Insomnia; and Other Disorders of Sleep

Lucid lethargy.—In certain cases of apparent death the patient exhibits all the external appearance of suspended animation, but the power of conscious perception does not cease. The senses of sight and hearing remain, and are, perhaps, intensified by inhibition of the power of voluntary movement. The sufferer sees and hears; perception, emotion, memory, the power of reasoning, judgment, volition, all persist. Only the power of executing voluntary movements is lacking.

The victims of this variety of apparent death are usually women, or men who are characterized by a feminine nervous organization. Great mental excitement, fatigue, semi-starvation, and exhausting diseases, are the principal exciting causes of the event. The following case, related by my friend, Dr. P. S. Hayes, of Chicago, illustrates the phenomena of lucid lethargy. The patient was a female physician, about thirty years of age, unmarried, and consumptively inclined. During the course of a long and wearisome hospital service, she was prostrated with typhoid fever. Placing herself under the immediate care of my informant, she was also attended by several of the most eminent physicians in the city. After a long and exhausting illness she appeared to be dying. In the presence of her physician, and surrounded by her relatives, she ceased to breathe. The pulse stopped, life seemed to have gone out. Bottles of hot water were applied to the limbs, and various restoratives were employed. After a considerable time she began again to breathe, and a gradual recovery followed. During the whole time of apparent death, consciousness had been preserved. She seemed to be looking down from a point above her bed; she could see the doctor feeling for her pulse, and was grieved by the sorrow of her friends. Ordinary sensation was temporarily suspended, and she could not distinguish the contact of the hot-water bottles that were applied to her limbs, though actually scalded by their excessive heat. Borne upon the wings of an excited imagination, she thought herself permitted to look into heaven, but was not suffered to enter its gates. In this exaltation of the imagination the reasoning faculties also shared, so that certain philosophical problems which had previously baffled her intellect were now perfectly comprehensible, and the memory of their solution persisted after recovery.

Many similar narratives have been duly authenticated, but the limits of the present chapter will not permit a discussion which properly belongs to an investigation of the phenomena of trance. The important fact for present consideration is the persistence of conscious life, despite the appearance of death. In this preservation of consciousness, notwithstanding the temporary suspension of certain kinds of sensibility and the power of voluntary motion, may be discovered a relationship between the phenomena of lucid lethargy and various disturbances of sleep, which will be considered in a succeeding chapter.

CHAPTER II.

We have seen that the condition of normal sleep is determined by a peculiar molecular state of the substance of the brain—a modification regularly alternating with that by means of which the condition of wakefulness is sustained. We have also seen that sleep is liable to variations in its intensity, and that its course may be partially interrupted by dreams, or even by a more or less complete resumption of the movements of locomotion, constituting the different varieties of somnambulism. Our attention must now be directed to the consideration of those greater disturbances of sleep which either serve to prevent its full development, or else to actually interrupt its course, rendering it incomplete and fragmentary, or even abolishing it altogether. But, inasmuch as the healthy brain, when associated with a healthy body, can only by an extraordinary effort of the will be kept awake beyond a certain period, and then only for a short time beyond the ordinary interval of wakefulness, it follows that the study of the usual causes of insomnia must be an investigation of morbid conditions of the bodily functions. Sleeplessness, therefore, must result, 1st, from a disturbance of the peripheral sensory organs of the nervous system; 2nd, from disordered conditions of the sensory nerves and nerve tracts; 3rd, from morbid states of the brain; 4th, from any or all of these conditions operating in association with each other. We may, therefore, consider, I, Insomnia caused by irritation of the peripheral portions of the sensory apparatus; and, II, Insomnia caused by morbid states of the central nervous organs.

I. Insomnia caused by irritation of the peripheral portions of the sensory apparatus.

Irritation of the sensory apparatus may be ranked in three classes:

1. Affections of the organs of special sense.—Prominent among these is the effect of light upon the eye. The darkness of night favors sleep; the presence of light hinders its incidence and renders it less profound. During the gloom of a total eclipse animals seek their shelter; birds hide themselves in their nests; domestic fowls arrange themselves upon the roost, and seem quite disconcerted by the speedy return of sunlight. Children often find it difficult to sleep in an illuminated room. I have known nurses who would sit with a wakeful infant under a powerful gaslight till after midnight, and then would express their surprise that the baby persisted in gazing at the flame instead of going quietly to sleep. The inhabitants of Northern Europe find it necessary to darken their sleeping rooms during the long polar day; and travelers in such regions often suffer for want of the natural sleep which only darkness affords. Judge Caton, writing of his travels in Norway[28] says: “We longed for darkness and for night. Do what we could to darken the windows to keep out the light, still it was not night as nature makes it, and which the habit of a lifetime had rendered necessary to sound repose. Artificial darkness, especially when incomplete, is as far from night as artificial light is from day.... These sunny nights can hardly conduce to health, they steal away so much of sleep. One does not readily get sleepy in the sunshine, and then we are so apt to forget to look at the watch to see if it is time to retire.”

In the tropical regions of the world it is usual for the inhabitants to sleep during the middle of the day; but they take great pains to exclude the light from their houses during the hours of sleep. The Pacific Islanders cover their faces with the bed clothes for the purpose of excluding the light while attempting to sleep. Repose thus obtained in the daytime often serves to convert the night into a season of wakefulness. The Africans sleep and dream away the heated hours of the day, and give up considerable portions of the night to festivity in the open air—a practice which undoubtedly contributes to the permanence of an inferior grade of social life.

Sudden illumination of the sleeping room will frequently awaken the sleeper. During the great fire in Chicago, A. D. 1871, many persons were thus aroused from their slumbers as the flames lighted up the streets adjoining their houses. One of my acquaintances was awakened one night by a flash of light from the lantern of a burglar who was moving noiselessly about her chamber. The experience of almost every one will testify to the effects of sheet-lightning silently illuminating the sky by night. Dreams, also, are not unfrequently excited by the incidence of light upon the closed eyelids.[29]

The sense of hearing is one of the most persistent of the special senses during the incidence of sleep. It is perhaps the most excitable of these senses during the period of repose. Long after the subject has become immersed in sleep his auditory apparatus remains sensitive to sounds. Dreams are often produced by impressions upon the ear. Often in sleep it seems as if the sense of hearing remained wakeful and watchful for expected signals, as when an alarm clock serves to arouse the sleeper at an appointed hour. Sometimes the sleeper may be shaken and tumbled about in his bed without waking, but if he be addressed by name he will usually reply. It is scarcely probable that the auditory apparatus is any more wakeful than other portions of the nervous system, but its external portions remain during sleep more completely exposed and adapted to the reception of impressions than is possible for the eye and for the organs of touch and taste.

