness. The
eyelids feel heavy, the muscles relax, there is an in-
stinctive disposition to shirk work, an inability to fix
the attention on anything which requires thought, a
sensation of supineness and enervation, a considerable
obtuseness of the senses. Yawning is a phenomenon
"indicative of a wearied attention." "The head nods
and droops upon the breast, and the body assumes
that position which is most conducive to ease, com-
fort, and entire muscular inactivity."
Another subjective antecedent of sleep is failure
*Za M^decine Moderne, 1891, p. 67.
22
of the attention. To this end, absence of sensorial
impressions is an important condition of sleep. There
are certain influences which are predisposing causes,
such as darkness and silence and muscular rest.
Habitual sensations, as the continuance of an accus-
tomed sound, are of the same class. It is owing to
the power of habit that some persons can sleep more
soandly in the neighborhood of noisy mills and cata-
racts, than elsewhere, the attention of the individual
being more attracted by the suspension of the sound
than by its continuance; for as the exercise of the
attention implies an awakened and concentrated con-
sciousness, during such exercise sleep is, in the nature
of the case, impossible. Other predisposing causes
are gentle tranquilizing sounds, such as the piping of
crickets, the rustling of foliage, the hum of bees,
hearing a dull book read, etc., which conduce to sleep
by making on the sensorium a series of monotonous
impressions which are neither interesting enough, nor
powerful enough to keep the attention aroused (Car-
penter).
Ovid places the cave of Somnus in the country
of the Cimmerians, the fabled land of shadows, of
silence, and of gloom. The river of Lethe flows there,
and invites to sleep by its murmur, and poppies luxu-
riate before the cave of the drowsy god. Spencer
locates the palace of Somnus in a dull and darkling
part of the earth. Archimago sends a little spirit
down to Morpheus to fetch him a dream:
— 23 —
" He making speedy way through spersed ayre,
And through the world of waters wide and deep,
To Morpheus' house doth hastily repaire
Amid the bowels of the earth full steepe,
And low, where dawning day doth never peepe,
His dwelling is. There Tethys his wet bed
Doth ever lave, and Cynthia still doth steepe
In silver dew his ever drooping head.
While sad night over him her mantle still doth spreade.
And more, to lull him in his slumber soft,
A trickling stream from high rock tumbling down.
And ever drizzling rain upon the loft.
Mixed with the murmuring wind, much like the soune
Of swarming bees did cast him in a swoone,
No other noise, nor people's troublous cries.
As still are wont to alarm the walled towne,
Might then be heard, but Careless Quiet lies
Wrapped in eternal silence far from enemies."
Amount of Sleep Necessary. — As sleep is a con-
structive process, it would seem that the amount of
sleep taken should be proportionate to the mental
and physical exercise of the waking hours. The
reparative value of sleep, however, is more depend-
ent on the depth and intensity of the sleep than on
its duration. The invigoration which follows sound,
dreamless sleep is remarked by every one; a little
sleep of this kind is worth many hours of disturbed,
dreamy sleep. It would seem that absolute quies-
cence and suspension of function is that condition of
the cortical cells most favorable for nutrition and
repair. The principle of making up for lost sleep is
a correct one; persons habituated to six or seven
— 24 —
hours' sleep a day may pass without inconvenience a
night or two without sleep, provided they can make
up for this loss by a more prolonged sleep afterwards.
It is by dint of the habit of sleeping profoundly
when they do sleep, that some persons sleep but few
hours out of the twenty-four, and yet continue in
health. Frederick the Great and John Hunter are
said to have required only five hours' sleep a day;
Pitt used to restrict himself to three hours. The
briefest sleepers are generally men of the greatest
mental activity. The best scholars, thinkers and lite-
rary men, according to Carpenter, do not spend more
than one-fourth of the diurnal cycle in sleep.
Persons of lymphatic temperament are said to be
the greatest sleepers, from natural lethargy of the
nervous centers.
Hard, muscular toil promotes somnolence more
than hard brain- work; the husbandman and day
laborer sleep longer and more profoundly than the
student or professional man. The waking state of
such persons is characterized by great activity; the
wear and tear of the muscular system is immense,
and long seasons of rest are needed, during which
the physical and vital energies shall be largely occu-
pied with the work of muscular reparation. Blood
goes from the brain' to the muscle, and there is rela-
tive anaemia of the cortex, a condition favorable to
the inertia of sleep. Moreover, the cerebral activity
of even the humblest day laborer is not inconsider-
— 25 —
able — the sensory, perceptive, and voluntary faculties
are kept constantly employed during their daily occu-
pations. They often toil for hours in obedience to a
painful exercise of the will, amid an almost overpow-
ering sense of muscular weariness. Now, a purely
voluntary act fatigues the brain more than an involun-
tary or automatic one. Hence, the protracted sleep
of the day laborer must be due in a considerable
degree to cerebral waste.
The relationship of muscular exercise and muscu-
lar fatigue to the intra-cranial energies and circula-
tion may not be demonstrably clear, but the fact is
none the less certain that muscular exertion is one of
the most powerful promoters of sound sleep.
Dreams. — Dreams, from a psychological point of
view, constitute the most interesting phenomena con-
nected with sleep; from a medico-physiological point
of view, they are chiefly of interest as indicating that
the sleep is not sound, /. ^,, only partial. In dreams,
the cerebrum is in part awake; the automatic (earliest
evolved, most organized) centres of mind resume a
measure of their activity, while the will* is still dor-
* I use the term as expressive of the sum of the higher
mental activities. These may be regarded as the latest
•evolved, most consummate results of evolution — the last
developed in individual biological history and the soonest
lost. The effects of physical tire earliest manifest themselves
in modifications of the functional efficiency of the organic
substrata of these faculties; the truly automatic substrata
are more stable and capable of more prolonged, unresting
— 26 —
mant. A limited area of brain is brought into a con-
dition of waking excitement; certain ideas and emo-
tions result, which, not being modified by comparison,
and reflection by other ideas and feelings which are
asleep, present a phantasmagorical succession of
images to the consciousness.
Hammond suggests that the cause of that sus-
pension of the judgment which characterizes sleep
resides in some alteration in the circulation of the
blood in that part of the brain which presides over
the judgment, whereby its power is suspended and the
imagination left free to fill the mind with its incon-
gruous and fantastic images.
And yet, judgment, like volition, is a very com-
plex phenomenon. It implies the possession of one's-
principal mental acquisitions, one's stores of experi-
ences; it implies comparison, choice. The experi-
ences themselves may not be actually present to the
consciousness, but certain residua — unconscious gen-
eralizations — from these experiences, must be there
that judgment may be exercised on the case at issue.
It is plain that the imperfect sleep consciousness is
inadequate to such exercise of comparison.
We have not time to linger on this interesting
topic covering which volumes have been written. It
is perhaps better to leave this domain to the poet and
activity, as is shown by abundance of pathological facts.
(See Hughlings Jackson's Lectures on Evolution and Dissolu-
tion in the Nervous Centres.)
— 27 ~
the metaphysician, to whom, as rightful property,
dreams belong. We may remark, in passing, that
the loss of association of ideas prevails as much in
dreams as in the waking state.
" Lulled in the countless chambers of the brain
Our thoughts are linked by many a hidden chain.
Awake but one, and lo! what myriads rise.
Each stamps its image as the other flies.
Each thrills the seat of sense, that sacred source
Whence the firm nerves direct their mazy course,
And through the frame invisibly convey
Their subtle, quick vibrations as they play."
The dream images that 'Hhrill the seat of sense"
are a revival of registered sense impressions rendered
peculiarly vivid because the natural channels between
the outward world and the sensorium are closed.
Hence, not being corrected by an incoming torrent of
objective impressions, they engross the relatively
meagre and imperfect sleep-consciousness, and seem
realities. The same brain tract which is excited by
the objective sense impression is occupied by the
revived subjective image (Carpenter, Bain, Spencer).
If we dream of things seen or felt or heard, it is the
centres of those respective senses that are called into
action, with such portions of the hemispherical (cor-
tical) ganglia as have organic connections with them.
It is remarked by Macfarlane that when many cen-
tres are active, dreams are consistent and coherent,
while when few centres are working, they are unreal
and extravagant, i. e., the difference in the quality of
the dreams depends on the depth of the sleep.*
Dreams are principally of interest to the phy-
sician as being an indication of unsound sleep. The
dreaming period seldom comes on in health till the
time for waking approaches. Then the centres that
are most automatic one by one recover their functional
activity, those which represent the higher mental
powers still remaining dormant. It is doubtless true
that in sound sleep we never dream. If anything has
been settled by the labors of physiologists during the
past forty years, it is I think this, that the vascular
and other conditions of perfect sleep forbid any men-
tal manifestations. The condition of sound sleep is
one of complete psychical inertia. A transcendental
philosophy which teaches that the mind is always
conscious and always active must have some higher
foundation on which to rest than common sense and
experience.
If the dreaming period comes on early, it is evi-
dence of some irritation in some part of the body
which is disturbing the rest of the brain. Thus, un-
seasonable dreaming is often symptomatic of indiges-
tion, teething, a febrile condition, the influence of
some toxic agent (tea, coffee, alcohol, etc.), and when
dreams become pathological, it is a part of the phy-
sician's duty to discover the cause and remedy it.
* Loc. cit., p. 31.
CHAPTER 11.
INSOMNIA.
If the essential condition of sleep be torpor of
the centres of conscious mentality, everything which
excites these centres and keeps them functionally
active will promote insomnia.
In discussing the causes of insomnia I shall adopt
in part Professor S^e's classification, and shall con-
sider these cases as: I. Psychical; and, II. Physical.
I. Under the head of Psychical Insomnia are
included cases of sleeplessness due to to mental emo-
tion, to thought, worry — /. e.^ internal causes not di-
rectly dependent on organic states or outward excita-
tions. This kind of insomnia is that with which the
author of " Night Thoughts " was (presumably)
affected:
" From short, as usual, and disturbed repose,
I wake. How happy those that wake no more!
I wake emerging from a sea of dreams
Tumultuous, where my wrecked despondent thought
From wave to wave of fancied misery
At random drove, her helm of reason lost! "
Insomnia of the psychical order is illustrated in
the student who is anxious about his examinations
and cannot obtain rest till the result is known; in the
candidate for political honors who cannot sleep till
the election is over and his fate is decided; in the
mother who will watch over her sick child night after
— so —
night, not closing her eyes till the crisis of the sick-
ness is passed. Multitudes of such instances happen
in daily experience. In order that natural sleep may
occur, the mind must be tranquil; on this point it is
useless to enlarge.
The' pure hypnotics — chloral, paraldehyd, ure-
than, sulphonal — are generally quite efficacious in the
insomnia due to emotional causes, the intensity of the
insomnia being of course propor^onal to the intensity
of the disturbing cause. Business cares and anxieties
of all kinds, and, I may add, homesickness and
disappointments, often produce a most obstinate
wakefulness, which hardly yields to even large doses
of chloral; sulphonal is almost without effect. In
such cases the therapeutist is almost without re-
sources.
" Who shall minister to a mind diseased,
Pluck from the memory a rooted sorrow,
Rase out the written troubles of the brain,
And with some sweet oblivious antidote
Cleanse the stuffed bosom of that perilous stuff
Which weighs upon the heart?"
Under the head of psychical insomnia may also
be classed sensorial disturbances of an unusual, in-
tense, or persistent nature, whether of sight or of hear-
ing, which prevent sleep. But these causes are so
familiar to everybody that it suffices simply to men-
tion them — illustrations are innumerable. Prof. See
alludes to the effect often produced by prolonged
— 31 —
application of the eyes to reading and to the micro-
scope, especially in the evening; this frequently pro-
vokes subjective excitations— "phosphenes "—whose
•constant reappearance prevents repose. It is useless
to say that this kind of insomnia, being caused by
physical agents, might properly come under the next
division.
II. Under the head of Physical Insomnia, I
shall, I, take up the group of physical causes, fore-'
most among which are organic conditions productive
of PAIN. If an irritation emanating from any organ
or tissue may keep consciousness aroused and the
cortex active when not painful, how much the more
will it be likely to produce insomnia when' raised to
that degree of intensity known as pain ? Pain implies
a peculiar excitation of the sensory cortical centre^
and an awakened consciousness, and its very exist-
-ence is inimical to sleep.
It is not necessary to dwell long on the causes of
pain. It may be peripheral or visceral; may be due
to inflammatory states of the nerve centres or their
membranes, or to functional disturbances of nerves,
contituting neuralgia; to conditions of anaemia or
hyperaemia; to inflammation and suppuration; to ul-
cerative processes; to the pressure of tumors, exuda-
tions, etc.
The leading therapeutical indication is to remove
the cause. This may be easy of accomplishment, as
when the pain is from a carious tooth, or an abscess,
— 32 —
or it may be impossible to meet, as in many cases of
locomotor ataxia with douleurs fulgur antes ^ in the pain
of internal cancer, etc. The pain of migraine offers
this peculiarity that it generally yields to the desire
for sleep; other forms of neuralgia are apt to be
worse at night. Often the causal indication must be
kept in abeyance; the first thing to attend to is the
indicatio morbi. A hypodermatic injection of morphine
may be imperatively required, and it may be waste of
time to attempt to relieve the pain by other remedies^
In the insomnia due to cancer, to acute inflammation
(pleurisy, pneumonia, peritonitis, pericarditis), abscess,
the lightning pains of ataxia, to severe neuralgic at-
tacks, it will not always be possible to obtain the
relief requisite for sleep without recourse to opium or
morphine. It is undeniable, however, that in anti-
pyrin, phenacetin, acetanilid, and other of the new
analgesics, we may often find good and comparatively
harmless substitutes for opium or morphine. Thus
there is a large amount of testimony to the benefits
obtained from phenacetin, antipyrin, etc., in the pains
of acute rheumatism, facial neuralgia, hemicrania,
lumbago and pleurordynia, neuritis, zona, sciatica,
and even in the douleurs fulgur antes of tabes.
The analgesic action of belladonna, cannabis
Indica, hyoscyamus, is sometimes sought in insomnia
due to pain; not much reliance, however, can be
placed on any narcotic but opium.
There will always be one objection against opiuna
— 33 —
when used for hypnotic intent; it is not a good hyp-
notic, as it produces and long keeps up, in many per-
sons, a cerebral excitation incompatible with sleep;
hence where other analgesics, as antipyrin, acetanilid,
prove to be sufficient to quell the pain, they should
always have the preference.
