Insomnia; and Other Disorders of Sleep

Ether, though possessed of the greatest value as an agent for the production of artificial anæsthesia, is rarely used as a mere hypnotic. Diluted with alcohol and ethereal oil, it forms the Compound Spirit of Ether, or Hoffmann’s Anodyne. In this form it is well adapted for internal administration. It is thus very serviceable in the treatment of those forms of insomnia associated with nervous irritability and hysteria. For the relief of wakefulness dependent upon a languid circulation, with cold feet and flatulence, the anodyne may be given in half-drachm doses well diluted with ice water, and repeated every fifteen minutes till relief is obtained. Nearly all forms of painful or spasmodic disturbance unattended by fever may be thus relieved. For this reason it is particularly useful in the treatment of uterine colic and in sleeplessness after childbirth, when opiates cannot be tolerated, or are contra-indicated on account of their tendency to excite the brain.

Chloroform, like ether, is an agent too powerful and too evanescent for use as a simple hypnotic. But for the relief of intense suffering caused by nervous irritation and spasm it is without any superior. In certain minor affections of a spasmodic character it, therefore, forms a valuable adjuvant to other remedies. Diluted with alcohol it forms the spirit of chloroform, a remedy which is useful in all cases for which the compound spirit of ether is usually prescribed. In this form it is an excellent addition to various mixtures designed for the relief of spasmodic coughs by which sleep is disturbed. Ringer recommends it in the treatment of the irritative cough so characteristic of fibroid phthisis. It should also be used in cases of spasmodic asthma. The asthmatic paroxysm may frequently be arrested by inhalations of the vapor of chloroform or ether; but, unfortunately, the lungs soon become tolerant of these agents, and they then cease to afford relief. The valuable mixture known by the name chlorodyne owes a considerable portion of its efficacy to the presence of chloroform as one of its ingredients.

Chloral.—Until the recent introduction of paraldehyde, chloral hydrate has for many years held the first rank as an hypnotic. It is particularly useful in wakefulness occasioned by exhaustion of the nervous centres. The conclusions of all experienced observers have been most concisely stated as follows:[45] “Chloral appears to be indicated when sleeplessness is dependent upon a vascularity due to exhaustion rather than to primary excitement of the brain; thus it has been found useful when loss of sleep follows severe and prolonged mental application or excitement of feeling, or accompanies the general debility following acute diseases attended with delirium or severe pain, or is associated with acute mania, especially of the puerperal form. The somewhat analogous condition which exists in delirium tremens is very amenable to this medicine, especially in the forming stage of the affection known as ‘the horrors,’ and which so frequently follows surgical injuries in drunkards; it is useful also when great nervous excitement and restlessness are associated with extravagant phantasms. Nevertheless, its depressing effects are to be guarded against in this affection as in the different forms of insanity.” This caution is directed against the frequent and repeated employment of the article in chronic cases, on account of the vasomotor paralysis and general cachexia thus induced. It is now claimed that many of these consequences may be avoided by the substitution of paraldehyde in the place of chloral, but it has been shown[46] that similar effects may follow the long continued use of this substitute.

Chloral is usually administered by the mouth in doses, for adults, of twenty to thirty grains, dissolved in sweetened peppermint water. If the first dose does not procure sleep, it may be followed at the expiration of an hour by a second dose of twenty grains. This seldom fails to induce refreshing sleep. When the medicine cannot be tolerated by the stomach it may be given by enema in milk. For this purpose a drachm of chloral should be suspended with the white of an egg in half a teacupful of milk.

Butylchloral hydrate.—This substance has been recommended as a substitute for chloral hydrate, in cases of cardiac weakness, on account of its being less powerful to depress the action of the heart. It is principally useful for the relief of facial neuralgia and hemicrania. As an hypnotic it is seldom used. For this purpose it may be given in a solution like that of chloral hydrate. For a simple anodyne effect the medicine may be given in five-grain doses, repeated every half hour or hour. As a means of procuring sleep it may be given in doses ranging from fifteen to forty-five grains. Liebreich has given the medicine in drachm doses, and recommended it as an hypnotic superior to chloral hydrate. It is useful in the sleeplessness of headaches, neuralgia, dysmenorrhœa, and chronic phthisis.