The persistent sensitiveness of the ear during sleep is not so much a capacity for noticing sounds as a sensibility to variations in sonorous impressions. Thus a steady and monotonous noise may, if long continued, serve to render one sleepy; but the sudden cessation of the same sound will awaken every one. Slowly lulled to sleep by the incessant rumble of the engine upon one of the old-fashioned Long Island Sound steamboats, how immediate the awakening of a whole cabin full of people, when the wheels were suddenly stopped! A recent traveler in Guiana[30] relates a curious experience with an Indian magician who undertook to cure him of a slight headache and fever. The method of cure consisted in placing the patient at night in his hammock, while the magician kept up a hideous succession of yells and shouts, shaking the walls and roof of the house with an uproar which never ceased for six hours. Before long the patient passed into a kind of fitful sleep or stupor, during which he seemed to be suspended in a surging ocean of sound. When the noise died away, as if growing fainter in the distance, he would rouse up into a semi-conscious state, but when it again increased he would fall back into stupor. At last, when the noise finally ceased, he awoke completely, but without the slightest relief from headache—an experience quite illustrative of the manner in which the brain may be affected by sound.

It is not often that the sense of smell becomes the avenue of impressions that interfere with sleep. So different are the capacities of individuals in this particular that an odor which might severely annoy one person, would pass almost unnoticed by another. Large cities are sometimes invaded by overwhelming stenches from the various factories which spring up in their neighborhood. While it is seldom true that the vapors discharged by such establishments are directly deleterious to health, they may become indirectly a cause of ill-health through the wakefulness occasioned by them among weakly invalids. The smell of smoke in a bed-chamber sometimes serves to awaken a sleeper, giving warning of the outbreak of a fire in the building. Less energetic odors may disturb the depth of sleep without actually waking the patient. Thus Maury records[31] that when he was made to inhale the vapor of cologne water while asleep, he dreamed of being in the shop of a perfumer.

Excitement of the sense of taste would, doubtless, operate in a similar manner; but it is so difficult to arouse this sense without at the same time irritating the nerves of common sensation about the mouth, that very little can be said regarding the matter. Dreams of gustatory sensations are usually of subjective origin, dependent upon some reflex movement, or upon some agitation of the organ of memory, within the brain.

If, with Sir William Thompson,[32] we recognize a sixth sense—the sense of temperature—it must be admitted that through the varying sensations of heat and cold, sleep can be greatly disturbed. Every one will recall to mind the story told by Dugald Stewart, of a gentleman who dreamed of walking over heated lava on Mt. Ætna when a bottle of hot water was placed against his feet, in bed, on account of some slight indisposition. The temperature of the air is one of the most important factors in the determination of sleep. A high temperature keeps every one awake—a fact well known among the unfortunate denizens of the garrets in our great cities. Not only is wakefulness the direct result of heat, but it is aggravated and embittered by the accompaniments of a torrid climate—insects, foul air, and cutaneous disorders. In the East Indies, so difficult is sleep under such conditions that the wealthy inhabitants compel their servants to cool them all night with the punkah, a large, swinging fan, suspended above the bed, and kept in motion by means of a cord leading outside of the bed-room to the verandah, where the punkah-wallah sits and pulls the string while his master sleeps. So powerful is the force of habit in the organization of the automatic apparatus of the body that, though these punkah-pullers often fall asleep, they still continue, without interruption, the successive movements by which the fan is kept in operation.

The evil effects of a high temperature are greatly aggravated by the presence of humidity in the atmosphere. Dampness interferes with the process of exhalation from the surface of the body, which, consequently, tends to become overheated. The tissues, under such circumstances, are imperfectly defecated, and rapidly pass into a condition of imperfect nutrition. This depresses all the functions of the body, and renders the nervous system inordinately irritable. Sleep cannot be profound and refreshing, because of the over-excitable state of the brain. During the long, hot season in tropical countries, it often becomes necessary to seek a temporary retreat among the highlands and mountains, in order to find a climate sufficiently dry and cool to furnish the condition for refreshing sleep. For the same reason many of the inhabitants of the Southern United States are forced to spend the summer months in the invigorating atmosphere of Minnesota and Northern Michigan. One of the most delightful of experiences may be procured on any warm day in summer by embarking, at Chicago, upon one of the steamboats bound to Mackinac. At the wharf, in the hottest and dirtiest part of the city, all is dust, perspiration, and discomfort. The wide cabins are filled with people who are tired, thirsty, and discouraged. Sickly, squalling babies swarm in numbers sufficient to drive one mad. As the sun goes down, the signal-whistle sounds, head-lines and stern-lines are quickly cast off, the propeller churns the mire behind the boat. Slowly swings the huge fabric away from the shore, gliding between the walls of sun-scorched brick that line the stream on either side. At last the light-house at the mouth of the river is passed, and we are out upon the blue waves of Lake Michigan, with a heavenly breeze searching every crack and cranny of the hull. New life animates every form, and presently a great silence pervades the brilliant cabins. The children have left their woes behind, and, for the first time, in many weeks, perhaps, they and their weary mothers sleep the sleep of innocence and peace.

The dependence of a high atmospheric temperature upon the direction of the wind renders the course of the aerial currents a matter of great importance in relation to sleep. The southerly winds which, in the northern hemisphere, are hot and enervating, always produce an increase of wakefulness. The winds that blow from the heated deserts of Africa, Arabia, and Australia, are greatly dreaded upon this account, as well as for the other numerous discomforts which fly in their train. Their cessation, and their replacement by a cool, polar current brings relief at once. The changes thus produced in the electrical condition of the atmosphere doubtless contribute more than is usually known to these results. A cloudless sky gives evidence of positive electricity, which is much stronger in winter than in summer.[33] Clouds are sometimes positive and sometimes negative. According to Fonssagrives[34] the atmospheric electricity is positive during northerly winds, and negative during the prevalence of winds from the southerly quarters of the horizon. Great disturbances of the electrical condition of bodies is often observed during the occurrence of the sirocco in North Africa. Arago has related the case of an officer in the French army[35] who saw sparks of electricity leaping from his epaulettes at every blast of the sirocco encountered on a march in the neighborhood of Algiers. Such atmospheric disturbances often produce very disagreeable effects upon persons of a nervous temperament. According to Fonssagrives (loc. cit.) such patients frequently experience, during the prevalence of storms which traverse great distances, a high degree of insomnia, together with headache, pains in the limbs, joints, and old injuries, and a general indefinable sensation of discomfort. S. Weir Mitchell has carefully traced the connection between these phenomena and the variations of barometric pressure which accompany the revolving storms that cross the continent in a northeasterly direction.[36]

Though the effect of a high atmospheric temperature is unfavorable to sleep, an excessive temperature produces the opposite condition. Stupor rather than sleep is the consequence of insolation and of exposure to great heat from artificial sources. This is a pathological process, and, therefore, must not be mistaken for natural sleep. It may result either from cerebral congestion, or from cardiac exhaustion, and is characterized by an extraordinary bodily temperature and a high rate of mortality.[37] So elaborate are the arrangements for the preservation of a uniform temperature throughout the body that it is practically impossible for a sunstroke to occur unless the regulative apparatus has been previously deranged by ill-health.