2. Insomnia due to overwork of the brain is the
insomnia of cerebral hyperaemia. Prolonged study,
constant application to business, literary undertak-
ings, speculative enterprises, etc., demanding vigilant
thought and entailing much worry and anxiety are
fruitful sources of insomnia. At the same time, ex-
haustive mental toil may be carried on with impunity
provided the hours of sleep be not interfered with;
provided also that suitable seasons of relaxation and
diversion be snatched during the working hours. It
is unremitting mental toil and worry that kills.
The theory that during mental work certain dis-
tricts of the brain are flushed with blood is consonant
with all the experiments and observations whereby
we have acquired a knowledge of the physiology of
the brain. It is also known that the blood supply to
the brain is controlled by the vaso-motors, and it is a
legitimate inference that in the insomnia from mental
overwork the blood vessels of the cerebral cortex are
overfilled from exhaustion of these nerves, or, what
means the same thing, from exhaustion of the tonicity
of the blood vessels.
Doubtless the age in which we live is peculiar in
3 BBB
— 34 —
the sense that multitudes are obliged to toil harder
with their brains than any previous race. Never be-
fore, perhaps, in the history of mankind, did arduous
strife and competition involving the higher nervous
centres become so necessary. The present genera-
tion is the heir to all the acquisitions of the past, but
these have been an ever accumulating burden, which
is almost too great for the strong to bear, while the
weak and exhausted must succumb beneath the load,
though the latter be no more than just sufficient to
equip its possessor for a fair chance in the struggle
for existence.
It has been proved, however, that hard study can
be borne with impunity provided that sufficient physi-
cal exercise be taken. This is a truth which the liter-
ary man and the student should ever have in mind.
We have a good instance of this in the life of the late
Frenchman, Littr6, one of the most indefatigable
literary workers of this age. His habit was to spend
most of the day out of doors in physical recreation
and exercise; and he only began his studies and his
writing about seven o'clock in the evening when he
would "enter his library and pore over his books, ab-
sorbed in study, or bend over his writing desk, work-
ing without cessation, till three or four o'clock in the
morning, when, yielding to fatigue, he would seek a
few hours' refreshing sleep.
In a recent spirited publication, Mary Mana-
— 35 —
c^ine * has traced the causes, effects, and remedies of
mental over-pressure in modern life. She lays great
stress on the want of gymnastic training in schools,
and the numerous unhealthy conditions of our civiliza-
tion. The besetting infirmities of the age are " cere-
bral angemia " and " nervous exhaustion." The causes
are complex, but they all act similarly, " by producing
irregularities in the vascular sphere," /. ^., by impair-
ing the tonus of the cerebral blood-vessels. " When
once the tone of the blood-vessels is lost, when their
nutrition is disturbed and the circulation no longer
responds to the exigencies of normal life, phenomena
of dissolution begin to manifest themselves." Doubt-
less Mile. Manac^ine is right in regarding the stimu-
lants (tea, coffee, alcohol, tobacco, etc.) in which the
people of this age are prone to indulge as being large
factors in producing a toneless condition of the cere-
bral vessels, but exhaustion by overwork, and especi-
ally by worry, are doubtless still more important
factors.
With regard to the influence of physical over-
work in producing insomnia, the explanation may not
be so easy. A state of great physical fatigue is cer-
tainly favorable to sleep, but over-fatigue is attended
with a painful aching of the muscles, which causes an
excitation of the cerebrum. Germain See adds as a
factor the accumulation of the products of denu-
*" Le Surmenage Mentale dans le Civilisation Moderne,"
Paris, 1890.
-36-
trition, which being in excess in the blood, act as
toxic agents and excite the cerebrum.
With regard to the treatment of insomnia by-
mental overwork, the indicatio causalis first demands
attention. The student must curtail his studies, his
hours of work; must be content with a less honorable
standing in his classes, must take more rest, more
recreation, more exercise. These injunctions are
especially imperative when the subject of insomnia
is a growing youth; in fact, the appearance of
insomnia, or dreamy, restless, unrefreshing sleep in
children should generally be the signal for removing
them for a time from school and prescribing suitable
sports and recreations, a course of gymnastics, and
other measures calculated to invigorate, subdue rest-
lessness, and procure natural sleep.
Dr. Dukes, of Rugby, is of the opinion that boys
under ten years of age require eleven hours' sleep,
and those under thirteen need ten hours and a half
set apart for this purpose.*
The same causal indications are applicable to
the man of business, who, when once he finds himself
unable to sleep of nights is on a downward scale,
which will end in ruin unless he can pause and reform
his habits. Even then he will realize the facilis
descensus Avernty while to retrace his steps — hie labor y
hoc opus est. One of the most annoying forms of in-
somnia among business men is this: The patient goes
*Quoted by Macfarlane, loc. cit.
— 37 —
to bed and falls asleep to wake up in an hour or two
with his mind full of the care and worry of the day,
and then there is no more sleep all night long; or if
sleep returns after several hours of wakefulness, it is
a disturbed, dreamy sleep from which he awakes
tired, jaded, and miserable. This kind of insomnia is
called by Germain See true insomnia.
The following table is modified by Macfarlane
from Friedlander, and contains his views as to the
best division to be made of the twenty-four hours in
the matter of rest, work, and sleep :
HOURS FOR
AGE.
Exercise.
Work.
Leisure.
Sleep.
7
7
3
4
ID
8
6
4
4
lO
9
5
5
4
lO
lO
5
6
4
9
II
5
6
4
9
12
5
6
4
9
13
4
7
4
9
14
4
8
3
9
15
4
8
3
9
Besides making the endeavor to pursue a course
of life the reverse of that which he has been pursuing,
the victim of insomnia from overwork will naturally
for a time seek relief from some of the safer hypnot-
ics, preeminently among which is sulphonal. From
- 38 -
my own experience, I would say that sulphonal is the
king of hypnotics, conferring a sleep which is the
most like natural sleep with the least after-discomfort.
Nor does the continued use of this drug seem to be
attended with real harm — at least with any such evils
as follow the prolonged use of morphine or chloral.
I know one business man who has been in the habit
of taking ten grains of sulphonal every night for six
months, nor has he yet found it necessary to increase
the dose.
Chloral was formerly regarded as the ideal hyp-
notic, and in many cases it produces a sound refresh-
ing sleep of several hours. The late Dr. J. R.
Nichols, of Haverhill, told me in 1873 that chloral
had been a boon to him — that one dose of ten grains
taken at bed time would quite banish his insomnia
for a whole week, the effect not wearing away for
several nights.
In comparatively tractable cases of insomnia
from overwork, a tablespoonful or two of old whisky
at bed time will often work like a charm; sleep
speedily ensues and lasts many hours; with many, a
glass of bitter ale has a still better effect.
As natural sleep may be hypothetically regarded
as brought about by certain toxic products of exercise,
and as muscular exercise is known to be more pro-
ductive of these hypnogenous substances than intel-
lectual, so the medical adviser may very properly urge
his patient to perform some severe muscular work
— 39 —
before going to bed — a long walk in the open air,
dumb-bell exercise, etc. Many a victim of insomnia
has found a remedy for his infirmity in garden work,
joinery, wood- sawing, or even in such active sports
as base-ball and lawn-tennis. Sleep is much more
certain to follow muscle-tire than brain-tire.
As the leading indication is to induce that cere-
bral torpor which is the necessary antecedent of sleep,
it is well to advise the insomnic patient to avoid all
cerebral excitants in the evening. He should not in-
dulge in tea, coffee, tobacco or spirits, with the excep-
tion, perhaps, of an occasional draught of old whisky on
going to bed, as above stated; he should refrain from
reading, writing, and other mental labor. Even novel
reading (recommended by some as a diversion) is of
questionable utility; listening to the reading of a dull
book is a much more rational expedient. If one can
succeed in breaking the train of thought by fixing the
attention on any series of monotonous sounds (the
singing of crickets, the roar of a distant waterfall, the
whistling of the wind down the"chimney, etc.), he will
often before he is aware of it be caught in the toils of
Somnus.
The sleep state being one in which the cerebral
arterioles are contracted, with lessened circulation in
the encephalon, the artificial production • of this con-
dition would seem to be favorable to sleep, and much
account has been made of cold applications to the
head made with the intent to exsanguinate the brain;
— 40 —
hot foot baths to determine blood from the head, and
the general warm bath as a powerful means of deriva-
tion. Hammond states that he has seen the applica-
tion of the cold douche to the heads of refractory-
prisoners bring on a deep sleep. I believe, however,
that cold to the head, as a means of provoking sleep,
oftener fails than succeeds, and I have even known it
to aggravate the insomnia. Of more efficacy is bath-
ing the trunk and limbs with cold water, followed by
a brisk rubbing to induce a reactionary glow; stand-
ing naked on the cold floor a few minutes, then a
hasty rub-down with a coarse towel or flesh-brush,
often does good in the same way by derivation. The
warm bath or wet-pack may be resorted to in desper-
ate cases.
Macfarlane gives some excellent hints for the
rational treatment of this kind of insomnia. To re-
store tone to the vaso-motor system, he advises a
combination of nux vomica with hydrobromic acid.
]^ Acid hydrobromic 3 vi.
Tinct. nucis vom •. 3 ii.
Aquam ad. § vi.
M. Sig. — A tablespoonful in a wineglassful of water
twice a day, before meals.
To calm and strengthen the nervous centres, the
patient should cultivate the habit of going to bed at
a regular hour, and of rising with punctuality. The
bed-room should be well ventilated, and the head
raised upon a high pillow. The hours for eating and
— 41 —
drinking must be laid down with precision, the diet
being adapted to the temperament and digestive
powers, the last meal being taken some three hours
before going to bed. The plethoric, whose vascular
tension is high, do best without alcohol in any form,
while the anaemic are often benefited by a moderate
quantity taken with the food to promote digestion
and a " night-cap " of brandy or whisky with warm
water and sugar. On account of its stimulant' and
derivative action, turpentine in thirty-drop doses at
bed-time is a powerful aid to sleep. It is easily taken
in capsules. If it is found necessary to resort to
hypnotics, the bromides are especially serviceable, the
•only contra-indication being great anaemia. Mac-
farlane prefers the bromide of lithium, as it contains
a half more bromine than the potassium bromide. Its
dose is from lo to 20 grains. , The bromides of so-
dium and potassium, which are in most frequent use
in this country, are given in doses of one-half to one
drachm. They are best prescribed in syrup and
water, a full dose being taken a few hours before
bed-time and another at bed-time. If these doses do
not succeed in procuring sleep, tliey may be asso-
ciated with ergot of rye and digitalis, both of which
are stimulants of the vaso-motor centres. Macfar-
lane's favorite prescription is as follows:*
*Macfarlane, Insomnia and its Therapeutics, page 88.
— 42 —
^ Bromidi lithii gr. xl.
Ext. ergot liquid 3 i.
Tinct. digitalis Vlxx.
Aquae chloroformi 3 xv.
M. Sig. — Take one-half two hours before going to bed
and the other half at bed-time.
3. To the third group belongs insomnia con-
nected with a disordered state of one or more organs.
{a) Morbid States of the Brain. — These cause
insomnia by interfering with cerebral nutrition. The
changes taking place in .the brain during cerebral
hyperaemia are more of a katabolic than of an anabo-
lic character, i.e^ are characterized by excessive waste
rather than normal repair, hence are antagonistic to
conditions which produce sleep. This hyperaemia
may be active or passive. Active hyperaemia is due
to overwork of brain (see preceding paragraph), to
alcohol or other toxic agents, to arterial degeneration,
to exposure to intense heat, the irritation of teething,
to tubercles, syphilis, etc. The passive kind is gene-
rally due to organic diseases of the heart and lungs.
Active cerebral hyperaemia is characterized by flush-
ing of the face, throbbing of the temporals, conges-
tion of the retina, suftusion of the conjunctiva, irrita-
tability, restlessness, giddiness, confusion of ideas,
loss of memory, etc. In passive congestion, stupor is
the most marked symptom.
In the active form, the indication is to lessen the
quantity of blood in the brain; in the passive form, to
increase the force of the circulation and lessen the
— 43 —
venous supply. The first indication is fulfilled *by
cold to the head, saline purgatives, leeches to the
temples or outside the nose, mustard to the epigas-
trium, the constant galvanic current for two minutes —
the positive pole being over the sympathetic, the nega-
tive on the nucha (Hammond). In this form of in-
somnia, it is necessary to prescribe the bromides, or^
these failing, chloral. In the passive kind, diuretics,
saline purgatives, and opiates rather than bromides
are called for.
Alcohol, which is contra-indicated in active, is of
great use in passive hyperaemia.
The cerebral hypersemia with which we are most
familiar either soon ends in recovery — the patient
gving up his severe tasks or his excesses in eating and
drinking, and living more rationally — or it is the avant
coureur of some severe and generally incurable brain
affection. I have seen children suffer from flushed,
hot head, vertigo, headache, irritability, peevishness
{i.e., the symptom — cortege of hyperaemia) for weeks
before becoming the victims of hydrocephalus. I
have seen it the precursor of apoplexy in the aged^
being the first manifestation of atheromatous degene-
ration. It may be the first symptom of general
paralysis of the insane (periencephalitis).
If simple hyperaemia be inimical to sleep, a fortiori
inflammatory states of the cerebrum or its membranes
must be so. The insomnia of acute meningitis, of
periencephalitis, of cerebritis, is sufficiently familiar.
— 44 —
and even when the usual restlessness, agitation
and delirium give place to the quiescence of coma,
it is the repose of paralysis and death, rather than
refreshing sleep, that is witnessed.
In tuberculous meningitis, among the first symp-
toms of the hyperaemia which precedes the developed
disease, is a restless, dreamy sleep, which next gives
place to complete insomnia.
In the treatment of sleeplessness due to inflam-
matory conditions of the cerebrum, the general prin-
ciples laid down*under cerebral hyperaemia are to be
carried out. Full doses of chloral with bromides
sometimes give brief seasons of quiet, if not product-
ive of real sleep. I have found a combination of
sulphonal with antipyrin more or less efficacious in
the restlessness and delirium of meningitis.
5 Sulphonal
Antipyrin aa gr. x.
M. Sig. — One powder. To be repeated every hour till
sleep or quiet is produced.
This combination is especially indicated in
hyperpyrexia.
Cerebral tumors are a cause of sleeplessness, both
from the inflammation which they excite and the pain
which is a constant attendant.