Amyl nitrite.—This drug has been recommended for the relief of insomnia resulting from the opium habit. Ringer considers it useful in the flushes of heat and other forms of discomfort which sometimes interfere with the sleep of women during the change of life. It should be inhaled in the form of vapor, from a handkerchief upon which five drops have been poured. The quantity will need to be gradually increased, as the system becomes tolerant of its effects. The stimulant effect of the medicine renders its use in this manner probably less dangerous than the similar employment of chloroform. Unlike the other anæsthetics above mentioned, it causes a hyperæmic condition of the brain, and is, for this reason, a useful hypnotic in cases of aortic obstruction with an insufficient cerebral circulation and consequent wakefulness.

Opium and opiates.—There seems to be no agreement among experimental physiologists regarding the manner in which opium produces its effects upon the body. By some it is ranked as a stimulant; by others it is considered a sedative. These different opinions are probably due on the one hand to differences in the dose and strength of the opiates employed, and on the other to idiosyncrasies on the part of the individuals subjected to experiment. The soporific effect of the drug appears to result from its direct action upon the substance of the brain. Under its influence the blood tends to accumulate in the veins, and loses its bright arterial hue. Small doses are said to contract the capillaries of the body, while they are dilated by excessive doses of the drug. From this it may be inferred that opium acts, like many other narcotics, as an irritant of the tissues when given in minute quantity, and as a paralyzing agent when a certain relative amount is exceeded. The experiments of Curci[47] indicate that under the influence of irritating doses of morphia the brain becomes hyperæmic.

Opium is a remarkably complex substance, no less than nineteen different alkaloids having been separated from it. Of these, however, only one has stood the test of therapeutical experiment—morphia. Several other constituent alkaloids, notably codeia, have been lauded as hypnotics, but they are, at their best, far inferior to morphia, and may well be omitted from the list of sleep producers. But, though the soporific properties of opium are chiefly due to the morphia which it contains, there are certain points of difference between the action of the two medicines that often render a choice desirable. According to Stillé and Maisch,[48] morphia does not stimulate circulation and the nervous system as much as opium, and its narcotic effects are less decided and speedy, though its after effects are more enduring. Opium increases the bodily temperature and sense of heat; morphia produces the last effect, but diminishes the temperature. Opium at first increases the frequency of the pulse, while morphia diminishes it. Opium is of the two the less liable to excite nausea and vomiting; hence the superiority of the tinctures and aqueous solutions of opium when nausea is specially feared.

Of all the remedies for the relief of pain opiates are the most effectual. Before the introduction of the alcoholic hypnotics and the bromides, they constituted the principal agents in the treatment of insomnia. Even at the present time they are indispensable for the relief of all forms of sleeplessness dependent upon pain. A combination of chloral hydrate, sodium bromide, and morphine forms one of the most generally useful hypnotic compounds ever employed.

Under ordinary circumstances morphia is the preferable opiate for the relief of insomnia. The sulphate is most frequently employed, but the acetate and the tartrate have been recommended on account of their supposed superiority in the formation of solutions that are unirritating and permanent in their character. The hypodermic method of administration forms the most prompt and efficient mode of procuring the effect of the medicine. It should be given in a dose of quarter of a grain about an hour before the time when sleep is desired. For some patients a longer time is necessary to develop its hypnotic effect. To children the hypnotic dose must sometimes be given at three o’clock in the afternoon in order to induce sleep at nine o’clock in the evening. As the effect of opiates is highly stimulant to the sweat-glands, and is often productive of nausea, it is advisable to associate atropine with morphine when thus given. For an adult the hundredth of a grain of atropine may be given with every quarter of a grain of morphine. The soothing and agreeable effects of morphia are thus intensified, while its disagreeable tendencies are reduced to a minimum. The injection should be made into the loose areolar tissue between the skin and the muscles. Its location is a matter of little importance so far as the relief of pain is concerned; but the neighborhood of the blood vessels should be avoided, since alarming symptoms have been observed after injection into a vein. The outer aspect of the arm near the insertion of the deltoid muscle is a favorite site for puncture. If, for any reason, the hypodermic use of morphia cannot be employed, it may be introduced into the rectum either in solution or in a suppository. The bowel should first be washed out with an enema of warm water; the opiate may then be introduced. The dose thus exhibited need scarcely exceed that usually given by the mouth; but, if the rectum is not previously cleansed, a double, or even triple, dose may be required.