Excessive cold operates in like manner to produce a condition of stupor that tends to a fatal termination. But moderate degrees of cold act as excitants of wakefulness. By effecting a contraction of the vessels of the skin cutaneous circulation is impeded. The venous side of the circulatory apparatus becomes overloaded with blood; the exhalation of carbonic acid and the production of heat are reduced. The discomfort that results from this disturbance of the natural functions of the tissues is sufficient to arouse the brain to wakefulness, just as an imperfect oxidation of the blood serves to excite the respiratory centre in the medulla oblongata. It is hardly necessary to allude in this connection to the increased flow of blood through the brain occasioned by this as by every other excitement of the sensorium. Local refrigeration of any portion of the body thus acts as a painful excitant of the cerebrum, and produces wakefulness, very much as distention of the intestines with gas will keep one awake. It is for this reason almost impossible to sleep with cold feet. Conditions of this sort are pathological, and are far in excess of the agreeable coolness which favors sleep. The effects of progressive diminution of the temperature of the air are well illustrated by the hibernation of animals.[38] As the temperature of the air diminishes, in winter, animals like the marmot fall into a species of sleep. Their movements of respiration and circulation are greatly reduced, and their bodily temperature falls, though it always remains several degrees above the temperature of the surrounding air. So long as the average degree of cold is maintained, the little creature sleeps naturally; but, if the air becomes extraordinarily cold, the physiological repose of the animal is disturbed. It becomes uneasy, wakes up, and seeks a warmer retreat. Too great a degree of cold thus becomes a cause of wakefulness. If the animal under these circumstances fails to secure protection against a falling temperature, it passes into a state of lethargy that is often fatal—a pathological condition being substituted for the physiological sleep of ordinary hibernation. In like manner the human animal may experience the threefold effects of refrigeration: first a pleasing coolness that favors sleep; then an uneasy sensation of cold which causes wakefulness; and, finally, a lethargy that paralyzes all the functions of the body and terminates in death.

2. Affections of the nerves of common sensation.—Chief among the causes of sleeplessness thus produced is pain. This is a modification of feeling, caused by excessive or extraordinary excitement of the peripheral nerves of sensation. The seat of the excitement may be in the skin or in the deeper tissues of the body. Cutaneous pain may be caused by the activity of various insects, like flies, mosquitos, fleas and bedbugs, or by the presence of certain parasites, such as the itch-mite, or by ordinary diseases of the skin, of which notable examples are found in erysipelas, erythema, urticaria, lichen, prurigo, certain varieties of eczema and psoriasis. The troublesome forms of pruritus which accompany icterus, or which may occur without any clearly defined cause, are frequent causes of wakefulness. The last mentioned disorder must, however, be sometimes recognized as a consequence of central nervous disorder, rather than a result of peripheral disease. Witness the frightful itching sometimes experienced during the progress of chronic myelitis. All kinds of injuries, wounds, ulcers, and other local inflammations are common causes of insomnia by reason of the painful impressions transmitted from them to the brain. Hence the great importance of anodynes and hypnotic remedies in the course of surgical practice. Diseases or injuries of the various peripheral nerves are notable causes of sleeplessness. Witness the horrible wakefulness caused by neuritis and by neuralgia. The development of neuromata in the stumps of amputated limbs may thus become a most painful cause of insomnia. Inflammations which encroach upon sensitive nerves produce intense pain with consequent loss of sleep. Of this very conspicuous examples are furnished by spinal meningitis, and by the effects of local periostitis causing compression of the branches of the fifth pair of nerves.

3. Affections of the sympathetic nerves.—So much still remains to be learned concerning the pathological functions of the sympathetic nerves that it is impossible to assign with any great degree of precision the exact amount of interference with sleep that may depend upon disordered conditions of this portion of the nervous system. Since their principal functions consist in the regulation of the flow of blood and lymph throughout the body, and in the control of the processes of nutrition, calorification, secretion and excretion, it follows that any considerable derangement of their healthy action must be represented by a corresponding disturbance of the brain. This may reach the field of consciousness in the form of pain, and thus may become a cause of sleeplessness. In all the phenomena of inflammation sympathetic nerves play an active part. In certain portions of the body, as in the principal viscera, and in the periosteal covering of the bones, they are the interstitial nerves of the structures. When the body is in a healthy condition these nerves convey impulses of a sensory character which do not reach the cerebral organ of conscious sensation. But in certain morbid states they become inordinately sensitive, and they then serve to convey and probably also to magnify sensations to an extent that may cause exquisite pain with all its consequences. Witness the pain experienced during the various forms of colic. Rheumatic inflammations, pleurisy, pericarditis, peritonitis, cystitis, metritis, ovaritis, gastro-enteritis, and other similar diseases owe their principal suffering to the affection of the sympathetic nerves connected with the respective organs which become the seat of pain. Including with the sympathetic nerve the pneumogastric nerve, which occupies a functional position between the strictly peripheral and the ganglionic nerves, all the various forms of pain and uneasiness experienced in the region of the heart and of the lungs may be assigned to this system of nerves. Thus the various species of respiratory disturbance, such as asthma and dyspnœa from any cause, and the forms of palpitation and other cardiac disorder may become causes of wakefulness. In like manner the vague and uneasy sensations associated with certain varieties of dyspepsia are frequent sources of sleeplessness, not merely by reason of the pain which they occasion, but also because of the general disorders of nutrition with which they are associated.

II. Insomnia caused by morbid states of the central nervous organs.

So intimately connected are the spinal cord and the brain that their disorders may properly be considered together. These may be classified as:

Disorders of circulation and nutrition.—Hyperæmia of the brain is a frequent cause of wakefulness. This may be maintained by an unconscious effort of the organ of the will under the influence of any great and unusual excitement of the mind. So soon as the mental excitement is allayed, the excessive afflux of blood subsides, and the brain becomes fitted for sleep. But, if excitement be too far prolonged, the nutrition of the nervous centres suffers, and the regulative apparatus of the cerebral circulation becomes exhausted, so that the brain cannot rest, because its inhibitory centres have lost their power of control over the lower ganglia of the organ. The cerebro-spinal centres are then in a condition analogous to that of a locomotive engine on which the engineer can no longer regulate the production and distribution of steam. Such a condition is usually the result of numerous antecedent causes. Long hours of work, scanty or improper food, insufficient sleep, bad hygienic surroundings and habits, with indulgence in the use of narcotics and stimulants, are among the most common causes of the disorder.