Anaemia of the brain, whether produced by ex-
cessive loss of blood, profuse discharges from the
intestines, from chronic abscesses, etc., by insufficient
food, by exhausting diseases or other causes, gives
— 45 —
rise to sleeplessness or imperfect, dreamy sleep. The
explanation of this insomnia is that in the anaemic
there is not only an exsanguinous state of the brain,
but a vice of nutrition resulting from insufficiency of
arterial blood. Germain See adds another cause
which applies to certain cases; the local oligaemias
are generally due to emboli or obliterations of arteri-
oles, and the failure of nutrition goes on rapidly to
ramollissement, the initial symptoms of which are
always those of excitation.
The following case illustrates the general treatment of
sleeplessness due to anaemia:
Mrs. M. B.; aged fifty; mother of eight children; con-
sulted me in May, 1883, for a uterine trouble whose principal
manifestation was excessive haemorrhages. I found her
weak and anaemic, obliged to keep her bed the most of the
time. The heart's action was feeble; there was a systolic
(anaemic) bruit; exertion, excitement, even ordinary food,
would often bring on palpitations; walking or an attempt to
work caused breathlessness. The face was frequently
flushed (paresis of the vaso-motors"*; there were ringing
noises in the ears, flashes of light before the eyes, and
other perversions of the special senses; it required but
little exercise of the eyes to tire them — reading, sewing, etc.,
after a few minutes became painful." There was an almost
constant headache, with mental enfeeblement, and inability
to apply the mind more than a few minutes to any subject.
The insomnia was marked.
I found a uterine polypus to be the cause of the profuse
haemorrhages; this I removed by an ecraseur, thus arresting
the loss of blood, but Mrs. B. suffered for months from the
anaemic symptoms just mentioned. The distressing insom-
- 46 -
nia would only yield to opiates with draughts of whisky
or bitter ale. A hypodermic of morphine always gave most
relief, but this was seldom resorted to through fear of forming
the morphine habit. A mixture of equal parts of red laven-
der and ammoniated tincture of valerian, dose a teaspoonful
in water, often had a marked soothing effect. Chloral was
avoided; when taken formerly while Mrs. B. was under the
care of another physician it had always produced excitement
rather than quiet, A cordial frequently prescribed consisted
•of compound tincture of lavender, one drachm; tincture of
valerian, one drachm; deodorized laudanum, twenty drops;
this was taken at bedtime. After a few weeks had gone by,
I omitted opiates altogether, giving only the whisky or ale
at night; this also was eventually abandoned, a little beef
tea or fluid beef being given instead. A course of physical
•exercise had been commenced — walks, rides in the open air,
parlor gymnastics which powerfully promoted natural sleep.
Throughout the treatment, nutrients were administered day
and night in as large quantities as could be assimilated; thus
always between meals a cup of beef tea or of warm milk
with bovinine was given; an egg-nog was taken the first
thing in the morning and a cup of milk with Mellin's food
and a spoonful of bovinine at midnight. Eventually the
recovery was as complete as could be desired.
I have on record numerous cases of a similar
kind, where the distressing insomnia brought on by
long-continued discharges has yielded to suppression
of the cause and the plentiful administration of stim-
ulants and nutrients.
The cerebral anaemia accompanying aortic-val-
vular disease finds expression in an obstinate insomnia,
in frequent attacks of vertigo, in intellectual disturb-
ances, and in a profound irritability which has been
— 47 —
■described under the name of irritable weakness. A
similar line of treatment to that above mdicated is
needed, but the main reliance must be in opium or
hypodermic morphine, in alcoholic stimulants, and in
nitro-glycerin. It is hard to draw the line between
anaemia and passive congestion, but it must be re-
membered that in aortic disease the brain is in-
sufficiently supplied with arterial blood, and hence is
anaemic. It matters not if the cerebral substance is
charged with venous blood, unless the subject is sup-
plied with plenty of arterial blood and there is a free
•circulation, the condition of the cortical cells is none
the less one of anaemia.
(U) Degeneration of the ^cerebral arteries is a cause
of haemorrhage or softening, and one of its common
symptoms is troublesome dreaming or insomnia,
though some cases are characterized by morbid som-
nolence. Dreaming in advanced life is generally
regarded as suggestive of pending apoplexy (Mac-
farlane). In the treatment of this kind of insomnia,
the general principles applicable to cerebral anaemia
are to be observed. Macfarlane speaks well of a
mixture of henbane and camphor, and of sumbul and
.hops,* and professes to have obtained good results
*His formulae are as follows:
1^ Spts. chloroform 5 ss.
Tinct. sumbul, § ss.
Tinct. lupuli 3 i.
M, Sig. — Two teaspoonfuls in water every hour till
sleep is procured.
- 48 -
5 Tinct. digitalis tt^xx.
TinQt. sumbul 3 j.
Tinct. lupuli § ij.
Aquam ad § i j .
M. Sig. — Take one-half at bedtime in water, and repeat,
in two hours if required.
from sponging the nape of the neck with hot
water and from the application of mustard plasters-
for a few minutes over the epigastric region or the
upper part of the spine.
(c) Hysteria, hypochondriasis, mania, melancholia,,
are affections due to disturbances of nutrition of the
cerebral cortex. The limits of this treatise will not
allow a separate consideration of each of these affec-
tions, which belong to the category of neuroses rather
than of organic diseases. Nor can we here discuss
the general subject of insanity in its relation to in-
somnia.
The sleep in hysteria may not be materially lessened in
amount, but it is often unrefreshing. The hysterical subject
wakes in the morning with a sense of physical fatigue or of
mental depression or irritability. Dr. Mary Putnam Jacobi
gives us an ingenious explanation which is worth repro-
ducing.
In the nervous system, and especially the brain, the
waste products do not pass directly into the capillaries, but
into the lymphatic sheaths surrounding the arteries. The
circulation of the lymph current, and its passage from the
perivascular to the sub-arachnoid spaces, is regulated by the
pulsations of the brain or its variations in volume, by which
the lymph spaces are rhythmically compressed. The braia
— 49 —
pulsation is composed of three factors: The arterial pulse
wave, the respiratory wave, and the vascular wave. The
respiratory wave results from the aspiration of venous blood
from the brain during respiration and the obstruction to its
flow during expiration. The vascular wave advances like a
peristaltic movement, and consists in rhythmic contractions
and dilatations of the arterioles, apart from the cardiac pulse
and dependent on intermittent vaso-motor influences. This
vascular wave is said by Buckhardt to be much more regu-
lar during sleep than in the waking period and constitutes
the principal motor mechanism for removing waste products
through the lymphatic channels. If it be true that this vas-
cular wave is of more importance in the lymph circulation
in the brain than either the pulse or respiratory wave, it is
clear that any disorder of the vaso-motor centres which gov-
ern it may greatly disturb the removal of waste products by
interfering with the normal development of such a wave.
If, for example, the normal intermittence of vaso-motor im-
pulses becomes exchanged for a permanent tonus, the dia-
stolic portion of the wave would disappear, and with it the
swelling of the hemispheres by which the ventricles are com-
pressed. There would remain the variations in volume due
to the cardiac systole and diastole, but in sleep these are re-
duced to a minimum. Hence in any person subjected to ab-
normal vaso-motor irritations must exist an imperfect
removal of waste products from the brain during sleep and
therefore imperfect refreshment by the great restorer.*
The above considerations are not to be regarded
in the light of mere speculation, but are legitimate
deductions from accurate experimental observations
by Buckhardt and Meynert. The same causes of im-
perfect sleep are doubtless more or less operative in
* Hysteria and Brain Tumor, New York, 1888.
4 BBB
_ 50 —
neurasthenia, and in all forms of functional brain dis-
ease.
(d) It is but natural that such painful affections
as spinal meningitis and myelitis, and locomotor ataxa
in its acute stages and painful crises should cause
sleeplessness, only allayed by benumbing the seat of
pain with anodyne narcotics, and only removed by
successfully combating the disease.
Antipyrin, or acetanilid, in ten to fifteen grain
doses, frequently repeated till its sedative action is ex-
perienced, often has a charming effect in relieving
pain, irritation, fever, and thus promoting sleep. No
medicine probably has given so much relief in these
forms of spinal disease as antipyrin, but the doses
must be large and continuous.
In one case of locomotor ataxia with lightning
pains that came under my observation, acetanilid in
doses of ten grains an hour never failed to subdue the
pains in the course of a few hours, though the patient
often became restive under the pain and demanded a
hypodermic of morphine.
INSOMNIA OF RESPIRATORY ORIGIN.
Under this head we propose to consider chiefly
dyspnoea and cough in their relation to insomnia. In
acute diseases of the respiratory organs, pain and fever
are influential along with other factors in the produc-
tion of an insomnia which naturally yields when the
acuteness of the disease subsides. In pleurisy and
* -- 51 —
even in pneumonia the pain may be severe enough to
require an opiate, and even a hypodermic of mor-
phine; with regard to pneumonia, I think that we
should be chary in the use of opiates, no matter how
severe the cough or the pain may be. This I say from
experience, without formulating any theory in explana-
tion. I know that the pain of this disease often yields
to a sinapism or hot poultice, to a full dose of quinine
with extract of aconite, and to repeated full doses of
veratrum viride. My friend, Dr. B. W. Bartlett, of
Rowley, has great faith in the application of a dozen
leeches to the chest in the onset of pneumonia, with
hot water fomentations prolonged for hours after-
wards; the pains are alleviated and rest promoted
without the assistance of any anodyne.
The dyspnoea of respiratory disease (apart from
cardiac complications) is either spasmodic or obstruc-
tive. Spasmodic dyspnoea is exemplified in false
croup, in bronchial asthma, and in true asthma. In
all the bronchial affections of children a neurosal
element can be clearly traced; this is especially
noticeable in the paroxysmal cough and dyspnoea of
whooping-cough.
Respiratory dyspnoea when not due to spasm
may be the result of obstruction: ^, by exudation
within the pulmonary parenchyma as in pneumonia;
^, by exudation within the pleural cavity (-pleurisy); ^,
by swelling of the bronchi and profuse bronchial secre-
tion (acute bronchitis, especially capillary bronchitis).
— 52 —
The treatment of insomnia from any of the above
conditions resolves itself into the endeavor, as far as
possible, to alleviate or remove the cause. Bronchitis
should be treated in the earlier stages by medicines
which 'allay febrile excitement, va-so-constriction and
spasm, in short, by remedies which diminish the peri-
pheral resistances. Among these, I think, antimonials,*
ipecacuanha, veratrum viride, and lobelia inflata still
hoJd the first place.
3 Antimon. et. pot. tart gr- j-
Nitrate of potassium 3 j.
Mucilage vel. aquae § vj.
M. Sig. A tablespoonful every two hours.
3 Vin. ipecac 3 ij.
Mucilage 1 vj.
M. Sig. A tablespoonful every two hours.
J5 Fluid ext. verat virid 3 ss.
Aquae ^ ij.
M. Sig. A teaspoonful every hour or two.
When the bronchial secretion is well established^
the antimonial and other depressant may be omitted
and carbonate of ammonia substituted in five grain
doses. A small dose of chloral may be admissible at
bed time; when the secretion is very profuse an
emetic of sulphate of zinc or turpeth mineral may be
given as Macfarlane recommends. After the tubes
*The combination of tartar emetic and morphine, -^
grain every hour till the oppressive cough ceases, is one to
which I have often had occasion to resort.
— 53 —
are emptied, a dose of^urethan (gr. xxx) of paralde-
hyd ( 3 j.)> OJ^ even a Dover's powder (gr. x) may
be administered.
The general principles of treatment of neurosal
dyspnoea are the same, whatever name may be appli-
cable to the particular manifestation. Antispasmodics
and anaesthetics are always indicated; in attacks of
spasmodic asthma and laryngismus stridulus, a few
drops of the anaesthetic mixture A. C. E., inhaled
from a sponge or towel, always give relief.
5 Alcohol I part.
Chloroform 2 parts.
Ether 3 parts.
Mix.
Nitrate of amyl, gtt. iii, inhaled from the palm
of the hand frequently gives instant relief; chloral
hydrate with potassium bromide in full doses is slower
in its action, but more permanently reduces inordi
nate reflex excitability. With some patients hypo-
dermic morphia is a necessity. In laryngismus stridu-
lus or spurious croup an emetic is generally sufficient
speedily to relax the spasmodically tightened air-
tubes. Of all emetics the turpeth mineral is the one
which in my practice has yielded the most satisfactory
results. Parke, Davis & Co. make tablets of this salt
containing two grains, which are very convenient.
A more frequent cause of insomnia is cough.
I have not space to review the various pathologi-
cal conditions productive of cough and supplement
— 54 —
such review by therapeutical hints. The most that I
can do is to touch upon a few points of practical im-
portance in connection with the relation of insomnia
to cough.
In the early stages of consumption, the patient
may be tormented with a teasing cough which is for
the most part dry. Every physician is familiar with
such cases. The physical signs are obscure; at the
most there is a slight dulness under one or both clavi-
cles, but there is a little febrile movement every day
with failure of appetite and strength. This cough
indicates an irritation of the respiratory organs by
bacilli and tubercles, and is not alleviated by the
ordinary expectorants. Here calmatives and seda-
tives with counter irritation do little or no good. A
pill of codeia, one grain, at bedtime will sometimes
effectively allay irritation and produce sleep. Chloral,
bromide of potassium, cannabis Indica, hyoscyamus
and belladonna may all be tried, with doubtless some
alleviation at first; while nothing will so promptly
relieve and so thoroughly as morphine. The latter
medicament may be combined with dilute hydrocyanic
acid, chloroform, and tolu, as follows:
^ Chloroform gtt, xvj.
Morph. sulph gf' ij«
Acid hydrocyanic, dilute gtt. xxj.
Syrup tolu § ij.
M. Sig. — A teaspoonful at bedtime and at midnight
when the cough is troublesome.
— 55 —
A spray of liquid albolene and menthol used by
a hand atomizer will *sometimes allay the tickling in
the upper air passages which seems to be the point of
departure of the cough.
^ Liquid vaseline 5J-
Menthol 3 ss.
M. For the spray-producer,
Such patients are often benefited by full doses of
*' Rock and Rye " on going to bed.
I have seen good results from small blisters ap-
plied to the upper part of the chest, or from painting
the upper thorax with tincture of iodine till the skin
begins to peel.
Of the various cough troches, there is one made
by Parke, Davis & Co. and other of the pharmacists,
containing a little cubebs with extract of licorice,
which has given satisfaction in my practice. I have
seen somewhere the advice to paint the throat with
liquor cocaine; this expedient I have never tried, but
I should think that it might produce some temporary
alleviation.