As an hypnotic morphia is chiefly useful in phthisis, in cardiac dyspnœa, in diseases of the stomach which cause insomnia, in fevers with prostration and delirium, in delirium tremens, in mania, and in the majority of painful or spasmodic diseases. If the patient be violently excited, the opiate should be combined with small doses of tartar emetic, ipecac, or tincture of aconite. But in the chronic diseases it is desirable to avoid its continuous administration, not only on account of the risk of creating the opium habit, but also by reason of the injurious effects of the drug upon digestion and nutrition.

Codeine is a mild hypnotic which may be used in doses about twice as large as those of morphine. It is expensive and not very efficient, but may be sometimes prescribed with advantage when moral considerations render the use of ordinary opiates inexpedient.

Lactucarium may be classed with the weaker opiates. It possesses very little value. Its fluid extract is sometimes prescribed at night to allay the cough of pulmonary consumption, so as to favor sleep.

Bromides.—According to Mitchell, Echeverria, and Bartholow, the soporific energy of the bromides may be ranked as follows: Lithium bromide first, sodium bromide second, potassium bromide third. Hammond praises calcium bromide. Hydrobromic acid is also employed as an hypnotic in certain cases. As a clinical fact the bromides of sodium and potassium are most frequently employed for the relief of insomnia. Of these the second is most useful when sleeplessness is associated with the phenomena of irritability; the first is less energetic in its effects upon the motor structures of the body.

The bromides act upon the protoplasmic constituents of the body, directly inhibiting their functional energy. Upon the spinal cord they act to diminish reflex excitability. Under their influence the receptivity and functional capacity of the brain is reduced. The minute blood vessels contract in consequence of the inactivity of the tissues which they supply. A lethargic sleep is thus induced.

For the reasons above stated the bromides find their greatest opportunity for usefulness in cases of over-excitement and exhaustion of the brain. When the cortical cells have degenerated into a condition of irritable weakness, characterized by inordinate instability of substance, the bromides serve to steady the fabric by retarding those movements of disintegration which produce morbid wakefulness. Almost useless in cases marked by active congestion of the brain, they are invaluable in the insomnia produced by excessive mental exertion, care, emotion, worry and fatigue. The wakefulness of hysteria, of asthenic mania, and of sexual excitement, is often greatly relieved by the administration of the bromides. The prodromic stage of delirium tremens, before any violent outbreak, and the wakefulness of convalescence from acute diseases are often cured by their use. Mental disturbances and morbid impulses associated with pregnancy or the puerperal state may be dispelled in the same way. The screaming fits of night terrors in children are benefitted by these medicines. They seem to increase the efficacy of chloral, chloroform, ether, cannabis indica, hyoscyamus, belladonna, and the opiates.

The hypnotic dose of hydrobromic acid is twenty-five grains, largely diluted with sweetened water. For this reason, and for its disagreeable taste, it is not an eligible preparation. Lithium and calcium bromides may be given in scruple doses every hour or two till sleep is produced. Sodium and potassium bromides should be given in doses of thirty or forty grains every two hours.

It is sometimes remarked that instead of favoring sleep the bromides only increase wakefulness. In such cases opiates and alcoholic stimulants are usually indicated.

Hops.—The principal sedative constituent of this plant is the yellow glandular powder found in the strobiles; this is called lupulin. Hops do not exhibit any directly narcotic property; but they serve to allay nervous excitement, and thus favor the occurrence of sleep. They are principally useful in cases of irritability of the bladder and sexual organs; in dyspepsia caused by irritable weakness of the stomach; and in the exhaustion of delirium tremens. The infusion is the best preparation for internal use. It may be taken in doses of one or two ounces, as required. Lupulin may be given in doses of ten grains or more. Its fluid extract is prescribed, fifteen or twenty minims in sweetened water whenever needed. The best method, however, of securing the beneficial effects of the medicine consists in the administration of a mild beer that is rich in hops. A glass at bedtime often forms a sufficient hypnotic.