Active hyperæmia of the nervous centers has been above mentioned as the consequence of cerebral function under unfavorable conditions. But, as the disorder persists, its type undergoes a change. We still speak of the disorder as functional in its character, but it continually tends to become organic. No visible alterations, perhaps, can be detected, but, evidently, there are radical changes in the substance of the nervous tissue. Nutrition suffers throughout the body to a degree that attracts attention. The blood diminishes in quantity and quality, till the patient becomes notably anæmic. In this condition the brain is inordinately excitable. It is incapable of sustained activity, and the patient may even be oppressed by an inclination to constant drowsiness; yet he will be unable to sleep soundly, and his sleep will be continually agitated by dreams. This state is one of the constant accompaniments of slow starvation. The molecular structure of the nervous organs seems to be so slightly constructed, under such circumstances, that its equilibrium is disturbed by the most trifling incidents. It may be likened to a lofty wall of bricks laid up without mortar—“if a fox go up,” the entire structure may be thrown down with a tremendous noise. Thus the anæmic and irritable brain will react excessively under the slightest impression; consciousness is invaded by perceptions which would never arise under normal conditions of the nervous tissue; and the mind is continually aroused. This form of wakefulness is very frequent among women who have become anæmic, and among patients who are slowly convalescing from exhausting diseases.

It is impossible in every instance to decide whether a given state of wakefulness is the result of cerebral hyperæmia or anæmia. In the one case the persistence of wakeful activity of the mind is due to excitement of the cerebral cells, accompanied by a lavish irrigation of their substance with the plasma of the blood. In the other case the excitement is occasioned, not so much by increased afflux of the blood, as by a morbid instability of the nervous substance. The outcome in both cases is very similar—mental excitement and wakefulness.

In a third class of cases the agitation of the brain is produced by the direct action of certain chemical agents upon the cortical substance. Tea and coffee are familiar examples of such agents. The caffeine, by virtue of which they produce their effect, when transported to the brain, enters into combination with its protoplasm in such a way as to stimulate molecular movement. Perception is thus quickened, and the mind is aroused. Sleep is postponed until the effect of the stimulant has subsided. This form of wakefulness is quite different from that produced by alcoholic drinks. These operate, when taken in small quantities, to favor cerebral equilibrium—and consequent equanimity—by producing a general dilatation of the smaller blood-vessels. Their anæsthetic influence is favorable to sleep, under such circumstances. But, if frequently repeated, these doses of alcohol modify the nutrition of the nervous system until, at last, a condition of irritable weakness is reached, in which wakefulness of a most distressing character is experienced.

Inflammations, degenerations, and neoplasms.—The early stages of inflammation involving the central nervous organs are marked by that form of insomnia which is associated with active hyperæmia. The headache and painful delirium which accompany the different varieties of meningitis, are causes of a wakefulness that persists until the brain is merged in the coma of compression. The interstitial changes which cause the various forms of insanity, are in like manner causes of wakefulness. Local injuries and degenerations of brain-substance, tubercular deposits upon the meningies, and all the different forms of intra-cranial tumor, are causes of wakefulness, both by reason of the direct irritation which they produce, and by reason of the circulatory disturbances which arise in their neighborhood.

Finally, it must be observed that wakefulness may result from excitement of the brain by irritating substances transported through the blood from distant centers of disease in remote organs of the body, or derived from articles that have been absorbed with the food and drink, or with the air that enters the lungs. Thus wakefulness may accompany cutaneous disorders that interfere with perspiration. Imperfect elimination through the liver, kidneys and intestines, leaves the blood charged with excrementitious substances which arouse the brain to wakefulness. In like manner, various poisons, like lead, arsenic, etc., different miasms of telluric origin, the products of putrefaction, and the various animal contagia, may produce insomnia by their prejudicial effect upon the nutrition of the nervous structures throughout the body.

CHAPTER III.

An occasional attack of wakefulness may fall to the lot of any one as a consequence of the various disturbances of health or equanimity of mind to which all are liable. Occurring as an accident in a state of health, it produces merely a feeling of lassitude and weariness during the subsequent day. This soon disappears, after a night of refreshing sleep, and the subject is nothing worse for the incident. But the recurrence of the disorder is a thing to be deprecated, not only for the reason that it denotes a departure from the physiological order of life, but because its frequent repetition prevents the adequate repair of the tissues of the body. The great function of nutrition suffers as a consequence, and the patient rapidly falls into a condition of premature old age. When this takes place as a result of some temporary error of hygiene, or as a consequence of diseases which admit of successful treatment, the patient may be restored to health by judicious management, but lost youth and elasticity of the tissues can never be fully regained. The most formidable cases of insomnia are those for which no adequate cause can be recognized in the habits, mode of life, and state of health of the patient. Grave and permanent disorder of the brain is then to be feared. Such wakefulness is a frequent precursor of acute meningitis in children and adults. It frequently ushers in the early, insidious, formative stage of tubercular meningitis, and of the infective fevers—notably typhoid fever. It forms one of the most suspicious symptoms among the introductory phenomena of insanity; and during the course of protracted diseases, its intrusion is an omen of most unfavorable augury. It will, therefore, be found useful to consider with some degree of detail the circumstances under which insomnia may occur, and the best means of averting its onset.

A severely logical reference to previous doctrines regarding the condition of the brain during sleep, has led many authors to consider the therapeutical treatment of insomnia chiefly as a matter of modification of the cerebral circulation. Sleep has been supposed to depend upon a comparatively bloodless state of the brain, and wakefulness upon the contrary state. For such theorists the treatment of insomnia consists very simply in the use of agents which are supposed to be efficacious in reducing the flow of blood through the head. Tourniquets, placed upon the carotid arteries, occupy a position of great honor in the armamentarium of such people. Recognizing the fact that changes in the force of the circulation accompany and sustain every change in the activity of the cerebral cortex, we, however, attach the greatest importance to the condition of the nervous substance itself. For a clear understanding of the proper mode of medication, it is important to ascertain whether the cerebral substance is in a state of normal activity, or whether it is in a state of healthy, but excessive, activity, or whether its seeming excitement is merely the result of irritable weakness. Since these opposite conditions may declare themselves during the course of any disease in which insomnia may become a troublesome phenomenon, it is impossible to make a classification of diseases upon the basis of these different states of the brain. It will, therefore, be found more useful to consider the subject of sleeplessness as it ordinarily presents itself during the clinical progress of the several forms of disease. It will, then, appear that the type of insomnia is liable to variation with the course of each individual malady; and its treatment must vary accordingly.

Before proceeding to a discussion of the therapeutics of insomnia in connection with particular diseases, it will be advantageous to pass briefly in review the different remedies which are useful in the treatment of wakefulness. These may be divided into two classes: Nervous stimulants, and nervous sedatives. Among the first may be also reckoned food, heat, baths, and counter-irritants. Like all nervous stimulants, they promote the complete and harmonious action of all parts of the nervous system, favoring that equilibrium of the circulation which is most favorable to the development of sleep. The second class of agents comprises all such remedies as act directly upon the nervous tissue of the brain, depressing its functional activity, and hushing to rest those particular organs which, by their undue excitement, serve to keep the remainder in a state of wakefulness. All these substances produce decided effects upon the spinal cord and the peripheral nerves, but it is their operation upon the brain which principally interests us in connection with insomnia.

NERVOUS STIMULANTS.