In the later stages of phthisis when expectora-
tion is profuse, it is not always safe to arrest the
cough by narcotics given at bed-time; there is so
much secretion from the vomicae and inflamed mucous
membrane that frequent fits of coughing are neces-
sary to remove muco-pus and prevent asphyxia. In
such cases an emetic of sulphate of zinc sometimes
-56 -
has a salutary effect in clearing the bronchi and per-
mitting a few hours' quiet sleep. I have found bella-
donna serviceable in restraining secretion; this may
be prescribed in the form of a pill of atropine, y^^j^th
grain, night and morning. Senega, turpentine, tar,
sulphur, and carbonate of ammonia have a reputation
when there is copious expectoration, and the spray of
ipecacuanha wine, as recommended by Murrel, may
be tried to advantage.
The syrup of tar, with carbonate of ammonia,
and the Compound Pine Expectorant of P., D. & Co.,
are preparations which have become popular.
The catarrh is a product of bronchial congestion
provoked and kept up by the presence of tubercles,
and cannot be much modified while active tuberculiza-
tion exists.
In the teasing, paroxysmal cough of pertussis,
full doses of antipyrin or acetanilid have proved of
great efficacy.
^ Acetanilid 3 ss.
Divide in chart, No. vi.
Sig. Give one powder every four hours night and day,
and keep up the treatment for a week or even a fortnight.
For a child of lo years, the five-grain tablets are
very convenient. The one-grain tablets (one every 4
hours) may be prescribed for infants.
Antipyrin, phenacetin, or exalgin in equivalent
doses may be given instead of acetanilid. I have
given infants two years old grain doses of antipyrin
— 57 —
every two hours in whooping-cough, and seen the
paroxysms markedly diminish in frequency and
violence under this treatment. The quantity of either
antipyrin or acetanilid may be increased, if necessary,
till a decided constitutional impression is produced.
I used to give bromide of potassium in whoop-
ing-cough, with or without chloral, and have seen
marked mitigation of the paroxysms thereby pro-
duced.
^ Pot. bromid " 3ij.
Hyd. chloral 3 ss.
Syr. tolu 1 ii J •
M. Sig. A teaspoonful every hour till sleep is pro-
duced. For a child 5 years old.
THE INSOMNIA OF HEART DISEASE AND ITS TREAT-
MENT.
In aortic disease (constriction, insufficiency,
aortitis, aneurism) the arterial outflow is embarrassed,
and unless the compensatory hypertrophy be sufficient
through the extra power thereby given to the heart-
muscle to ensure filling of the arteries, the whole
organism suffers in its nutrition and function, and no
department more than the cerebrum. Hence, the
insomnia of aortic disease is essentially the insomnia
of anaemia.
But there is generally more than this. The
blood-depurating organs participate in the general
disturbance of nutrition, and imperfectly eliminate
waste elements, and to the poverty of arterial blood
_S8-
in the system is added a more or less toxic condition-,
of the blood.
Now that we are better acquainted with the con-
ditions productive of aortic affections, we know that
the latter are very often the expression of that wide-
spread disease of the arteries, arterio-sclerosis; the
victim of heart disease has interstitial nephritis, and,
sooner or later, becomes anaemic.
A peculiar state of mental irritability generally
accompanies aortic disease, and may even give rise to
a form of insanity.
Among the symptoms of aortic disease are par-
oxysmal crises of dyspnoea (cardiac asthma), especi-
ally frequent at night, and attacks of precordial pain,
which arrest the patient in his occupation; if he is
walking, compel him to stop and lean against some
support.
The pain in the earlier stages of aortic disease is
characterized by momentary pangs, and is the result
of exertion; in extensive atheromatous disease of the
aorta involving the coronary arteries, it is of a much
more intense, prolonged, and agonizing kind, and is-
true angina pectoris.
In the treatment of the insomnia of aortic dis-
ease, the mechanism by which this insomnia is brought
about must be kept in mind. A leading indication is
to promote the arterial blood supply of the brain, and
thus improve its languishing nutrition. The pure
hypnotics, chloral, paraldehyd, sulphonal, are rarely
— 59 —
useful, while there is one remedy which is of sovereign
efficacy, which energizes the circulation and relieves
dyspnoea and pain. "Opium," says Gabler, "deter-
mines a particular excitation, gives fullness to the
pulse, raises the temperature, augments the injection
of the teguments and promotes diaphoresis. The
countenance brightens, the eyes become brilliant and
moist, the pupils contracted, the skin covered with
perspiration, then quiet sleep ensues."
The morphine may be associated with atropine
and administered hypodermically, and for this pur-
pose the compressed tablets (sulph. morph., %. grain;
sulph. atropia, yj-g- grain) are very useful. It may be
necessary to resort to these injections very often —
every day, with gradually increasing dose — and there
will be the risk of rendering the patient a morphio-
maniac, but it is a choice between two evils in an in-
curable disease steadily becoming worse.
As to the question of the applicability of digitalis
in aortic disease, there is considerable difference of
opinion. A weak, struggling heart always seems to
demand this potent remedy, but practically it has not
been found, at least in the earlier stages of aortic
disease, to be so beneficial as nitro-glycerin and the
vaso-dilators. The reason is probably this, as stated
by Huchard: that the "cardio-aortic" patient is not
only suffering from anaemia, but from a poisoned con^.
dition of the blood — the dyspnoea and the precordial
anguish are often toxic, and are the expression of
— 6o —
spasmodic constriction of the arterioles, a condition
which is favored by digitalis, whose tonic action ex-
tends to the whole arterial system. Under the in-
fluence of this drug, the arterioles are tightened
rather than relaxed, while, on the contrary, nitrite of
amyl and nitrite of soda, and especially nitro-glycerin
systematically and perseveringly administered, relax
the arterial system, thus inviting rather than opposing
the sanguineous outflow, and lightening the work
of the heart. To these remedies may be added
an exclusive diet of milk, which by its nutrient pro-
perties, its easy digestibility, its absence of toxic ex-
tracts, and its marked diuretic action wonderfully
promotes the comfort and well-being of these ''cardio-
arterial " subjects.
The insomnia of mitral disease, as well as of a
number of other forms of heart disease, is closely
associated with the dyspnoea that attends those affec-
tions, and this is a convenient place for a few more
general considerations on cardiac dyspnoea and its
treatment.
CARDIAC DYSPNCEA.
When we consider the frequent coincidence of
cardiac lesions with dyspnoea, we cannot regard it as
surprising that in the infancy of pathological anatomy
Rostan, noticing in a large number of aged patients
•at the Saltpetri^re, recorded as asthmatic, definite
lesions of the heart and aorta, should have concluded
that asthma, as an idiopathic malady, does not exist.
— 6i —
being always symptomatic of diseases of the circula-
tory organs.
When we inquire into the conditions of cardiac
dyspnoea, we find them to be: Mitral stenosis and in-
sufficiency; myocarditis and fatty degeneration of the
heart-muscle; dilatation of the ventricles and aorta,
from whatever cause; and uncompensated lesions of
the valves of the aorta and pulmonary artery.
In the case of most of the above causes, the
modus agendi is very simple; the dyspnoea is of
mechanical origin, being the result of pulmonary
stasis; the heart is unable to clear the capillaries in
the sphere of the lesser circulation.
Most persons affected with mitral disease are
short-breathed; when at rest they have little or no
dyspnoea, but they immediately suffer for want of
breath when they attempt any considerable exertion,
as going up a flight of stairs or ascending a hill. In
the earliest stages of mitral insufficiency the dyspnoea
may be hardly noticed, except when the heart is
severely taxed, as in the effort of running; in advanced
stages the difficult breathing becomes permanent on
account of the constant pulmonary engorgement.
There is nothing asthmatic about this, for the essen-
tial characteristic of asthma is the intermittent and
paroxysmal character of the dyspnoea.
The difficult breathing attending aortic-regurgi-
tant disease, aortitis, dilatation of the heart cavities
and aorta, fatty degeneration, etc., is generally parox-
— 62 —
ysmal in its nature, and the attacks come on in the
night time rather than in the day. The explanation
given by Professor S6e was formerly regarded as sat-
isfactory: '• The blood-stasis in the lungs, which is
the first cause of the oppression, manifests itself gen-
erally in the night time, because it is favored by de-
clivity, that is, by the dorsal decubitus; to this first
cause are added others which contribute much toward
provoking the explosion of those attacks of respira-
tory distress which often present a formidable inten-
sity. These purely mechanical causes are: Disten-
sion of the stomach, and the forcing upward of the dia-
phragm, which notably diminish the respiratory area,
already insufficient for haematosis. Add, as accessory
causes, bronchial catarrh and frequent concomitant
emphysema, and you have the entire aetiology of par-
oxysmal dyspnoea linked to affections of the heart." *
The dyspnoea due to dilatation of the heart, ac-
cording to Professor S^e, is almost always continuous,
though there are paroxysmal exacerbations, and that
due to fatty degeneration is sui generis^ " presenting
sometimes real paroxysms of distress and suffocation
at the same time that careful examination of the
lungs does not reveal any morbid signs; there is not
the least acceleration of the breathing, or any appar-
ent impediment to respiration."
Irritation of the cardiac and. respiratory plexuses
♦Maladies du Coeur, etc., 1883, p. 30.
-6s-
of nerves, as Peter, Trousseau, etc., teach, has been
believed to have some share in the respiratory dis-
tress; and the magical relief conferred by a hypodermic
injection of morphine or other calmative before even
the pulmonary congestion or oedema is mitigated, has
been cited in confirmation of this doctrine.
Henri Huchard has of late written much and
lucidly on the paroxysmal dyspnoea of aortic regurgi-
tation and aortitis. The dyspnoea of aortitis is, like
that of mitral disease, at the first a dyspnoea of effort,
coming on during rapid walking, lifting, etc.; it is
paroxysmal and often intense, rarely spontaneous.
Later on in the disease the attacks come on in the
night time, often reproducing themselves with great
regularity, so that the patient is obliged to pass the
night in his arm-chair. Huchard regards this " aortic
pseudo-asthma " as due to arterial hypertension which
" augments by the recumbent posture and under the
influence of sleep, as also by walking, and under the
influence of movement." The cause of the dyspnoea
is " mechanical," as Professor See taught, but not in
the same sense as he taught, for in Huchard's view
we have to do with " peripheral resistances," and
" spasm " of the blood-vessels. If, says Huchard,
-distension of the stomach has anything to do with the
paroxysmal dyspnoea, abstinence from the evening
meal or a very frugal repast ought to keep the patierit
free from his nocturnal attack; this is, however, sure
to come, whether he eat little or much.
- 64 -
This dyspnoea, Huchard affirms, is also of toxic
origin. Experiments like the following seem ta
demonstrate this: He injects under the skin of a
guinea-pig normal urine; death ensues in several
days. He injects the same quantity of urine from a
woman affected with arterio-sclerosis of the heart and
aorta, and the guinea-pig scarcely suffers any detri-
ment. This proves-, he says, that the blood of his
patient was poisoned by the products of disassimila-
tion which the kidneys, already impermeable by the
fact of the aortitis and a commencing arterio-sclero-
sis, could but incompletely eliminate. These views,
he urges, are not simply theoretical, they are con-
firmed by practice. In fact, blood-letting, purgatives,
nitrite of amyl, nitro-glycerin, etc., which depress
arterial tension, contribute in large measure to dimin-
ish the intensity of the attacks. But nothing works
so well as an exclusive milk diet, which acts marvel-
ously in combating these attacks of aortic dyspnoea,,
often keeping them completely in abeyance. Now
milk diet, according to Huchard, acts in two ways
and meets two indications: First, by the abundant
diuresis which it provokes, the milk diminishes the
arterial tension and promptly eliminates the toxic
principles contained in the blood; then it acts by vir-
tue of its very harmlessness and because it does not
contribute to the blood in circulation, like other ali-
ments, and meat in particular, materials which, not
being completely eliminated, become rapidly toxic ta
the economy.
- 65 -
INSOMNIA OF GASTRO-INTESTINAL ORIGIN.
Writers have dwelt much on the cerebral hyper-
aemia attending disordered states of the stomach.
That indigestion causes insomnia by exciting the
cerebrum is a matter of common experience. With
many persons, even, the active exercise of digestion,
if this be at all difficult, is incompatible with sound
sleep. Such individuals refrain from lunching or par-
taking of a hearty meal before going to bed. Certain
valetudinarians cannot drink a glass of milk or eat a
biscuit late in the evening without atoning for the
indiscretion by hours of sleeplessness.
Such inhibition of the cerebrum by the stomach
is of frequent experience in the nursery. The first
thing the physician thinks of when consulted with
reference to insomnia in a young child is the proba-
bility of indigestion as the main factor in the case.
What is the quality of the food, what about the quan-
tity, and what is the condition of the digestive organs?
Attention to these points, in the absence of objective
signs of importance, as fever, will generally put one
on the track of the cause and suggest the remedy.
The indigestion may be functional or organic,
and all pathological conditions of the stomach are
likely to be accompanied by insomnia. Structural
diseases, as gastritis, ulcer, gastrectasis, cancer, cause
sleeplessness, both by the pain and discomfort, and
the consequences of indigestion which attend them.
5 BBB
— 66 —
One of the most frequent symptoms of indigestion is
flatulence. The stomach, by failure of the normal
peptonization process, is inflated and oppressed by
the gases of decomposition; the distended stomach
presses on the thoracic organs, embarrassing the
heart and causing troublesome palpitations. Toxic
products are often formed by the mal-elaboration of
peptones; these irritate the nervous centres and
render the cerebrum hypersemic.
But there is another aspect of the question. In
persons with healthy stomachs and normal arterial
tone, the digestive process is not prejudicial to sleep.
Somnolence, in fact, often attends digestion, espe-
cially after a hearty meal. This has been attributed
to the flushing of the stomach — at the expense of the
cerebrum— which is a necessary condition of its func-
tion. Digestion normally occurs without attracting
the consciousness, and there is no reason why on
proper occasions sleep should not follow a hearty
meal in men as well as in carnivorous animals. It is
not true that during sleep the digestive functions are
practically suspended, as some authorities have said:
" During sleep the medullary centres relax their act-
ivity, digestive fluids are not secreted, and the move-
ments of the gastro-intestinal canal almost, if not
entirely, cease."* It is surprising to meet with an
error of this kind in a writer ordinarily so accurate as
Insomnia and its Therapeutics, p. 192.