Gelsemium is a very powerful agent for depressing the pulse and the functional activity of the spinal cord. It thus favors the induction of sleep in cases attended with violent excitement, such as may be witnessed in acute mania. It has been employed in the treatment of delirium tremens; but the poisonous qualities of the plant render its use somewhat dangerous. The toxic effects are sometimes developed quite suddenly, and in a manner very alarming to the laity. For these reasons it is not to be recommended as a soporific, unless the patient can be continually under the eye of the physician or of an intelligent nurse.

Conium has been found useful in the insomnia of mania, not through any narcotic property of its own, but by reason of its sedative effects upon the spinal cord and nerves. Under its influence the excitement of the patient is so far reduced that other hypnotic remedies can produce their effect. For this purpose Squibb’s fluid extract, in doses of about one-third of a drachm, or one-sixtieth of a grain of coniine, may be given sufficiently often to repress excitement. The alkaloid may be given hypodermically, and in gradually increasing doses. With it should be associated other remedies, like hyoscyamus and chloral hydrate, in order to procure sleep.[49]

CHAPTER IV.

Insomnia in acute affections of the brain.—Acute intra-cranial inflammations may result from general diseases, like rheumatism, the eruptive fevers, tubercular infiltration, insolation, the development of tumors, or syphilitic growths. In all such cases the earlier stages are marked by a painful exaggeration of cerebral function which renders sleep impossible. The wakefulness of this stage soon becomes complicated with delirium; and the whole is finally merged in a fatal coma. Cerebral excitement is the principal feature which arrests attention. This is accompanied by an inordinate determination of blood to the head, producing that cerebral hyperæmia which figures so largely in the works of the humoral pathologists. The treatment of acute inflammation becomes the best means of relieving this excitement, allaying the hyperæmia, and procuring sleep. The treatment should be derivative, counter-irritant, and calmative. The first indication must be fulfilled by the exhibition of an active purge. Ten grains of calomel with five grains of sodium bicarbonate may be given for this purpose. Leeches or wet cups should be applied to the temples, or to the back of the neck. The feet should be placed for a short time in a hot foot-bath, and an ice-cap must be drawn over the scalp. The internal medication must consist of arterial sedatives and cerebral depressants. For the first, tincture of aconite forms an admirable example—better even than the tartar emetic so much lauded by Graves. Aconite may be given with the bromides. When sleeplessness in an acute meningitis is accompanied by severe pain, an excellent combination will be found in the following:

Sig.—A teaspoonful every two hours, till relieved.

As the disease progresses, the quantity of morphia should be reduced. In epidemic cerebro-spinal meningitis, opiates may be safely employed in much larger doses than are tolerated in the simple forms of the disease. When in doubt regarding the proper hypnotic the bromides alone should be used. Chloral hydrate may also be safely employed in the first and second stages of meningitis; but if given in full doses near the close of the second stage it sometimes seems to hasten the appearance of coma.

Insomnia in insanity.—Persistent insomnia is often one of the premonitory symptoms of insanity. It is likely to present itself as a most formidable complication at any stage of the disease. To consider aright the relations that exist between sleeplessness and insanity would far exceed the limits of this work; we can only review the leading indications for its treatment. It is occasioned either by an excited state of the brain, accompanied by hyperæmia and general functional exaltation, or by an exhausted and irritable condition of the cerebral substance. The first of these two varieties of wakefulness is encountered in cases of violent maniacal excitement where the disorder is comparatively recent, and the bodily vigor has not been depressed by long continued disease. The indications for treatment call for sedative measures. Leeches behind the ears and the application of the ice-cap are sometimes of great service. Derivative action upon the bowels with aloetic purgatives has often yielded good results. In like manner, hot mustard foot baths are recommended. The soothing effect of a warm bath at 90°-95° F. is sometimes sufficient to calm excitement, and to induce sleep. The combined effect of cold applications to the scalp and a warm bath to the general surface is still more tranquillizing. This method of treatment is particularly useful in maniacal forms of insanity, and in certain cases of melancholia—especially those in which the skin is dry and the secretions are disordered.

Cold affusions and shower baths have been employed for their revulsive and sedative effect in mania. This mode of treatment is sometimes effectual, but is not without risk.