It may at first sight seem to be a contradiction in terms when it is asserted that sleep may result from the administration of a nervous stimulant. This does occur, but only indirectly, and as a consequence of a restoration of energy to those portions of the nervous system which serve to moderate the activity of the organ of the mind—the cortex of the cerebrum.

Heat, for example, is an undoubted stimulant. When added to the body in quantity sufficient to overcome chilliness, it tends to equalize the circulation of the blood, and produces throughout the body a nervous equilibrium that prevents any particular organ or member from arousing the others to wakefulness.

Baths.—The application of heat in the form of a warm bath constitutes one of the most admirable means of tranquilizing the brain. Children who are restless at night are delightfully soothed by a warm bath every night and morning. The water should be of an agreeable temperature—this is better than any exact figure upon the scale of a thermometer—and the bath should not last lounger than ten minutes. Similar baths exercise a happy effect upon adult patients who are moderately feverish, nervous, and wakeful. If strong enough, they may take a full bath at bedtime; but if too feeble to leave the bed, gentle sponging with warm water will prove most refreshing, and will usually be followed by restful sleep. The well-known derivative effects of hot foot baths scarcely need to be more than mentioned in this connection.

Turkish baths form an invaluable adjuvant in the treatment of chronic cases of insomnia arising from rheumatic, gouty, and dyspeptic disorders of the health. The copious perspiration induced by the heated air of the hot chamber is depurative, while the cold douche and the massage with which the bath is concluded have a powerful effect to stimulate all the functions of the body. By this means the brain is enabled to resume a healthier mode of action, and sleep follows as a matter of course.

Massage.—This constitutes a process of rubbing and kneading the body. It has been practiced from time immemorial among the oriental races and the Pacific Islanders as a means of relief from fatigue of every kind. Among the Japanese the practice of massage is a monopoly in the hands of the blind, who are thus enabled to support themselves. Various modifications of the oriental method have been introduced under the names of percussion, shampooing, and the Swedish movement cure. They all possess the common features of friction applied with the hand to the skin, compression of the muscles with the hands, and passive movements of the different articulations of the limbs and body. For effecting all these processes nothing has yet surpassed the Sandwich Island lomi-lomi as practised by the court-retainers of the ancient chiefs. As a means of relieving fatigue, and of removing muscular soreness, after violent exertions of every kind, it is far superior to the imitations performed by European and American professional masseurs and masseuses. Nervous headaches, the pains that accompany spinal irritation, and all conditions of restlessness and wakefulness which depend upon exhaustion are relieved by this method. The well-known soothing influence of a mother’s hand stroking the face and forehead of her sleepless child, is an example of only one of the effects thus produced by the skillful masseur. These salutary results must be assigned to the uniform friction of the skin, causing the liberation of heat, and modifying the electrical conditions of the body. By this, the impressions derived from the peripheral nerves are reduced to a more harmonious series. The circulation of blood and lymph is rendered more active in the substance of the muscles, and all the processes of nutrition are thus stimulated to a degree that restores the equilibrium of function throughout the nervous system. Being no longer irritated by suffering portions of the body with which it is connected, the brain then yields to the effects of its own fatigue, and sleep supervenes.

Electricity is chiefly useful in those cases where it is impossible to discover anything but cerebrasthenia as the cause of wakefulness. According to Beard and Rockwell,[39] sleep may result from the use of any one of the different methods of electrization. The passage of a moderate current, either galvanic or faradaic, through any portion of the body often produces a temporary feeling of sleepiness; but the long continued employment of electricity is needful to effect those changes in cerebral nutrition which are necessary for a permanent cure of insomnia. In cases of sleeplessness caused by worry and overwork, great benefit is often experienced from the daily passage of the faradaic current from the back of the neck, or from the pit of the stomach, to the feet. Static electricity, and the electric bath, are also very effective in many cases of so-called spinal irritation and insomnia.

Counter-irritants are substances which are applied to the surface of the body for the purpose of communicating to the superficial sensory nerves impulses (irritation) which may serve to inhibit the morbid functions of distant or central nervous structures. Various explanations of this process have been presented; notably a most ingenious argument by Dr. T. Lauder Brunton[40] in favor of the theory of inhibition by interference of vibrations—impulses from the periphery interfering with vibrations originating in morbid conditions of the central nervous organs—very much as darkness is produced by the interference of luminous undulations, and silence is effected by interference of sonorous waves in the atmosphere. This hypothesis is the one that is most conformable to the present requirements of science, and is hereby accepted as the most satisfactory explanation of the action of counter-irritants.

The drugs in general use for the purpose of counter-irritation are cantharides, capsicum, mustard, thapsia, turpentine, aconite, and croton oil. Cups, leeches, and certain special applications of electricity, also owe much of their virtue to the same power of modifying functions at a distance. Under the influence of all these agents the molecular vibrations of the brain may be profoundly influenced; pain may be annulled, and sleep be procured. The circulation of the blood is so powerfully affected by these measures that their good effects are usually attributed to the circulatory changes thus produced. But, as in all other modifications of the circulation, the nervous tissues and the vascular channels must first be reached by influences unconnected with the blood itself before its current can be diverted from one region to another. The inhibitory action upon the nervous organs is the primary effect. The diversion of the circulation is a secondary consequence, by which, undoubtedly, the degree of nervous change can be estimated, and by which the inhibitory effects in the brain are intensified and sustained.

Food.—In a considerable number of cases of insomnia, its cause lies in an irritable weakness of the nervous tissues. Exhausted by overwork, or debilitated by the loss of blood, or half-starved during the course of a long illness like typhoid fever, a condition of wakefulness may be established which will add to the dangers experienced by the patient. In this state there is great restlessness—the sufferer experiences no severe pain, but he cannot lie still. This form of sleepless agitation is often encountered during the later stages of exhausting diseases; and, if not properly treated, it soon leads to a fatal termination. The most important remedy for such distress is found in food. This must be soluble, diffusible, stimulant, and nutritive. Milk, alcohol, eggs, and meat-juice, are the typical representatives of such food. Milk should be as fresh as possible, and should be slightly salted, in order to hinder the formation of hard curds in the stomach. For young children it may be peptonized with advantage by gently heating one pint of milk with five grains of sodium carbonate and five grains of pancreatic extract dissolved in half a pint of water. The mixture may be sufficiently warmed by placing it in a bottle immersed for half an hour in a jug of hot water (Fairchild). By this process the milk is partly digested before it is drank, thus relieving the alimentary canal of a corresponding amount of work.