- 67 -
Macfarlane. The stomach and intestines continue
their function during sleep, though with lessened act-
ivity; the secretions are not suspended, the unstriped
muscular fibre continues a constant though dimin-
ished action; the spinal cord even seems preternatur-
ally active, the inhibiting restraint of the cerebrum
being withdrawn. In reality, in sleep all the essential
functions continue to be exercised. Those most
indispensable to life, circulation, respiration, diges-
tion, etc., are performed as during the waking period,
though more sluggishly. Thus, the heart beats more
slowly during sleep. " Pulsus in somno parvi, lan-
guidly rari,'' says Galen. With the retardation of the
circulation, there is diminished activity of the secret-
ing glands (gastric, intestinal, pancreatic, etc.), but in
healthy persons these organs are adequate to the work
imposed upon them, as is proved by the fact that mul-
titudes can eat a full meal on going to bed, sleep
soundly, an«l be ready for another meal on awaking.
Nor can it be said that the peristalsis of the gastro-
intestinal canal ceases during sleep, any more than
the contraction of other unstriped muscles (the arteri-
oles, for instance), which are not under the will.
Germain See, who refers most cases of digestive
insomnia to difficulties attending the secondary or in-
testinal digestion (and here he is seconded by Macfar-
lane) thus defines this kind of insomnia: "Intestinal
digestion generally begins three hours after a meal
and ends in seven or eight hours. The patient, we
— 68 —
will suppose, sups at 6 o'clock p.m. At lo o'clock he
goes to bed, but cannot sleep till long after midnight.
This is the time when the pancreatic-intestinal diges-
tion is going on; when this is finished, the patient
goes to sleep.
" To prove that I am right as to the cause of the
insomnia, let the patient eat a light supper at the
usual time, or let him sup at 4 o'clock in the after-
noon, and he will find that he will go to sleep at the
proper time."*
In the treatment of insomnia from indigestion,
the quantity and quality of the food must be taken
into account, the conditions of the stomach, intes-
tines, and the auxiliary organs.
(i) Errors are most frequently committed as to
quantity. The digestive organs may be competent to
dispose of a certain bulk without pain or difficulty,
while an excess causes embarrassment to the stomach;
decomposition and flatulence set in under unmolested
microbic rule; putrid and more or less toxic gases
and ptomaines are generated, and a "bilious" condi-
tion supervenes, such as every one has experienced at
times. It is doubtless true that while multitudes are
underfed, more persons are injured by excessive eat-
ing than by a spare diet. Insomnia naturally comes
in as one of the consequences of over-eating and over-
drinking, for a burdened stomach will not let the
brain rest.
* Des Dyspepsies, etc. Second edition. Paris, 1883.
-69-
The proper remedy for sleeplessness arising from
this cause is apparent; it is to curtail the daily rations
to the physiological standard. The necessity of eat-
ing slowly and deliberately with thorough mastication
of the food, is apparent; those that "bolt" their food
are sure to eat to excess.
(2) Food of poor or insufficient quality produces
anaemia and starvation of vital organs, including the
cerebrum, and hence engenders insomnia. Physicians
cannot too much insist on the necessity of a full diet,
that is, of an adequate admixture in the daily fare of
albuminoids, fats, and carbo-hydrates. Food of in-
digestible quality produces essentially the same evils
as excessive alimentation. Under this head may be
included food improperly or insufficiently cooked
(good cookery under our civilization has become in-
dispensable to healthy digestion), and foods that
most persons of sedentary habits find hard to digest,
as unripe fruit, pastries, hot bread, fried pork, confec-
tionery. Of course, butcher's meats should be selected
that are tender and juicy, and in the light of recent
discoveries (Gautier, Selmi, etc.), it is doubtful if
meat or game that has become high (faisand^) is fit
for food.
Foods of themselves sufficiently digestible may
become indigestible if too many kinds are eaten at a
meal. But this brings us again to the evils of excess-
ive eating.
It need not be repeated that he who would sleep
— 70 —
well must avoid those articles of diet which have been
found to be indigestible, or should indulge in them
sparingly. Much depends, of course, on the muscular
work done. Horace speaks of the dura ilia messorum.
The hay-makers on the salt marshes need food hard
of digestion, that is, food that is slowly digested, yield-
ing up force for many hours; food that m common
parlance " stays by," such as baked beans and pork,
boiled beef and cabbage, and mince pie. Such per-
sons sleep well, despite their hearty fare; it is especi-
ally the '•' brain-workers," the men of sedentary habits
that are upset by a rich diet.
(3) A healthy digestion presupposes a healthy
state of the stomach, intestines, and accessory organs,,
and any derangement of these viscera must be cor-
rected by suitable medicinal and dietetic means before
normal sleep can be enjoyed.
To enter on a consideration of all these derange-
ments would tak*e more space than we have at our
command. The hygienic treatment of indigestion in-
cludes dieting, exercise, recreation, cold bathing etc.
The cold shower-bath in the morning is sometimes a
powerful aid to digestion. Exercise promotes a more
vigorous circulation and favors peristalsis and chymi-
fication; equally necessary are change of scene, diver-
sions, and the cultivation of a contented, cheerful
frame of mind.
Among the medicinal means are:
(i) Such as favor gastric digestion, namely, alka-
— 71 —
lies before meals, and acids with pepsin, after.
Clinical experience has proved pepsin to be of some
value. Small doses of strychnine are useful.
(2) For acid dyspepsia full doses of bicarbonate
of soda are naturally indicated. Professor S^e ad-
vises dyspeptics with excess of acid secretion to take
a drachm of bicarbonate of soda in hot water on go-
ing to bed. It is certain that in certain morbid states
of the stomach and intestines, whether due to " hyper-
chlorhydria " or to excess of mucus, the beneficial
sedative effects of alkalies are pronounced.
(3) Constipation is another recognized cause of
insomnia, whether by the reflex irritation of retained
excreta, or by the flatulence which frequently attends
a loaded colon. Here the remedy is obvious; such
laxatives as rhubarb, Glauber salts, cascara, enemata
of hot water, etc. Persons who sleep poorly from
this cause often find a hot water enema on going to
bed a sovereign remedy.
When that old bugbear, a torpid liver, is at fault
(if this can be determined), of course a blue pill, a
dose of enonymin or podophyllin would seem to be in-
dicated.
There is an acidity of the stomach which depends
on abnormal acid ferments, the products of decompo-
sition of starches or sugars in the food. In these
cases, washing out the stomach by means of emetics
and copious draughts of warm water every night for
three or four nights, as Macfarlane recommends,
— 72 —
often proves very efficacious. The same writer ad-
vises ferro-alumen in three-grain doses for pyrosis
along with three drops of dilute hydrocyanic acid, and
turpentine in ten-drop doses for flatulence, as most
effective remedies.
Gastralgia and gastrodynia demand anodynes
and anti-spasmodics. In the experience of many
authorities, a pill of opium, or an equivalent of the
deodorized tincture is more efficient in gastralgia
than morphine hypodermically or by mouth.
In the treatment of gastric neurasthenia, the fol-
lowing therapeutic regulations may be carried out:
1. The patient may take with each meal 5 grains
each of salicylate of bismuth, magnesia, and bicarbon-
ate of sodium.
2. He may take, on going to bed, a dessert-
spoonful of compound licorice powder.
3. Every day he may have a cold jet-douche of
15 seconds' duration applied along the vertebral col-
umn; energetic dry friction with a flesh-brush after
the douche.
4. Walks in the open air, muscular exercises
(fencing, opposition gymnastics, etc.,) are beneficial.
5. There should be only two meals a day, the
one at 10 a.m. and the other at 7 p.m. The diet
should consist chiefly of eggs, cereals, green veget-
ables and fruits; the eggs to be nearly raw, the
starchy foods and vegetables to be thoroughly
cooked, the fruits to be stewed. Drinks to be water
— 73 —
or a light white wine with ordinary water; no gaseous
waters, no pure wine, no whiskey or other distilled
liquors. Such patients often do best on a dry diet.^
Intestinal indigestion is to be treated mainly by
dieting. The liquor pancreaticus has been recom-
mended by some writers; it is doubtful if pancreatin
exercises any action outside of the stomach. Diar-
rhoea and constipation are to be treated by the appro-
priate remedies.
Sleep, in this form of indigestion, is often im-
proved by the nightly use of massage, and also by the
application of a bag of hot water over the abdomen
(Macfarlane).
THE INSOMNIA OF CYSTITIS.
Chronic cystitis produces obstinate and painful
insomnia. This disease is a common consequence of
-enlarged prostate, calculus in the bladder, of gonor-
rhoea, and stficture of the urethra. Micturition is
frequent, and attended with scalding pain; the urine
contains muco-pus, which adheres to the bottom of
the vessel when turned upside down.
Sleep is interfered with both by the pain (which
in chronic cases may, however, be absent) and by the
frequent calls to urinate. The victim of cystitis and
prostatitis is obliged to get up every hour or two
*Dujardin-Beaumetz, Therapeutic Gazette, January
15th, 1890.
— 74 —
(sometimes every half hour) in the night to make-
water, and the act of micturition is often attended
with a tenesmus that is most distressing.
The treatment should aim at removal of the-
cause. If there is a stricture or enlarged prostate or
stone in the bladder, the proper measures should be
taken for their removal or relief. If the cause can-
not be reached, recourse must be had to palliative-
remedies. Washing out the bladder every day, or
twice a day, with warm water, to which some antisep-
tic is added, as Marchand's peroxide of hydrogen,,
carbolic acid, boric acid, thymol, is now recommended
by the best authorities, and certainly often gives-
marked relief. I have known patients, who had been
long sufferers from prostatic disease which made
their nights wearisome and life a burden, able to-
obtain several hours of quiet sleep after irrigating the
bladder with a little warm carbolic water. For this-
purpose the soft rubber catheter i£ very useful.
These are of various makes. The Jacques French^
catheter, the Tiedmann, the Davidson, are those with
which I am best acquainted. The peculiar merit of
these instruments is that they may safely be left ta
the patient to be passed by himself. The catheter is-
first greased with a little eucalyptus vaseline and
passed into the urethra, then carefully pushed along
till the flow of urine by the distal end indicates that
it is in the bladder. After emptying the bladder, the
cannula of a little hand-ball syringe, which is filled
— 75 —
with the antiseptic solution, is introduced into the
mouth of the catheter and the contents injected into
the bladder; the solution is then allowed to run out,
and more is injected till the water flows off clean and
free from mucus.
Too much pains cannot be taken to have the
catheter always clean and aseptic; obstinate cystitis
has been more than once started by the use of a foul
catheter.
Suppositories of morphia, of opium, of hyoscya-
mus, etc., are often advantageous. The following-
prescription is frequently employed in the Jefferson
Medical College Hospital of Philadelphia:
^ Pulv. opii gr. xij.
Camphorae gr. xxx.
Ext. belladonna gr. iij.
Cacao q. s.
M. et in suppos. No. vi, divide.
S. One each night on retiring.
A teaspoonful of the tincture of hyoscyamus at
bedtime sometimes proves to be a useful hypnotic in
cystitis. The ordinary hypnotics (chloral, sulphonal,
paraldehyd, urethan) are of little or no benefit.
INSOMNIA FROM GENITAL IRRITATION.
In this connection it is necessary to allude
to the insomnia which attends genital irritation.
While excess in venery sometimes causes insomnia by
impairing nervous tone, there is another frequent
- 76 -
cause in individuals otherwise healthy, viz., contin-
ence. Every physician is now and then consulted by
vigorous young men who have at some time given
loose reins to their passions, and who afterwards in
consequence of prolonged continence have trouble-
some erections at night which waken them and keep
them awake. In such cases, in the event of the
physiological satisfaction of an imperative want being
impracticable, recourse must be had to sedative medi-
cines, to anaphrodisiacs.
The suppository of camphor and opium (see
above) may be given to advantage, or a full dose of
chloral, or of bromide, has a great reputation in in-
somnia due to genital irritation. It should be given
in large doses and followed up for some time.
]^ Pot. bromide 3 iv.
Tinct. hyoscyami 5 ss.
Mist camph § vss.
M. Sig. A tablespoonful three times a day and at
bed time.
Lupulin, which may be given in drachm doses
stirred into a small cup of hot water at bedtime, is of
ancient repute, and the same may be said of full doses
of camphor.
Not much can be said in favor of cold douches
to the perineum, which would be likely to aggravate
the trouble.
The patient should sleep on a hard mattress, not
on feathers, and should accustom himself to sleep with
very few bedclothes over him.
— 77 —
The utility of avoiding romances of a certain
character as well as everything else that can stimu-
late the sexual passion (and under this head come
tobacco and alcohol) is sufficiently obvious.
INSOMNIA OF TOXIC ORIGIN.
The natural effect of alcohol on the cerebral
functions is to impair healthful sleep. It excites the
cerebrum by increasing the heart's action and the
blood-flow, and by directly stimulating the cortical
cells concerned in conscious activity. This is the
ordinary action of alcohol when taken moderately,
the effects of liquors being, as a rule, the less baneful
the less impurities they contain, ^and the nearer they
approach by rectification or by age to the type of
pure ethyl alcohol.
It is possible that the stimulant effect of the alco-
hol on the stomach, rendering that organ hyperaemic,
may sometimes promote sleep by temporarily anaemi-
ating the brain. On the whole, however, alcohol is a
most unsatisfactory hypnotic, and the sleep which
attends its ingestion is generally brief, and followed
by a period of wakefulness later on.
It is by no means proved that alcohol in any
form ever fulfils the prime requisite of a hypnotic,
that of lessening the amount of blood in the brain.
The stupor which follows small medicinal doses is
regarded by many authorities as a minor degree of
that narcosis which comes on after excess. Into this
- 78 -
narcotism enter as factors the toxic effects of the
alcohol on the cerebrum, vaso-motor paresis, and the
paralyzing action of blood poisoned by carbonic acid,
whose retention is due to interference with the respi-
ratory function. Jaillet, moreover, has shown that
the blood globule, when impregnated with alcohol,
loses the property of transforming all its haemoglobin
into oxyhaemoglobin; for the oxygen of respiration
unites at the same time with the alcohol and the
haemoglobin of the corpuscles; in other words, the
alcoholized blood becomes too poor in oxygen to pro-
perly subserve either the nutrition or function of the
cerebral cells. These considerations show how com-
plex is the action of alcohol on the brain, and the
necessity of caution in prescribing it in derangements
of sleep. Certainly the continued use of alcoholic
stimulants, even in moderate doses, for hypnotic
effect, is likely to defeat the purpose for which the
remedy is given, by producing in the end a very ob-
stinate insomnia, if we can trust some recent authori-
ties; and this it does by inducing a permanent loss of
tone in the cerebral blood-vessels, if not by favoring
arteriosclerosis. "The effect of alcohol on the
brain," says B. W. Richardson, " is to produce and
maintain the relaxation of its vessels, to keep them
charged with blood, and so hold back the natural
repose. Under this divergence from natural life, the
sleepless man lies struggling with unruly and uncon-
nected trains of thought. . . . The more he tries.