The medicinal treatment of insomnia is frequently facilitated by the measures above indicated. In cases of great excitement with restlessness and bodily agitation, it is desirable to arrest the movements which are wearying the patient and keeping him awake. This may be accomplished by the use of conium, as indicated by Kiernan (loc. cit.). Twenty minims of Squibb’s fluid extract may be given for the first dose. Half this quantity should be repeated every half hour until the patient becomes quite calm. Bromide of potassium and hydrate of chloral in drachm doses should be given in connection with conium. Recently, paraldehyde has been employed as a substitute for chloral. These remedies reduce cerebral excitement, and favor the induction of sleep which is at least refreshing, if not curative of the disease. They should not, however, be used habitually, for fear of producing the characteristic consequences of over-dosing with such drugs.

The varieties of insanity in which depression and exhaustion are the prominent features require different management. Nutritious food, alcoholic restoratives and stimulant doses of opiate remedies are most serviceable. The sleeplessness of melancholia and of paretic dementia may be thus relieved. Opium may be given in the form of a pill, or in the deodorized tincture. The old fashioned “black-drop” is highly esteemed by some. Others prefer the salts of morphia. If cerebral hyperæmia be present in these cases, it is usually associated with asthenic conditions of the brain, indicated by paleness of the face and weakness of the pulse. The hyperæmic state is then easily overcome by the administration of alcohol or of chloral with an opiate. If opiates alone are given in cases of insanity with great depression, there is danger that death by syncope may occur, precisely as it sometimes happens in delirium tremens when treated with large and frequent doses of opium.

Cases are occasionally encountered which receive no relief from opiates. The remedy seems only to aggravate the existing irritability and insomnia. For such patients the tincture of hyoscyamus may be employed in doses ranging from two to four or even six drachms. Associated with bromide of potassium and hydrate of chloral, it has been used with great success. Spitzka prefers the simple tincture rather than the fashionable alkaloid, hyoscyamia.

Cannabis indica associated with bromide of potassium is a useful hypnotic in cases of moderate depression and excitement. Clouston finds as a result of his experiments that “forty-five grains of bromide of potassium and forty-five minims of the tincture of cannabis indica are rather more than equivalent to a drachm of laudanum as a means of allaying maniacal excitement.”[50] In his recent work,[51] the same author deprecates the use of opiates in states of depression, and advises the substitution of tincture of cannabis indica (x min.) and bromide of potassium (xx grs.). He also emphasizes the importance of abundant exercise in the open air, as the best hypnotic in every case that can be trusted abroad.

Insomnia in Chronic Alcoholism and Delirium Tremens.—The insomnia of chronic alcoholism is dependent upon the extensive morbid changes produced in the digestive apparatus and in the nervous system by the habitual use of alcoholic drinks. Sleep becomes greatly disturbed and unrefreshing. It is frequently broken by horrible dreams. The successful treatment of this condition requires complete abandonment of the use of alcohol, and a general correction of the condition of the alimentary canal. For the immediate relief of insomnia, full doses of bromide of sodium will be of service. Strong infusions of hops may be given ad libitum. Cannabis indica, in the form of the extract, so as to avoid the use of alcohol in the tincture, is of service. Hypodermic injections of morphia are frequently employed, but should be avoided if possible, for fear of the opium habit. Chloral hydrate is exceedingly useful, but should be given in milk, and as seldom as possible, for fear of adding to the injuries already sustained by the stomach. For the same reason the use of paraldehyde in such cases is quite inadmissable.

When chronic alcoholism has culminated in delirium tremens, more energetic measures become necessary in order to procure sleep. If the patient be of a vigorous constitution, and if the delirium be very active, tartar emetic with morphia may be given, as advised by Graves. Large doses of tincture of digitalis, sometimes reaching an ounce every four hours, were used by Jones, of Jersey. Capsicum, in scruple doses every three hours, is said to induce sleep in many cases of delirium,[52] especially in exhausted conditions of the circulatory organs. Hydrate of chloral and bromide of sodium, each in scruple doses, may be given every two hours. Opiates should be used with moderation, and all attempts to induce profound narcosis should be avoided. Drachm doses of tincture of cannabis indica and of compound spirit of ether, may be given when a diffusible stimulant must be associated with the soporific. In desperate cases it is sometimes necessary to resort to inhalation of ether, but if sudden death should occur, it would be popularly ascribed to the effects of the anæsthetic. By reason of a certain tendency to death from syncope during this disease, it is imprudent to place such patients under the influence of chloroform or the other stronger anæsthetics.