Furnished in the form of koumiss, milk is not only presented in a digestible form, but the alcohol and the acids yielded by its fermentation are powerful aids to the process of digestion. Fermented milk forms a considerable portion of the daily food of the nomad tribes of Central Asia, and it is highly esteemed among the Russians in the treatment of pulmonary consumption. It is useful in all diseases affecting the digestive organs, and can often be tolerated, even by very young children, when nothing else will remain in the stomach. Considerable mystery is made of its preparation by those who sell it for an enormous price; but its composition is really very simple, and its actual cost is within the reach of every one. The following formula for its preparation has given great satisfaction to many of my patients:

Dilute five quarts of milk with three quarts of hot water. When lukewarm, add half a cupfull of sugar of milk (which can be obtained from any wholesale druggist), and one bottle of well fermented koumiss (or a little yeast). Stir the mixture thoroughly, and let it stand in an open jar, at a temperature of about 72° F., till it begins to curdle. Then stir in half a cupfull of pulverized coffee sugar, and cork tightly in champagne bottles with the best velvet corks. The bottles should be kept quite cool, as fermentation proceeds very briskly, and will break the containers if left in a warm room. A large ice-box is the best receiver during hot weather. The koumiss thus prepared is ready for use at the end of a week. It may be most conveniently drawn from the bottle with a champagne tap. The entire cost of the article need not exceed seven cents a bottle.

Sleeplessness caused by chronic dyspepsia will often yield to a diet of koumiss, when every other remedy has failed. When the stomach is very intolerant, it should at first be taken in very small doses, repeated as often as every hour. It will soon become possible for the same patient to drink two or three quarts each day.

Eggs form one of the most nutritious and easily digested articles of diet. They should be taken uncooked, beaten up with milk to which a small quantity of wine or spirits and sugar have been added. A glass of eggnogg, thus prepared, is invaluable in the insomnia of fevers and other conditions of exhaustion.

Meat-juice can be procured in numerous forms. The various soluble extracts of meat, Valentine’s liquid extract of beef, Murdoch’s liquid food, all represent the juice that oozes from rare beef. Its nutritive value is not very great, but it possesses considerable energy as a stimulant. Meat juice, therefore, occupies an important place as an excitant of those functions which must be aroused in order to secure the proper digestion of other articles of food. It should, therefore, be administered in connection with them. As the ordinary meat extracts are frequently very unpalatable, they may be administered in fresh broth or soup, to which they give body and energy without unpleasantly affecting their savory taste.

Neurasthenic patients, whose insomnia results from physical exhaustion, should never retire at night without taking some form of light and easily digested food. A simple slice of bread, or a piece of plain sponge-cake, with a glass of koumiss, forms an excellent model for such a meal.

Digitalis is only indirectly useful as an hypnotic. In cases of cardiac disease, with enfeeblement of the heart, dyspnoea, dropsy, and sleeplessness, digitalis is often of the greatest service. It has also been highly recommended in delirium tremens. Administered in the form of an infusion, it has been given in doses of a tablespoonful, every four hours, with apparently good effect. Its use is indicated in cases characterized by weakness of the heart, with a rapid and feeble pulse. Under its influence the state of the circulation improves, delirium ceases, and sleep occurs.

Camphor.—This substance is not an hypnotic, but it forms a valuable addition to various hypnotic compounds. It is a cerebral stimulant, and aids in the establishment of that nervous tranquility which favors the incidence of sleep. It may, therefore, be advantageously associated with opiates in the restlessness and insomnia of exhaustion. Tully’s Powder, a valuable substitute for Dover’s Powder, contains camphor. This renders it preferable to the ordinary opiates in typhoid fever, and in other exhausting diseases.

Musk, the dried secretion of the preputial follicles of the musk-deer, is a substance which, on account of its high price, is rarely used as an hypnotic. Given in doses of ten grains, every two or three hours, it is exceedingly valuable (Stillé and Maisch) for the relief of “all those nervous phenomena which are represented by the term ataxia, and among them subsultus tendinum, mild muttering delirium, floccitation, muscæ volitantes, and hiccough, with a small, frequent, tremulous or irregular pulse, without coma and without collapse. Under these circumstances musk tends to produce refreshing sleep, while it calms muscular spasm and favors perspiration, while the pulse grows fuller, more regular, and less frequent.... In proportion as ataxic prevail over adynamic phenomena is musk advantageous.” Such conditions are chiefly encountered in typhus, typhoid fever, the eruptive fevers, and pneumonia. Musk is very efficacious for the relief of “wakefulness resulting from combined mental and bodily fatigue—such cases, in fact, as are benefitted by valerian, camphor, asafetida, and ammonia.”

Valerian and its different preparations form a typical class of agents which indirectly favor sleep by their gently stimulant effect upon the brain. They are all useful in quieting that form of hysterical excitement to which women are liable during the “change of life.” That form of restlessness, usually resulting from fatigue, in which the patient feels as if she cannot sit still, is often relieved very promptly by the valerianate of ammonia. Wakefulness caused by neuralgic pains, or by exhaustion, often yields readily to scruple doses of valerianate of zinc or ammonia. The elixir of the valerianate of ammonia is a very elegant preparation of the drug.

Cannabis Indica.—A cerebral stimulant which produces, at first, an agreeable exaltation of the mental faculties. This is followed by a condition of delirium, succeeded in its turn by sleep. It is, therefore, impossible to use the drug for merely hypnotic purposes; but it is a useful adjuvant, in small doses, to other hypnotic remedies. Given in doses of ½-1 grain, it may be advantageously associated with opiates, or with hyoscyamus or belladonna in cases which do not easily tolerate the preparations of opium. The tannate of cannabin, given in doses varying from five to ten grains, has been recommended as an hypnotic; but, like the extract from which it is derived, its effects are rather uncertain. The pure alkaloid, cannabin, has been recently introduced as a soporific, in doses of three-quarters of a grain to a grain and a half. According to Stillé and Maisch, the wakefulness caused by the itching of eczema may be relieved by the use of cannabis indica. The uneasy sleep attendant upon ungratified sexual appetite may also be relieved in the same way, since the drug is decidedly anti-aphrodisiac.

Belladonna is not directly hypnotic, unless given in poisonous doses, but its medicinal operation tends to overcome certain conditions that hinder sleep. By its anti-spasmodic effects it relieves many forms of spasm which would otherwise interfere with sleep. Spasmodic asthma furnishes an example of such an affection. This may be relieved by the hypodermic injection of atropine. Whooping cough is another disease which may be largely controlled by the internal administration of the drug, especially by inhalation of a spray that has been medicated with belladonna. Neuralgia, especially the form that involves the head, face, and intercostal nerves, is greatly mitigated by the use of belladonna, or its alkaloid, atropia. Its association with opiates seems to increase their hypnotic effect, while at the same time neutralizing their disagreeable action. According to Curci,[41] it opposes the tendency of opiates to cause cerebral hyperæmia. For this reason it is generally advisable to combine sulphate of atropia with sulphate of morphia for hypodermic use. Of the former 1-100—1-80 grain may be used with ¼ grain of the latter. Certain patients are exceedingly intolerant of belladonna and its derivatives, a fact that must be kept in mind, especially when using the alkaloid, atropia. Fatal consequences are very rare, but uncomfortable dryness of the throat, dilatation of the pupils, and some degree of delirium are not uncommon. At the same time it must be admitted that in many instances relief from suffering is not obtained until these physiological effects of the drug have been manifested.