— 79 —
the less he succeeds, till the morning dawns." Rich-
ardson affirms that arterial atheroma is a frequent
consequence of even moderate indulgence in alcoholic
beverages, and doubtless there is much testimony in
support of this contention. As for the effects of long
continued intemperance, there is no doubt that this is
one of the most prolific sources of arterial degenera-
tion. Nor is even beer exempt from harm of the same
kind, and there is warrant for the belief that "the use of
beer in many instances produces a species of degener-
ation of all the organs, profound and deceptive fatty
deposits, diminished circulation, conditions of conges-
tion and perversion of functional activities; local in-
flammations of both liver and kidneys are always
present." Intellectually, a stupor amounting almost
to parajysis arrests the reason, changing all the higher
faculties into a mere animalism, sensual, selfish, slug-
gish, varied only with paroxysms of anger that are
•senseless and brutal. A writer in the Scientific Amer-
ican, who makes this assertion, claims & wide observa-
tion of the effects of beer-drinking among the various
ovilized nations.
But the point which we wish here to emphasize
is, that the moderate use of alcohol in any form may
produce insomnia by its exciting action on the heart
and circulation, and on the cerebral cells; that the use
of it as a hypnotic may, in the long run, defeat the
end for which it is given; and that prolonged, immod-
erate indulgence, even in the milder intoxicant bever-
— 8o —
ages, may produce grave cerebral disturbances and
such as are incompatible with healthful sleep.
The remedy for alcoholic insomnia is that of al-
coholism in general — the most complete abstinence
from the toxic cause. Prolonged mental rest, the
natural vaso-motor tonics, out-door air, massage, in-
vigorating exercise, cold bathing, and perhaps sea-
bathing, are indicated, and a nutritious diet adapted
to the enfeebled state of the digestive organs. These
patients are often benefited by a prolonged course of
strychnia. One-thirtieth of a grain may be given
three times a day, or ten drops tincture of nux vom-
ica, just before meals. Hypnotics will be temporarily
needed — chloral or paraldehyd. The combination of
twenty grains of chloral with twenty drops of tincture
of capsicum, in two fluid ounces of chloroform water^
is a good one.
Physicians are seldom called upon to treat insom-
nia due to tea-drinking or coffee-drinking. The num-
ber of those w4io abuse these beverages is probably
small, and the congenitally feeble and neuropathic
early learn by experience to indulge sparingly in
them. The tea-drinking malady is characterized by
" sleeplessness, or sleep disturbed by dreams or night-
mare, headache, irritability of temper, depression,
hypochondriasis, disorders of special senses, auditory
and visual disturbances, neurosal palpitation, dyspep-
sia, intestinal torpor (with the accompanying flatu-
lence and constipation), neuralgia, muscular enfeeble-
ment and tremor." (Macfarlane.)
— 8i —
Insomnia is a frequent consequence of excesses
in the use of tobacco. This is brought about, partly,
by the digestive and circulatory troubles which char-
acterize chronic nicotinism.
But the nervous centres are most violently smit-
ten, especially the medulla oblongata, whence the car-
diac, circulatory, and respiratory disturbances. The
direct excitant influence of nicotine on the cortical
centres is considerable; the existence of vaso-motor
paresis is undoubted.
Entire abstinence is the only remedy; the poison
is quickly eliminated. It has been found that the
wakefulness is lessened- by four-gramme doses of
monobromide of camphor at night (Macfarlane), but
any of the milder hypnotics may be administered.
The only other toxic agent necessary to allude to
is opium. Opium and morphine may almost be said
not to deserve a place among true hypnotics, so little
do they bring about the conditions of normal sleep.
It is known that they render the cerebrum hypersemic;
they paralyze the vaso-motors, and act upon the
nerves which supply the respiratory muscles so as to
interfere with the process of respiration (W. A. Ham-
mond); hence the sleep which results from their use
is more like stupor than natural sleep.
A most obstinate and unmanageable insomnia
attends the opium or morphine habit, for the cure of
which special treatment is necessary (especially in
aggravated cases), and, generally, isolation in an insti-
6 BBB
— 82 —
tution possessed of properly trained nurses, and
where restraint can be exercised.
The literature of morphinism is now quite exten-
sive; prominent among works devoted to this subject
are two treatises lately published, one by Regnier, the
other by Oscar Jennings.
In breaking off the habit, Jennings declares in
favor of the gradual method; and in conjunction with
Professor Ball he has made some careful experiments
on the power of sparteine and nitro-glycerin to com-
bat the circulatory disturbances which attend the
period of amorphinism.
INSOMNIA OF CONTINUED FEVERS AND ITS TREAT-
MENT.
In typhus and typhoid fever, sleeplessness is a
frequent, troublesome, and often dangerous symptom.
Dr. Murchison, writing of the necessity of sleep in
typhus, says: "The practitioner cannot be too forci-
bly impressed with the fact that loss of sleep at any
stage of typhus, if it continue for two or three nights,
is of itself sufficient to kill."
In typhoid the necessity of sleep is no less ur-
gent. One of the first symptoms of approaching dis-
solution is a restlessness which forbids sleep, and the
return of refreshing sleep is hailed by physicians and
attendants as a presage of recovery.
In the earlier stages of these fevers, insomnia is
pretty certain to accompany the hyperthermia, while
- 83 -
sleep often attends a fall in the temperature. It
would seem that over-heated blood is itself inimical
to sleep by exciting the cerebrum.. Certain it is that
cold bathing — the cold or tepid bath — and anti-
pyretics that bring down the fever quiet the nervous
disturbances and promote sleep. Hence, for the rest-
lessness and insomnia of typhus and typhoid fevers,
there is often no better treatment than a cold bath of
about fifteen minutes' duration, the temperature of
the water being from 60° to 75^ F., and during the
bath cold water may be poured on the head in cases
of extreme pyrexia with restlessness and delirium.
While fifteen minutes ought to be long enough to de-
press the febrile heat to nearly the normal, in some
cases the bath may be of longer duration. "The
earlier the stage, the higher the fever, the more
robust the constitution, the colder should the water
be. The later the stage, the weaker the constitution,
the more affected the nervous system, the warmer
should be the water." *
Some writers claim to have found cold sponging
and the wet-pack a sufficient substitute for the cold
bath. Others have derived only a temporary refresh-
ing from these milder means.
Where the cold bath is impracticable, from diffi-
culties on the part of the patient or his surroundings,
some one of the new antipyretics may be tried. There
*J. C. Wilson.
- 84 -
is much testimony in favor of acetanilid as a nervous
sedative in fevers. Five grains every hour for three
or four doses (in an aduh) will generally lower the
febrile temperature two or three degrees, and one
or two hours of quiet sleep (especially if the medicine
be given in the night-time) is almost certain to follow.
By many practitioners and hospital physicians, anal-
gesin is regarded as the preferable hypnotic; the dose
should be double that of acetanilid.
These antipyretics, though they undoubtedly
have a marked action on the thermogenetic and
thermotaxic hoat-centres, which are under abnormal
irritation by the fever-poison, an action which is ex-
tended to the higher cerebral centres, certainly do not
affect the infectious agent, and hence the course of
the fever is not influenced by them. Their prolonged
use is probably attended by some cardiac depression
(an evil to be especially shunned in fevers), and the
best clinical authorities are shy of them, seeing no
permanent advantage in the continued administra-
tion of these medicaments, but possibly mischief. At
the most, their employment is restricted to the obten-
tion of such sedation as is needed for the nervous dis-
turbances.
Among the pure hypnotics, chloral still deservedly
takes the lead in the treatment of the insomnia of
fevers. It calms the delirium, saves the forces, mod-
erates the fever, and produces a sleep strikingly like
natural sleep in its refreshing effects (Liebreich,.
- 85 -
Nothnagel, Flint, Russell, Dujardin-Beaumetz). The
only contra-indication is cardiac weakness. In the
latter stages of typhus and typhoid it is better to
avoid chloral, substituting opium or morphine, and in
the earlier stages, where there is much jactitation and
delirium, and especially when diarrhoea is a prominent
symptom, 20 drops at bedtime of the deodorized tinc-
ture of opium in a little camphor-water is a useful
adjunct to other measures intended to subdue rest-
lessness and produce sleep.
With regard to sulphonal, we think that experi-
ence has proved this hypnotic to be of little utility in
the obstinate insomnia of fevers, and the same may
be said of chloralamid and other of the more recent
hypnotics. Paraldehyd, were the taste not so ob-
jectionable, might render considerable service in the
delirious insomnia of typhus.
Alcoholic stimulants judiciously administered
sustain the heart and circulation, promote the nutri-
tion and restoration of the nervous system, and thus
come under the head of remedies useful to combat
insomnia. Given in too large or too frequent doses,
they undoubtedly defeat the end for which they are
given, and aggravate existing nervous disturbances.
There is another reservation, — they must be cautiously
prescribed where there is renal insufficiency.
Stokes, in his lectures, speaks of the well-marked
calming and sedative effect of wine in fever. '' A pa-
tient who has been restless, sleepless, and delirious
— S6 —
will sometimes become quiet and fall asleep after the
administration of a little wine. This occurs where
the nervous symptoms are probably due to an anaemic
or spanfemic condition of the brain associated with a
weak heart and a flagging circulation."*
Febrile insomnia is essentially a toxic insomnia;
this has been made apparent by the investigations of
the last few years. Whether it be the microbes or
their ptomaines, or both, which excite the cerebrum
and derange the nervous functions, has not been yet
positively determined. Uraemia probably enters as
an important factor; in the active stages of fevers,
and in the declining stages when the circulation is
oppressed and languid, and the prognosis is grave,
elimination by the kidneys is always imperfect.
Hence an important part of the treatment should be
to promote the excretion of the poison and the re-
moval of effete matters. Unfortunately, this indica-
tion can be but imperfectly met. All that can be
done is by suitable nutrients and stimulants to sustain
the organic forces in their struggle with the foe, and
to favor elimination by the kidneys and other emunc-
tories. The various diluents (lemonade, barley-water,
effervescent drinks, plain water, etc.) which are so
freely given, because so constantly craved, promote
excretion by the kidneys. Milk is often prescribed
dt^ //^//2^;« as the sole drink and nourishment; its di-
* "Lectures on Fever," Lea Brothers & Co., 1876.
_ 87 -
uretic properties are well known. Some clinical
authorities are in the habit of ordering mild diuretic
mixtures (solutions of nitrate of potassium, of sweet
spirits of nitre, with sometimes the addition for
several successive days of a little digitalis) all through
the fever, and claim good results.
The bowels should be kept open, suitable mild
laxatives being given if there be constipation, and fre-
quent cold or tepid ablutions, followed by brisk rub-
bing, will do something towards promoting the func-
tions of the skin.
We have hinted at anaemia and spanaemia as be-
ing part causes of the insomnia of continued fevers.
Emphasize as we may the poisoned condition of the
blood and the abnormalities of the circulation, the
fundamental factor in the insomnia, headache, jactita-
tion, delirium, and hebetude of continued fever is
malnutrition of the highest nerve-centres, and against
this our therapeutic resources are meagre. The
necessity of nourishment is apparent; but little food,
however, can be assimilated; and, in the absence of
any specific medication (for which the profession is
looking), the best that can be done is judiciously to
combat dangerous symptoms The insomnia is the
measure of the cerebral disturbance, and, if this can
be successfully overcome, one important obstacle at
least in the way of recovery is removed.
*********
[^Chapters on syphilis^ rheumatism, gout, and lith-
(Bmia, as producers of insomnia^ were originally drafted^
but it was found impossible to include them without mak-
ing this volume too bulky. A treatise on all the causes of
the derangements of sleep would comprehend almost the
whole of internal^ and even surgical pathology^
CHAPTER HI.
HYPNOTICS.
The limits of this treatise will allow of only a
t)rief consideration of the leading agents that properly-
come under this head. I shall take up first the med-
icinal hypnotics, then the remedial agents not med-
icinal.
I. OPIUM AND NARCOTICS.
Opium is the most ancient and still the most
universally employed hypnotic. The narcotic prop-
erty of opium is the result of its morphine, codeine,
papavarine, and cryptopine — all somniferous alkaloids.
Opium is far from being a pure hypnotic; in small
doses its action is that of an excitant of the cerebrum,
and generally it is only in tolerably large doses that
it is hypnotic. Many persons find opium, and espe-
cially morphine, powerful promoters of wakefulness,
sleep only following many hours after the ingestion
of the narcotic.
Opium is par excellence the hypnotic where the
^ insomnia is due to pain. Opium undoubtedly exerts
its power by a stupefying action on the cortical cells,
rather than by any changes which it effects in the
circulation. " It is the peculiar virtue of narcotics,"
says Stille, " to blunt the senses and steep the mind
in forgetfulness, in spite of pain, of nervous irritabil-
ity, or of tormenting thoughts."
— 90 —
The combination of opium or morphine with the
pure hypnotics, as chloral, sulphonal, paraldehyd,
urethan, is often highly efficacious. The following
formulae are recommended: (These prescriptions-
are designed for adults only.)
CHLORAL AND MORPHIA.
3 Morphinae sulph gr. ij.
Hyd. chloral 3 ij.
Syrup tolu § ij.
M. Sig. — A teaspoonful when needed to induce sleep.
PARALDEHYD AND TINCTURE OF OPIUM.
9 Paraldehyd 3i.
Tinct . opii deod gtt . xx .
M. For one dose. To be taken in a little old rum and
water. Valuable in the insomnia of melancholia, in deli-
rium tremens, incipient paralytic dementia, etc.
SULPHONAL AND MORPHIA.
^ Sulphonal 3 ss .
Morph. sulph gr. %.
M. One powder, for a hypnotic effect where there is
great nervous irritability or pain.
MORPHINE WITH CHLORAL AND BROMIDE OF SODIUM.
(From Macfarlane.)
9 Liqui morphin acet f3i.
Hyd. chloral 3i.
Bromid . sodii 3 ij •
Syrup tolu 3 iv .
Aquam add § i v .
M. Sig. — Take one-fourth part in water before bedtime,,
and repeat in two hours if required.
— 91 ~
Other narcotics— belladonna, hyoscyamus, Indian
hemp, stramonium — have but feeble hypnotic power.