Insomnia in diseases of the heart and blood vessels.—I can fully indorse the opinion of Ringer regarding the beneficial effects of morphia in the treatment of the wakefulness caused by advanced diseases of the circulatory organs, “In such a case, the comfort afforded by a hypodermic injection is almost incredible.... In cardiac dyspnœa, a sixth of a grain twice or three times a week often suffices, but the dose and frequency in severe cases must be gradually increased to a quarter of a grain each night. Doctors are often afraid to administer morphia in the case of a patient propped up in bed, with livid ears, nose and nails, with distended jugulars and dropsical extremities, with weak, frequent and irregular pulse. They dread lest the morphia should weaken the heart, make the patient worse, if not kill him outright. This fear is quite groundless,” if the opiate be given in moderate doses. It is the stimulant effect of the medicine that is safe and useful.

When wakefulness is caused by angina pectoris, or by simple cardiac neuralgia, such as sometimes follows excessive use of tobacco, relief may be obtained through the exhibition of alcoholic stimulants, hydrate of chloral, or nitrite of amyl. These remedies act more speedily than morphia, and may be associated with it, to the great advantage of the patient. They should not be habitually used, however, in cases of cardiac exhaustion, as their chronic employment favors accumulation of blood in the right side of the heart, with a tendency to paralysis of the cardiac muscles. It is in stenosis of the coronary arteries, and in aortic obstruction, that nitrite of amyl and nitro-glycerine are most useful. The insomnia that results from the remote consequences of these diseases is often relieved by remedies which assist the circulation of blood. For this purpose digitalis is the most useful stimulant in mitral disease; nitro-glycerine, in aortic valvular lesion.

Insomnia in diseases of the respiratory organs.—Pleuritic pain and its consequent wakefulness may be relieved with opiates, guarded by appropriate vascular sedatives. Dover’s powder, or morphia and aconite, form excellent examples of the remedies most useful, so long as the lungs are not overwhelmed by excessive exudations into the pleural cavities. Pneumonia and bronchitis are accompanied by wakefulness, in their earlier stages, as a consequence of harassing cough. This may be allayed by the judicious use of expectorants and sedatives. If symptoms of asphyxia appear, indicated by blueness of the lips and nails, opiates should never be given. Respiratory stimulants are then indicated, and sleep must be allured by the use of alcoholic beverages and moderate doses of chloral hydrate, with musk and camphor. The early, irritative cough of incipient pulmonary consumption may be soothed with camphor and opium. Paregoric and a demulcent, like Iceland moss tea, or flaxseed tea slightly acidulated with lemon-juice, form an excellent type of such a compound. But the chronic duration of the disease renders the constant use of opiates undesirable. Chloral hydrate, for the same reason, cannot be given without intermission. It is well in such cases to employ the different alcoholic beverages at bedtime. Inhalation of warm vapor, and respiration of air charged with ether, or carbolic acid, will often quiet an irritative cough. In advanced cases belladonna is useful, to check the profuse sweating and to calm the thoracic pain that hinders sleep. In the later stages of the disease, when relief from suffering is the only end in view, morphia and dilute hydrocyanic acid will often render quite tolerable the few remaining nights of life.

One of the most distressing forms of insomnia is occasioned by the different varieties of asthma. Dyspnœa is the feature that is common to them all, and is the principal exciting cause of wakefulness. In recent cases, which are characterized by spasm, the various anti-spasmodics are useful. Tincture of lobelia, tartar emetic, and ipecac, are of great service. Inhalations of ether or of chloroform, or of nitrite of amyl, will often cut short a paroxysm; but the nervous system soon becomes tolerant of their action. Chloral hydrate and alcoholic stimulants are less vigorous, and cannot be long tolerated by the stomach, especially if there be a gouty diathesis behind the disease. The fumes of burning pastiles containing nitre and stramonium leaves are often of great service if so breathed as to thoroughly fill the lungs with the smoke. In like manner, the smoke from smouldering nitre-paper, or from cigarettes that have been dipped in an arsenical solution, is sometimes useful. Air charged with ozone has been found curative in some inveterate cases. Hyoscyamus, belladonna, and tobacco, have been recommended. It may even become necessary to employ hypodermic injections of morphia.