Hyoscyamus.—As might be inferred from their close botanical relationship, hyoscyamus and belladonna present many points of similarity. Their alkaloids are almost identical in chemical and physiological properties. The extract of belladonna is considerably stronger than the extract of hyoscyamus. Like other solanaceous plants, this is powerfully narcotic and anodyne. Sleep is produced only by the use of the drug in large doses, which also tend to excite delirium, sometimes even reaching to the height of maniacal fury. Children tolerate hyoscyamus in doses proportionally larger than can be taken by adults. By many physicians it is considered the hypnotic par excellence for children. In the various forms of insanity the tranquilizing influence of hyoscyamus is highly esteemed. The derivative preparations, hyoscyamine and hyoscyamia, are preferable for use in this class of cases. The first may be given in doses of 1-16—1 grain; the latter is much more powerful, and should be given in doses not exceeding 1-100 grain until the degree of its tolerance has been ascertained.

Stramonium.—This is another of the solanaceous plants, possessing many qualities like those found in belladonna. It is not directly hypnotic. Poisonous doses produce delirium and persistent insomnia. But its anti-spasmodic effect upon the paroxysm of nervous asthma renders it indirectly hypnotic in that affection. For the relief of bronchial spasm the smoke of the dried leaves should be inhaled in considerable quantity. It may be smoked in a pipe; or, mixed with saltpetre, it may be made to smoulder upon a tin plate, while the smoke is drawn by inspiration into the lungs. Various kinds of medicated pastiles have been prepared, to effect a similar result by furnishing the drug in a convenient form for use. Tobacco and lobelia operate in a very similar manner upon all spasmodic affections of the respiratory passages; but their energy is almost too great for the comfort of the patient.

Phosphorus.—Bartholow has recommended this drug in “cases of wakefulness dependent on cerebral anæmia and exhaustion,” and in “the wakefulness of the aged, accompanied with muscular cramps, feebleness of memory, giddiness, and trembling of the voluntary muscles on exertion.” In minute doses, it is true that phosphorus acts as an irritant of nervous tissue. It promotes destructive changes in the tissues of the body, and thus produces a temporary excitement which may favor the processes of nutrition. Indirectly, it may thus prove beneficial in many cases of cerebral exhaustion; but as a direct hypnotic it will be found of very little service. It should be given in doses of 1-100 grain every four hours.

Acids.—In those forms of sleeplessness which are dependent upon disordered conditions of the digestive apparatus, acids are often useful. Their topical effects upon the mucous membrane of the stomach are stimulant and alterative; hence they are useful in atonic dyspepsia, where there is deficient secretion of the gastric juice. In such cases hydrochloric acid and lactic acid are useful. The first should be given, in doses of five drops diluted with half a pint of water, after each meal. Lactic acid may be given in doses of one or two teaspoonfuls, similarly diluted. It has been asserted, on theoretical grounds, that lactic acid and the lactate of sodium are directly hypnotic, but its experimental use has never given satisfactory results. Phosphoric acid has been used in the same way, with very similar effects. An impure solution of phosphoric acid, known as Horsford’s Acid Phosphate, has been extensively used for its supposed hypnotic properties. It assists digestion, stimulates the kidneys, and by its general diffusion promotes molecular activity throughout the body. It is thus indirectly beneficial in cases of insomnia. No small part of the benefits thus obtained must, however, be ascribed to the water with which these acids are diluted. When the liver becomes sluggish in its action, nitric acid, in doses of five drops diluted with half a pint of water, may be taken every four hours with great advantage. Thus used, the mineral acids may often yield invaluable service in the treatment of insomnia occasioned by cachectic conditions of the body—notably such as are produced by malaria, oxaluria, and the so-called phosphatic and rheumatic diatheses.

NERVOUS SEDATIVES.

The remedies thus far considered are but indirectly hypnotic in their effects, though exceedingly valuable as agents for the production of conditions favorable to sleep. We may now pass to the consideration of a class of remedies which operate more directly upon the brain to depress its energy. They are, therefore, called nervous sedatives, and they include the majority of narcotic substances.

Cold.—The operation of cold upon the body has already been sufficiently considered. It only remains to note the effects of cold applied through the agency of baths and local refrigerants. A full account of the theory and practice of hydrotherapeutics can be found in the second volume of Von Ziemssen’s Handbuch der Allgemeinen Therapie. The English reader will find the subject treated at sufficient length in Ringer’s Handbook of Therapeutics.

According to Ringer, the sitz-bath, taken at a temperature between 60° and 80° F., is very useful to soothe “an irritable restless state of the nervous system.” It should be employed once or twice a day, from five to thirty minutes at a time. Among other beneficial consequences is the promotion of quiet sleep.

For the relief of the pungent heat and restlessness which add so much to the danger of the specific fevers cold baths have been highly recommended. These have been employed with great energy in many of the German hospitals; and often with great benefit to the patient. The preferable method is the one advised by Von Ziemssen and Immerman. The patient is placed in a tub of water at 95° F. This is very gradually cooled down, in the course of half an hour, to 60° F. The bath should be repeated from three to five times a day, according to the temperature of the patient. By this method of treatment the patient is made more comfortable; he becomes less restless or delirious, and secures a larger amount of refreshing sleep.

The difficulty of administering such a laborious course of baths outside of a well equipped hospital renders its adoption almost impossible in private practice. Here the physician must rely upon assiduous sponging with water of an agreeable temperature. In severe cases, such as measles before the appearance of the eruption, scarlet fever during the period of heat and agitation, and typhoid fever during the corresponding stage, great benefit will be derived from the cold wet sheet. In order to humor the prejudices of the laity, this should be wrung out of warm water and applied with sufficient deliberation to insure its considerable loss of heat. A blanket should first be spread upon an empty bed; the wet sheet should be spread over the blanket. The patient must be placed naked upon the sheet, which should then be drawn around the entire body, and the blanket may be folded around the whole package. Children generally insist upon leaving their arms uncovered. This may be allowed with safety in many cases, but generally a wet napkin should cover the upper part of the chest and the neck which cannot be reached with the sheet when the arms are exposed. After remaining from half an hour to two hours in the pack, the patient becomes comparatively cool and quiet, and the eruption, if delayed, begins to appear. Sleep often occurs as an immediate consequence of the relief thus obtained.

Similar good results may be secured by the use of cold affusion in cases of high temperature and great restlessness. I well remember a little boy, about eight years old, whom I once found rolling and tossing and burning up with scarlet fever. Calling for an empty wash-tub, I had him stripped and placed upright in the tub. I then began to pour cold water over him from a large pitcher. Scarcely had the water touched his skin, before he seized the pitcher, and began to drink from it. He was permitted to completely slake his thirst, and then the affusion was resumed. After four or five gallons of water had been thus poured over him, he was wiped dry, and was returned to his bed, where he immediately turned upon his side, and fell into a peaceful sleep. A few more affusions relieved him from danger, and he made a rapid recovery. Were people less afraid of such measures, a considerable portion of the danger in fevers might be obviated. Great discretion, however, is necessary in the application of such treatment, for Ringer states that he has “seen a child, suffering from scarlet fever, killed by an over-energetic employment of cold.” The temperature of the patient should be carefully noted, and its reduction below the normal standard should never be permitted.