They are not absolutely devoid of this power, as some
writers have affirmed, but they are not to be depended
on.
In insomnia ducto genital irritation (such cases
as sometimes come before the notice of the physician
in connection with habits of masturbation and at-
tempts at reformation, or in continent young men
who are kept awake by troublesome erections), also
in the insomnia produced by gonorrhoeal chordee,
hyoscyamus is often of real efficacy. The camphor
and hyoscyamus pill is a convenient formula:
5 Pulv. camph gr. i.
Ext . hyoscyam gr. iij .
M, For one pill. To be taken at bedtime. A supposi-
tory of ext. hyoscyamus, 3 grains, and pulv. opii i grain,
with cacao butter, may be often used to advantage.
In chordee, I have given teaspoonful doses of
tincture of hyoscyamus three times a day without
producing any troublesome dryness of the mouth and
throat or dilatation of the pupils, and seen quiescence
and sleep follow.
Lettuce and hops possess true hypnotic virtues,
with mildly stupefying properties, and do not produce
any arterial or cerebral excitement or delirium, or any
subsequent paralysis of nervous or muscular function
like other narcotic agents, and particularly opium and
belladonna; they act in this respect more like chloral
— 92 —
and paraldehyd than like opium, engendering a calm
which soon passes into natural sleep.
I know certain aged patients who sleep poorly in
consequence of cerebral arterial degeneration, but
who affirm that when they are able to indulge freely
in lettuce as an article of diet, they sleep very well.
I have not, however, seen the least hypnotic benefit
from any pharmaceutical preparation said to contain
lettuce.
HOPS-LUPULIN.
I have known simple insomnia from neurasthenia,
from care, worry, overwork, etc., temporarily relieved
by teaspoonful doses of lupulin on retiring. I say
temporarily, for I have never known the effect to last
longer than two or three nights. The doses must be
rather large. Hop tea can be of little use, as hops
do not yield their active principle to water. Lupulin
is a yellow powder formed on the surface of the scales
of hops; it is obtained by rubbing or threshing or
sifting the strobiles, of which it constitutes from one-
sixth to one-tenth by weight. It contains a volatile
oil and bitter principle which are readily soluble in
alcohol. Lupulin may be given in pill form, or be
taken in the form of a paste, mixed with water or
syrup.
Doubtless in. cases of insomnia from irritable
bladder, and from genital irritation, nearly all practi-
tioners have occasionally found lupulin in teaspoonful
doses useful.
— 93 -
It will not do in closing this topic to omit to men-
tion the hop pillow, which has sometimes proved
beneficial in allaying restlessness and producing sleep
in nervous disorders. The pillow should be moistened
with spirits before being placed under the head of the
patient (Dr. Geo. B. Wood).
Pills for Satyriasis (Dujardin-Beaumetz).
Lupulin 2 grammes.
Bromide potassium 2 grammes.
Ext. nymphoea (water lily), q. s.
For 20 pills. Sig. Take two pills every two hours.
II. ALCOHOL, AND OTHER STIMULANTS — EUPEPTIC
AGENTS.
Alcohol sometimes acts as a hypnotic, and is in
fact frequently resorted to for that purpose. It pro-
duces sleep, not because it is a vascular stimulant,
clearing the over distended blood-vessels, but because
it is taken in a sufficient dose to have a narcotic effect.
Ale is especially chosen for hypnotic effect; the hops
with which it is impregnated undoubtedly aid the calm-
ative action. Whiskey or brandy to have a soporific
effect should be of pure quality, and the older the
better. The theory that liquors long mellowing in the
cask get rid of fusel oil and other alcohols not ethylic,
and develop soothing ethers, seems actually sustained
by facts; certain it is, moreover, that new liquors
adulterated with the higher atomic and more fiery
alcohols are excitant, and therefore antagonistic of
— 94 —
sleep. A tablespoonful or two of pure whiskey taken
on going to bed will often relieve the insomnia of the
exhausted, the irritable, the nervous; the insomnia
due to mental overwork or worry will often promptly
yield to the alcoholic potion. It is well to administer
the spirit in a tumbler of hot water — as hot as can be
drunk — as the heat favorably excites the stomach, and
through that organ reflexly soothes and inhibits the
cerebrum.
Unfortunately, the sleep produced by alcohol is often
of short duration; the patient awakes after a couple of
hours but little refreshed, and may lie awake much of
the night without being able to go to sleep again.
The combination of whiskey with a little sulphonal
may, however, remedy this. The sulphonal may first
be taken in fine powder, well stirred, till it is about
the thickness of cream, into a little water; this is fol-
lowed by the draught of whiskey. When the effects
of the alcohol begin to subside, those of the sulphonal
(which is slow to undergo absorption) are just com-
mencing. I have known a dose of only lo grains of
sulphonal, followed by a tablespoonful of old whiskey
in a little hot sweetened water, to oe succeeded by
eight hours of sound sleep.
Ginger, peppermint, camphor, lavender, carda-
mom, and other gastro-intestinal stimulants and
" carminatives," taken with hot water, occasionally
prove hypnotic. Even hot water alone may induce
sleep if drunk freely on going to bed; in such cases
— 95 —
it may be supposed that the insomnia is the result of
a dyspeptic state, and that the increased vasculariza-
tion of the stomach may cause diminished vasculariz-
ation of the brain, thus producing one of the condi-
tions of sleep. A few drops of the aromatic spirits of
ammonia, of the ammoniated tincture of valerian, of
the fluid extract of skullcap, will sometimes enable
the individual speedily to pass the barrier which sep-
arates the waking from the sleeping state. Many a
person rendered sleepless by a disordered stomach —
the seat of acrid fermentations — has been enabled to
realize immediate quiescence of both stomach and
brain by a dose of rhubarb and soda, a drachm of
Carlsbad salt in a cup of hot water, or even the same
quantity of bicarbonate of sodium taken in the same
way.
III. BROMIDE OF POTASSIUM AND BROMIDES.
Among the newer hypnotics must be mentioned
bromide of potassium, which still has a great reputa-
tion as a remedy for chronic insomnia. It probably
produces its effects, as Vulpian taught, not by anaemi-
ating the cortex,* but by the influence which it directly
exerts on the anatomical elements. " It simply less-
ens the functional activity of the brain, without dis-
turbing the relation of one part to another" (Brunton).
Where the indication is to diminish cerebral or spinal
irritability; where the brain is hyperaemic from excess
*Le(ons sur les Vaso-moteurs, t. ii, chap. i.
- 96 -
of mental toil, from prolonged watching, from abuse
of stimulants; in nervous erethism characterized by
emotional excitability, exaggeration of the reflex
activity; in the insomnia of fevers, and in genito-
urinary insomnia, bromide of potassium (at least till
the discovery of chloral) has been the best hypnotic
known to the profession. It depresses innervation
generally, and is a debilitant of the heart; hence, in
the feeble, asthenic, and cardiac, it is to be prescribed
with caution. It may often with advantage be asso-
ciated with chloral and morphine; if given with
whiskey its depressant action is less marked; the com-
bination with calisaya, with simple elixir, with anise
cordial, makes it often more acceptable to the stomach.
I^ Pot. brom grs. xxx.
Anise cordial § i.
M. For one dose.
5 Pot. bromid | ss.
Elix. calisaya,
Sherry wine, ''
M. Sig.: A teaspoonful three times a day and at bed-
time.
5 Pot. bromid., ) ^^ _ ••
Hyd. chloral, f ■*'
Tinct. valerian 3 vi.
Spts. lavend. co 3 vi.
Aquae camph q. s. ad § vi.
M. Sig.: A tablespoonful every two hours till sleep is
induced.
The above formula has been of great use to me-
in the treatment of alcoholic insomnia.
— 97 —
BROMIDE OF LITHIUM.
The bromide of lithium, according to Macfar-
lane, is the best hypnotic of the bromide salts, as it
contains a half more bromine than the potassium bro-
mide. Its dose is lo to 20 grammes. Macfarlane
recommends the combination with ergot of rye and
digitalis, both of which are stimulants of the vaso-
motor centres.
I^ Bromidi lithii grs. xl.
Fluid ext. ergot 3 i.
Tinct. digitalis tt[, xx.
Chloroform water 3 xv.
M. Sig.: Take one-half two hours before going to
bed, and the other half at bed-time.*
IV. CHLORAL.
The discovery by Liebreich, in 1869, of the hyp-
notic properties of hydrate of chloral may be regarded
as one of the most important therapeutic discoveries of
modern times. The experience of the past twenty-two
years has more than justified the first conclusions
respecting its actions and uses, and chloral may still
be regarded as, on the whole, the best hypnotic we
possess. Its principal advantages are: i. It is speedy
and generally certain in its action. 2. There is no
preliminary period of excitement. 3. Its effects are
prolonged, and the sleep which it produces is calm,
tranquil, and refreshing; the patient wakes out of the
* Insomnia and Its Therapeutics, p. 88.
7 BBB
- 98 -
chloral sleep as out of natural sleep. 4. It can be
given with good results in cases where opium is not
tolerated. 5. There are seldom any unpleasant or in-
jurious after-effects; it does not disturb the secretions
or excretions, as do many other hypnotics. 6. It has
a wide range of usefulness besides being simply a
sleep-producer; in all morbid cerebro-spinal condi-
tions attended with excitation, delirium, or spasm, it
is markedly beneficial; in the insomnia due to delirium
tremens, acute mania, general paralysis of the insane,
puerperal mania, chorea, tetanus, etc., it is of great
value.
Among its disadvantages are: i: It is a cardiac
depressant, and therefore must be given with great
caution, or withheld in organic affections of the heart.
2. It is a dangerous remedy when long-continued, its
effects on the brain, and consequently on the mental
functions and disposition, being deplorable. The
chloral habit is, doubtless, quite as bad as the morphine
habit. "Its employment," says Macfarlane, "is so
fraught with risk that its use, except under medical
advice, is much to be deprecated.
" At first the mental depression and melancholia,
from which the patient suffers, are alleviated by a
dose of the drug; after a time it fails to soothe, and
may even excite. The victim gravitates into a pitia-
ble state of mental weakness and demoralization, be-
coming childish, vacillating and untruthful, some-
times dejected, at other times excited, and having
— 99 —
suicidal tendencies. Tiie symptoms are due to
cerebral anaemia and enervation of the heart,
lungs, etc."*
Chloral may be given in doses of from one grain
up to twenty, and even thirty. I have given grain
doses to infants with good results. In some rebellious
cases of insomnia, in the adult, I have administered
forty grains in one dose. It is in delirium tremens
and in acute delirium generally that I have found the
maximum doses necessary. In mild cases of insom-
nia, in the adult, grain doses every half-hour till sleep
is induced will generally ^have happy effects. The
combination with peppermint-water is a good one.
^ Hyd. chloral 3 i.
Peppermint-water § vi.
M. Sig. — A teaspoonful every half-hour, till sleep is
produced. In obstinate cases of insomnia, give of this solu-
tion a tablespoonful every hour. The smaller dose is a safe
one to administer to children.
Chloral may be advantageously combined with
morphine, bromide, urethran, and alcohol; when its
cardiac depressant properties are feared, the nightly
♦dose may be given with a full dose of whiskey.
V. SULPHONAL.
Next, perhaps, in importance to chloral comes
rsulphonal. This is a proprietary medicine, the exact
* Loc. cit.
process of whose manufacture is probably unknown
except to the monopoly which is enriching itself at the
expense of the public by charging for a relatively in-
expensive substance an enormous price.
Sulphonal is a pure hypnotic; it does not excite,
cause delirium, affect the secretions, etc., like nar-
cotics. The sleep which it produces is marvelously
like natural sleep. Few unpleasant symptoms — at the
most a little nausea, vertigo, titubation, which are
temporary — follow its use. It is, however, not an an-
algesic nor an antispasmodic; does not depress reflex
spinal excitability like chloral or bromide; does not
enfeeble the heart. In tKe insomnia of neurasthenia,
mental depression, disappointment, overwork and
worry, it often has a charming effect.
There is a class of patients who are especially
benefited by sulphonal. They are men of business
who are beset with cares. They go to sleep at a cer-
tain hour, but are sure to wake between one and three
o'clock in the morning, and then they will lie awake
till morning; may possibly snatch an hour or two of
sleep after daylight. Here a dose of lo grains of sul-
phonal at bed-time will hardly fail to give a good
night's sleep, and by being taken a few nights in suc-
cession, a morbid habit may be broken.
In the insomnia due to arterial degeneration of
the cerebral vessels in the aged, sulphonal sometimes
works admirably; it may be taken in lo-grain doses
every night for months without any seemingly injuri-
ous effect. The dose is from lo to 60 grains, an hour
before the usual bedtime. The sulphonal may be
stirred into a little water and taken in suspension, or
it may be taken in mucilage. Dr. Stewart of Jeffer-
son Medical College, Philadelphia, in a recent num-
ber of the Medical News gives a new method of ex-
hibiting sulphonal. He directs that just before retir-
ing the sulphonal powder be stirred in a glass two-
thirds full of boiling water (about 6 fluid ounces) until
nearly dissolved. The water must be boiling, and to
ensure that it is at the boiling point when brought in
contact with the sulphonal, it had better be heated on
the spot (in a tin cup over the gas, or over a spirit
lamp). After the sulphonal has entered into solution,
cold water may be cautiously added to reduce the
liquid to a drinkable temperature, which, if the pa-
tient is accustomed to taking hot fluids, will be one
not sufficient to cause the slightest precipitation of
the drug. To insure success, the sulphonal must be
taken wholly dissolved, and the hotter the solution is
drunk the better. The hot solution dilates the gastric
vessels and stimulates them to rapid absorption, so
that diffusion takes place from the stomach probably
before slight or any precipitation of the drug occurs.
The period of therapeutic incubation is thus practic-
ally done away with; sleep results in most cases in a
few moments, and seems to be more profound and
dreamless than from a large dose taken in any other
way.
J02
VI. PARALDEHYD.
Paraldehyd as a hypnotic agent dates from 1883.
Cervello, of Strasbourg, first called attention to its
hypnotic virtues, and it shortly came into use in all
civilized countries.