If, however, the disease should resist all these anti-spasmodics and soporifics, besides the remedies addressed to the predisposing causes of the malady, the only thing that remains is a change of locality. Many very desperate cases have thus been restored to health and comfort.

Insomnia in renal disease.—In the acute forms of renal disorder this is usually caused by pain and fever. It is, therefore, to be relieved with opiates given in connection with such arterial sedatives and diaphoretics as each individual case may require. But the tendency of inflammatory diseases of the kidney to merge in uræmia must not be forgotten, and the soporific must be used in such cases with great caution. For this reason hyoscyamus is often preferable to an opiate. In extreme dropsical conditions the measures that are useful for the reduction of anasarca constitute the most efficient means for the induction of sleep. In nephritic colic pain is too severe to admit of any rest while it lasts. The general treatment of colic is all that can occupy the attention until relief is secured. The dyspnœa and wakefulness sometimes experienced in advanced cases of Bright’s disease may be greatly relieved by the judicious use of morphia, very much as in the similar disorder occasioned by chronic diseases of the heart.

Insomnia in diseases of the liver.—Inasmuch as the majority of these diseases interfere with the formation and proper discharge of bile it is desirable to avoid, as far as possible, the use of opiates in the disturbances of sleep that are so commonly consequent upon disorder of the liver. Simple restlessness at night can usually be obviated by the ordinary treatment that is remedial of the disease by which it is caused. But it often happens that hypnotic remedies must also be employed. Hyoscyamus, belladonna, chloral hydrate, and compound spirit of ether, are frequently useful. Sometimes when the evacuations exhibit a deficiency of biliary coloring matter, a grain of opium, with a few grains of calomel, forms a very efficient hypnotic. Alcoholic soporifics are not well tolerated when the gastro-intestinal mucous membrane is diseased. Biliary colic demands treatment similar to that that is required in nephritic attacks. Warm baths, fomentations, and a broad belt of oiled silk around the body, are very grateful, and are favorable to the induction of sleep. A course of nitro-muriatic acid, internally and externally, is often useful when wakefulness is associated with torpidity of the liver.[53]

Insomnia in gastro-intestinal diseases.—In acute inflammatory conditions of the stomach and bowels, sleep must be invited by the use of opiates. Bismuth and morphia, with hydrocyanic acid, are the favorite means of obtaining relief. Opium in solid form is sometimes preferable when a slowly developed and long continued impression is desired. Warm baths and hot poultices also give great relief.

In all chronic affections of the alimentary canal opiates must be used with great caution, for fear of the opium habit, unless the case be incurable. Cancer of the stomach requires their free use. The milder disorders should be managed largely with hygienic treatment. The diet should be so regulated as to prevent the liberation of gas in the intestines, for their distention in this way is fatal to refreshing sleep. A gentle aperient or a large injection of warm water, often proves itself decidedly soporific in such cases. Catarrhal conditions of the mucous membrane prohibit the entire class of alcoholic and ethereal soporifics. Nervous and atonic dyspepsias are often benefitted by the use of bitter beer, and by drachm doses of brandy or whisky largely diluted. These should be taken at mealtime, or with food at bedtime. A glass of hot water shortly before retiring is often useful.

The relief of insomnia in dyspeptic derangement, however, must not be sought through the administration of anodynes and hypnotics alone. Only when the entire life of the patient has been regulated upon a physiological basis can refreshing sleep be obtained. Change of habits, change of occupation, change of locality—these are the only curative measures in a vast number of the cases of wakefulness that occur in modern life. Alcohol, tobacco, tea, coffee, foul air, late hours, and mental excitement, are the principal causes which must be abolished before healthy sleep can be enjoyed.