Anæsthetics.—All anæsthetics are hypnotics. In other words, they possess the power to abolish consciousness, and thus to produce a condition resembling sleep. This is effected by the direct action of the anæsthetic substance upon the cellular structure of the brain, reducing the molecular movements of the living protoplasm below the degree requisite for the excitement of consciousness. This sedative effect is preceded by a brief period of cerebral exaltation, occasioned by the disturbances caused by the first introduction of the drug into the current of the circulation.[42] It is with the subsequent hypnotic effect only that we are now concerned. Of the numerous anæsthetic substances that have been discovered, but few comparatively have been found sufficiently manageable and safe for general use. These are alcohol, paraldehyde, ether, compound spirits of ether, chloroform, chloral, butylic chloral, and amylic nitrite.

Alcohol.—The hypnotic effect of alcoholic drinks is very decided, though not speedily manifested unless the beverage be taken in considerable quantity. Distilled liquors produce the effect of alcohol in its simplest form; wines, containing various forms of ether, arouse the nervous system more thoroughly and agreeably than the pure alcoholic stimulants. Beer and porter are rendered more powerfully narcotic by the active principle of hops which they contain. The nutritive substances held in solution by these last render them peculiarly appropriate in cases that require nourishment as well as rest. The considerable quantity in which they must be taken, renders them inconvenient for use in cases of severe illness. Wines and distilled liquors are then most available.

Alcohol is principally useful as an hypnotic when wakefulness is associated with great bodily exhaustion, such as may be experienced in advanced stages of the infective fevers. In such cases the heart is weakened, the pulse is rapid and feeble, the muscular apparatus is wasted and irritable, the blood is diminished in volume and tends to accumulate in the venous channels. Under such conditions the patient is usually delirious, tossing from side to side, and quite deprived of sleep. An ounce of brandy, repeated at intervals varying according to the severity of the symptoms, and given with milk and egg, in the familiar form of eggnogg, will often quiet this harassing restlessness, and will procure refreshing sleep. The temperature of the patient will then decline; the tongue will grow moist; and the delirium will diminish or subside altogether. Sometimes, however, a contrary result is observed. Alcohol should then be administered with a sparing hand, and it will probably be necessary to resort to the bromides or other cerebral sedatives.

The great exhaustion which is manifested in delirium tremens sometimes requires the use of alcohol to support the patient, so that sleep may be procured. It is in such cases advisable to combine the administration of capsicum with that of alcohol. According to Ringer, capsicum should be given for this purpose in scruple doses, made into a bolus with honey, and repeated every three hours.

Wakefulness caused by neuralgic pains is speedily relieved by full doses of alcohol. The various species of abdominal and pelvic neuralgia may thus be temporarily suspended. In like manner the “rheumatic” pains which afflict the overworked and underfed poor may be calmed for a season sufficient to procure sleep. The obvious dangers attendant upon such medication, however, need no comment.

Old people not unfrequently suffer with a form of insomnia that is associated with feeble and painful digestion. This is probably caused by insufficient gastro-intestinal secretion. The use of wine containing a large proportion of compound ethers gives relief through the improvement in digestion consequent upon the stimulant effect of small doses of alcohol and ether. Under their influence the digestive fluids are more abundantly secreted, and all the bodily functions are quickened. Such good results, however, only follow the moderate use of the stimulant. It must never be taken in quantity sufficient to affect the intellectual functions, or to disturb any of the normal processes of life. The best results, so far as digestion is concerned, are obtained by the use of wine with the meals; but a night-cap, in the form of hot toddy, is sometimes necessary in addition. This is especially useful if there be any form of irritative cough or local excitement, such as the aged sometimes experience.

The insomnia that attends excessive fatigue may be very quickly relieved by the use of food and alcohol. For this purpose any form of alcoholic drink will be found useful. The quantity administered should only be sufficient to produce a uniform and general vascular relaxation. By this means the circulation is equalized throughout the body, and the brain passes into a state of tranquil sleep. Any excess in the use of alcohol under such conditions will be followed by headache and discomfort on awaking. In all cases the intoxicating dose of alcohol must be avoided, if its truly hypnotic effect be desired.

Paraldehyde.—This is a derivative from ethyl alcohol. It is, when pure, a colorless liquid, with an agreeable odor, somewhat like that of ether. It is soluble in the proportion of one part in eight or nine of water. It may be used internally in doses varying from forty-five to one hundred and sixty grains. A watery solution, containing one part to ten, has been recommended for internal administration. It may also be given in milk or in beer. M. Yvon[43] recommends the following formula:

An ounce of this mixture contains forty-five grains of paraldehyde. When taken it should be still further diluted with sweetened water, or with beer, to obviate, as far as possible, the disagreeable taste of the drug. Sleep follows after the lapse of about half an hour, and continues from five to seven hours. The physiological action of the medicine is very similar to that of chloral hydrate, and its use is indicated in the same class of cases to which that drug is appropriate. By many it is considered the preferable hypnotic. It has found considerable employment in the insane asylums of Europe, and in other institutions where disagreeable medication is no obstacle to experiment. In private practice the peculiar taste and smell of the article, and its pungent effect upon the mucous membranes of the alimentary canal, render its exhibition more difficult. But the weight of testimony is in its favor as an hypnotic in all cases, uncomplicated with disease of the stomach, in which insomnia is not dependent upon pain, and is associated with cerebral hyperæmia. Its administration is followed by no unpleasant consequences. Among the insane it is particularly recommended during periods of excitement and wakefulness. It has been employed with great satisfaction[44] in cases of insomnia during the course of such varied diseases as emphysema, bronchitis, phthisis, nervous and spinal disorders, diseases of the heart, jaundice, chronic rheumatism, and insomnia from other unrecognized causes. Undoubtedly, with greater skill in its purification and exhibition, it will become one of the most valuable of hypnotic remedies. Almost useless for the relief of pain, it is indicated in cases of uncomplicated insomnia. Having very little power, in moderate doses, to depress the action of the heart, it is preferable to chloral hydrate in cardiac diseases and debility. Sleep procured with doses of fifteen to sixty grains is calm and refreshing, and is not followed by any disagreeable consequence. A certain degree of tolerance is gradually established, so that larger doses may become necessary. It has been given in quantities amounting to three drachms; but, if large doses be given before the development of tolerance, the patient will experience headache, uneasiness, nausea, and vomiting, after waking from the sleep thus induced. Another advantage possessed by paraldehyde consists in the absence of the period of excitement produced by chloral before the advent of sleep. It is an hypnotic, without narcotic properties, limiting its effects chiefly to the brain, and leaving the spinal cord in a condition nearly like that of natural sleep.