This medicine is so nauseous that many patients re-
fuse to take it. It is less analgesic than chloral, and is
not a cardiac poison. It is thought to be superior to
chloral in mental alienation, in nervous insomnia, and
in the insomnia due to abuse of alcohol. It has been
found to be very valuable as a calmative and hypnotic
in hysteria; like chloral, it is antispasmodic. It is said
not to produce injurious effects if taken for a great
length of time, nor does it soon lose its effect. It is-
more effectual than sulphonal in the insomnia of
acute or chronic disease where pain, cough, dyspnoea,
or fever exist (C. M. Hay). It belongs to the class of
pure hypnotics, along with sulphonal and chloral. The
dose is a teaspoonful, which may be given with muci-
lage, rum, or sweetened water. A good formula is:
3 Paraldehyd 3 i •
Mucilage acaciae §i.
Syrup aurantii corticis 3 i.
If taken in rum or kirsch, the disagreeable taste is
totally disguised (Dujardin-Beaumetz).
VII, URETHAN.
Urethan is the carbonate of ethyl (Cgli^NOg).
It was introduced into therapeutics in 1884 by
Schmiedeberg, of Strasbourg.
— I03 —
Experiments on animals proved this agent to
have marked hypnotic properties; it was not found
to have any toxic action on the heart, or to depress
the arterial tension.
Administered to the human subject, and in the
dose of thirty to sixty grains, it produces a calm and
tranquil sleep, which is not followed by headache or
other uncomfortable symptoms on waking. The dose
is necessarily somewhat large; it cannot be depended
on for hypnotic effect if less than a scruple be admin-
istered. Huchard regards it as a pure hypnotic, not
disagreeable to the taste, but little toxic, inferior to
morphine only when there is pain to combat.
Urethan is regarded. by Huchard, Von Jacksch^
Eloy and others as peculiarly safe in diseases of the
heart, and in, particularly, aortic insufficiency. Be-
sides the insomnia of heart affections generally, other
kinds of insomnia — that of tubercular diseases, of
neurasthenia, of melancholia, of physical and mental
overwork — are said to be tributary to urethan. This
remedy, however, has but a limited range of useful-
ness as compared with chloral and sulphonal.
Urethan being soluble, may be given in watery so-
lution flavored (or not) with peppermint, lavender, or
bitter orange-peel.
VIII. SOMNAL.
Somnal has been for too short a time before the
profession to permit any critical judgment of its
merits. In 30-grain doses it is said ** to act half an
— I04 —
hour after the ingestion, causing a calm sleep of six
or eight hours' duration, without any disagreeable
after-effects. It has no action on the pulse, respira-
tion, or temperature."
The writer from whom I have quoted (Boymond)
adds that it " possesses the hypnotic properties of
chloral without any of the disadvantages of the latter
drug."*
IX. AMYLENE HYDRATE.
Amylene hydrate is given in large doses — 60 to
90 grains. The most recent and thorough testings of
this drug have been made by Dr. W. H. Flint (see
Therapeutic (lazette, Jan. 15th, 1890, p. 69). *' In
therapeutic doses it produces sleep by its soporific ac-
tion on the cerebrum. It is applicable therapeutically
to insomnia from nervousness, from excessive mental
exertion, from anaemia, fevers, insanity, cardiac dis-
eases, the opium habit;" is not efficacious in insomnia
from pain, cough, and from that due to cardiac and
ursemic dyspncea. After-effects are slight or ;///.
X. CHI.ORAT, AMIDE.
This is another pure hypnotic which seems to be
of considerable value. f According to some recent in-
vestigations, this new drug is a less powerful hypnot-
ic, weight for weight, than hydrate of chloral. The
*Semaine Medicale, 1889, p. 408.
f See Therapeutic Gazette, 1889, pp. 6ir-686.
— I05 —
ordinary dose for an adult is from 30 to 45 grains.
Sleep comes on in from half an hour to three hours
after the drug has been taken. Chloralamide shows
itself to best advantage when the sleeplessness is of
purely nervous origin, and is not contra-indicated
where there is some amount of pain, and where there
is a moderate amount of cough, as well as in a num-
ber of mental affections not accompanied by any con-
siderable degree of excitement. It has proved service-
able in delirium tremens, and even in cardiac asthma.
It possesses a real advantage over chloral in not be-
ing a cardiac depressant.
XI. REMEDIAL MEASURES NOT MEDICINAL.
Baths. — The effect of the cold bath is to promote
arterial tone and invigorate the circulation.
'J'he first effect is to contract the arterioles and
send the blood from the peripheral to the internal
organs, the brain included. Afterwards the vessels
of the periphery dilate and the arterioles of the vis-
cera contract; there is a temporary depletion of the
internal organs while the skin and external parts are
flushed with blood. This physiological action may
sometimes be put to profit in the treatment of in-
somnia, especially in the insomnia of young and
vigorous people, on condition that a healthy reaction
after the cold bath or cold plunge ensues. In the in-
somnia of fevers, the hypnotic effect of a cold bath
has often been noticed. In the aged and feeble the.
— io6 —
cold bath is contra-indicated on account of the de-
pression and want of reaction that follow. In those
affected with cardiac and arterial disease, the cold
bath ^ight be positively dangerous.
The warm bath or hot bath taken at bed-time is
sometimes of unquestioned utility in promoting sleep.
It IS hard, however, to tell just what cases of insomnia
are likely to be benefited by the warm bath. In feb-
rile insomnia it is certainly efficacious, if followed by
a fall in the temperature and gentle, not excessive,
perspiration. In digestive, cardiac, respiratory and
purely "nervous" insomnia, the warm bath is not of
much therapeutic value, and there is danger that it
may excite rather than calm the brain. There is
much testimony, however, as to the singular efficacy
of prolonged warm baths in combating the insomnia
of acute mania. "Prolonged warm baths," says
Moreau de Tours, "have an exclusively calmative
property which is everywhere recognized." The indi-
cations, he says, are the youth of the patient, prompt
explosion of the mania, acute mania associated with
melancholia, great physical activity, lucidity of ideas,
a continual state of furor, of agitation, etc.; while ad-
vanced age and cachectic states contra-indicate the
warm bath.
Hot foot baths are excellent means of derivation,
and are often sufficient to induce sleep. Some neur-
asthenic patients even find relief from their insomnia
by going to bed with a hot water bottle to their feet.
— loy —
and almost everybody has experienced the difficulty
of going to sleep when the feet are cold.*
The Wet Pack. — This is a very active hydro-
therapic method, being a " derivative or calmative
of the highest order" (Macfarlane).f A sheet is
wrung out of cold water, and the patient is enveloped
in it from neck to ankles, the head and feet not being
included. Several dry blankets are wrapped around
the patient, a hot water bag is applied to the feet, a
cold wet cloth to the forehead, and the patient is
allowed to remain in the pack from half an hour to
an hour. At the end of the process he is rubbed
down with dry cloths to promote vigorous reaction.
The Turkish Bath.—Th^ Turkish bath is highly
recommended in many cases of insomnia. It relieves
cerebral congestion, and promotes circulation and
* Hammond employed with success, in a young girl
whose extremities were habitually cold, electrization of the
sciatic nerve.
f Experiments of Weir Mitchell have shown that the
effect of chilling the cerebrum is a brief sedative action.
Then phenomena of motor excitation are developed, sensi-
bility is lessened, and if the application of cold is continued,
the animal falls into a profound stupor, and surgical opera-
tions may be performed on him without the least movement.
When cold is applied to the medulla oblongata, the respira-
tory movements are first tumultuous, then they are slowed,
and finally cease altogether. (Quoted from " Clinical Thera-
peutics," by Dujardin-Beaumetz. Published by G. S. Davis,
Detroit, Mich.)
— io8 —
arterial tone, as well as digestion and assimilation.
The Turkish bath consists of three rooms. The tem-
perature of the first, or dressing room, is moderate,
that of the second is higher, that of the third is higher
still. In the first room, the bather, after dressing,
winds one towel around his loins and a second
around his head in the form of a turban. If he has any
tendency to cerebral congestion, the second one may
be wet. He then passes into the second room, where
he waits a short time before passing into the third
room. Some people, however, go directly into the third
room. In both the second and third rooms the bathers
partake freely of cold water. A few minutes' stay in
the warmest room is usually sufficient to make the
bather perspire freely, and he then returns to the
second or cooler room, where he may remain half an
hour or more, according to circumstances. He may
then be shampooed, the surface of the body being
rubbed, the muscles kneaded, and the smaller joints
extended. He is then washed with a lather of soap,
and sluiced with basins of tepid or warm water. For
some people it is most agreeable after this to be
simply wrapped in warm towels and allowed to repose
in the dressing-room. Others prefer to finish up with
a cold douche before proceeding to the dressing-room.
Here they remain resting for a considerable time be-
fore they again dress.*
Brunton's Pharmacology and Materia Medica.
— I09 —
Hot Compresses^ consisting of layers of flannels
wrung out of hot water and covered with dry flannels,
are sometimes of benefit in insomnia when applied
over the abdomen.
In an interesting lecture recently published in
the Dietetic Gazette (Dec, 1891), Dr. C. L. Dana, in
speaking of the benefits of hydrotherapy in nervous
diseases, regards the wet pack as a most useful seda-
tive in neurasthenia and insomnia, and a good sub-
stitute for medicinal sedatives, like the bromides. It
should be given three or four times weekly, or for a
short time daily. The tepid bath ranks next in its
sedative efficacy. The shower and jet baths are a
• most valuable means for securing tonic effects.
In weak, sensitive and anaemic women, he pre-
scribes, first, dry hot packs for a week, then wet packs,
and, finally, the drip sheet or cool shower. The
Turkish bath and the hot Sitz bath (the patient sitting
for twenty to thirty minutes in water at blood heat)
have also been found to have excellent sedative
effects and to be promotive of sleep.
Electricity. — My experience, like that of most
general practitioners, has been confined to faradism.
• I have resorted to this form of electricity for the re-
lief of obstinate insomnia. I have never applied the
current to the head, but have sought to obtain a
powerful derivative effect by applications of the wet
sponge, or the metallic brush, to distant parts of the
body. I have seen neurasthenic patients quieted and
— no
made able to sleep by faradization up and down the
spine about bed-time; also by a general electric mass-
age, given with the hand, which is made to communi-
cate the current.
Stille (Therapeutics and Materia Medica) speaks
of obtaining success " by passing a fine secondary or
primary current from the cervical vertebrae to the
epigastrium, and from the dorsal vertebrae to the en-
tire front of the chest." " Drowsiness," he adds, "is
not uncommon in anaemic and debilitated persons
during the use of a generally applied direct inductive
current. It has occurred only under the influence of
a fine interrupted current of the second order, with a
low intensity. In old persons who are restless and
sleep badly, a current of this kind passed over the
forehead, while the negative is carried over the shoul-
ders and down the arms, quickly promotes sound and
prolonged sleep."
Doubtless cutaneous faradization produces that
anaemic condition of the encephalon which is favora-
ble to sleep; in confirmation of the view that this is
the case, we have the observation of Nothnagel that
^' cutaneous electrical stimulation is followed by a re-
flex contraction of the vessels of the pia mater."
Central galvanization has proved efficacious in
the experience of Berdet, Meyer, Erb, Skene, Keith,
Macfarlane, and others. According to the experi-
ments of Legros and Onimus, currents of descending
direction (positive pole over the forehead, negative
— Ill —
pole to the neck) determine, contraction of the vessels
of the pia mater; reverse the poles, and a directly-
contrary effect is obtained.
Doubtless electro-therapeutists, by their ready
control (through the proper currents) of the vaso-
motors, are able to modify the intra-cranial circula-
tion at will, and if sleep were only a circulatory phe-
nomenon, they would be able to give us infallible
recipes for all kinds of insomnia. Unfortunately the
laws of natural sleep are not exactly the same as the
laws of the vaso-motors: sleep is, as has before been
said, something more than a plus or minus of blood
in the brain. If galvanism is a remedy for insomnia,
it is by improving the tone of the vessels, and the
nutrition of the cerebral cells, rather than by any
transient influence on the circulation, that it does
good.
The subject is one on which a long chapter
might be written, but such a chapter would be inap-
propriate for this treatise. The successful treatment
of insomnia by galvanism presupposes, on the part of
the practitioner, a knowledge of technical details and
a skill which can only be acquired by a study of the
, best special, treatises on electro-therapeutics and by
long practice. Moreover, the range of usefulness of
electricity in insomnia is largely limited to neuro-
pathic or neurasthenic cases.
Lewandowski and Eulenburg state that they
have obtained very favorable results with franklini-
— -112
zation. The head plate \s used, and the electricity is
conveyed in the form of breezy currents which are
both agreeable aud soothing to the patient. By
means of the discharging hand electrode, the patient
is also electrified through his clothes; the seances last
about half an hour, and the patient goes to bed
soothed and ready to go to sleep. At the Adams
Nervine, Jamaica Plain, much account is made of
static electricity in the treatment of nervous insomnia,
and my friend Dr. B. W. Bartlett, of Rowley, informs
me that he relies principally on this form of electric-
ity (along with other hygienic means) in the treatment
of neurasthenia and its accidents, insomnia included.
To conclude the chapter on Hypnotics — if drugs
have had the greatest prominence among the thera-
peutic means, it is not because they are really the
most important. I think that physicians should be
very chary in prescribing the medicinal hypnotics. We
still know too little about their action on the delicate
cells of the brain and on the vaso-motors. Many of
them, by constant or frequent use, become positively
baneful. It is, therefore, with a caution against the
careless employment of hypnotics that I close this
book, and with an exhortation to physicians first to
try fully (when possible) all available hygienic
resources before resorting to medicinal hypnotics.
INSOMNIA.
SLEEP, poetically expressed, is " Life's nurse sent from
Heaven to create us anew from day to day." It is, in-
deed, "Tired Nature's sweet restorer."
Insomnia may be dependent upon derangement of the
nervous, circulatory, respiratory or urinary organs, the alimen-
tary tract, the liver, or upon febrile or general disease. It
may also be caused by unhygienic conditions of heating, light-
ing, ventilation, diet, or occupation.
Whatever its cause, which must be sought for, and as far
as possible removed, resort must often be had to medicinal
agents.
Preparations of the Bromides, Chloral, Gelsemium, Opium
and Henbane are most universal y employed.
We supply these in combination in two different formulae,
under the name of
CEREBRAL SEDATIVE COMPOUKD
(Formula A, with Opium; Formula B, with Henbane substi-
tuted for Opium, the latter for cases in which Opium is contra-
indicated).
The following prescription is an eligible one for admin-
istration:
5 Cerebral Sedative Compound,
Syr. Sarsaparilla Compound, aa | iv.
p., D. & co.'s.
Sig. : Dessertspoonful when indicated.
Descriptive literature of our products sent to physicians
on request.
PARKE, DAVIS & COMPANY,
DETROIT AND NEW YORK.
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