Insomnia in febrile conditions.—In the early stages of all acute fevers wakefulness is a very common incident. It is then occasioned by irritation of the brain, and must, therefore, be relieved with opiates. If the patient is not depressed by the disease, the opium should be associated with tartar emetic or aconite, or ipecac. Dover’s powder is very useful in such conditions. In malarial fevers wakefulness should be combatted with full doses of quinine in addition to the opiate. Gelsemium is sometimes a very satisfactory remedy—especially in the febrile attacks to which children are liable. If any evidence of cerebral hyperæmia be observed, it is well to give chloral hydrate and the bromides. Hyoscyamus, belladonna, and cannabis indica are useful when the pupils are contracted and when spasmodic symptoms are present. Lukewarm baths, wet packs, and cool sponging are exceedingly grateful, and often assist in the evolution of a suppressed eruption in the exanthematous fevers.

In the later stages of fever a condition of cerebral exhaustion is sometimes encountered. Irritable weakness caused by starvation of the brain is the prominent feature. The pulse is small and weak. The patient tosses and rolls from side to side. He is perhaps greatly emaciated by an illness of considerable duration. An elevated temperature requires frequent sponging of the body.

Opium, alcohol, and liquid food, are the best hypnotics in such cases. The acetum opii and the deodorized tincture of opium are among the best preparations of the drug, by reason of their stimulant effect. The equivalent of two grains of opium with a full glass of eggnogg, will often procure sleep for such a patient. If there be evidence of blood stasis, with blueness of the nails, hypostatic pneumonia, etc., musk and strychnia should be given in place of opium, and the circulation should be assisted with carbonate of ammonia, as follows:

To be given in a little milk, as required. Chloral and the bromides are of comparatively little value in all cases where there is considerable depression of the vital forces.

Insomnia in rheumatism and gout.—Opium in a diaphoretic preparation, and associated with alkalies or with colchicum, has always been the most approved remedy for sleeplessness in the acute forms of these painful diseases. Salicylic acid and the salicylates have in great measure superseded the use of opiates for the relief of pain and wakefulness in rheumatism, but they are not always efficient. Opiates, with or without chloral, must then be used. Sometimes a painful case that has resisted all other remedial agents yields promptly to the action of a series of blisters. The chronic forms of rheumatism require the use of stimulant diaphoretics, anodyne liniments containing chloroform and belladonna, and chloral hydrate, or even a Dover’s powder, at night.

Acute gout is rarely seen in this country, but its rudimentary forms, described by Da Costa as lithæmia,[54] are not uncommon. They are associated with wakefulness of a very troublesome character, which only yields to a persistent and long continued course of treatment directed against the diathesis. Careful regulation of the diet, change of air, and anti-arthritic remedies, are of infinitely greater service than any particular hypnotic drug.

Insomnia in syphilis.—In advanced stages of syphilitic cachexia, a variety of wakefulness independent of pain is sometimes observed. It is marked by a tendency to wake at a fixed hour of the night, frequently about two o’clock in the morning, after which time sleep is impossible. The symptoms of constitutional disease are not prominent in these cases, but the history and the evident cachexia make their nature apparent. They usually yield to a mercurial treatment. In their comparative freedom from severe pain, such patients present a striking contrast to certain cases of syphilitic rheumatism, or neuralgia. The nocturnal suffering in such instances is frightful. It can be finally overcome by anti-syphilitic treatment; but, while waiting for the radical cure, palliatives are needed. Chlorodyne and similar combinations of all the anodyne drugs afford the most effectual means of relief. I have sometimes found it necessary to increase the dose until the characteristic delirium produced by solanaceous drugs was manifested. The relief thus procured sometimes continues for many days after the cessation of hypnotic medication.

Insomnia in various disorders of nutrition.—The wakefulness experienced by syphilitic patients is not peculiar to their cachexia. It is a result of blood disorder and impoverishment that is common among the victims of rheumatism, lithæmia, syphilis, malarial poisoning, cancerous dyscrasia, chronic toxæmia of every form, and ordinary anæmia. Imperfect blood supply deteriorates the nutrition of the brain, and renders it so excitable that sleep is interrupted so soon as the period of profound repose is past. This occupies about four hours (see p. 16), hence the patient who falls asleep at ten o’clock is ready to wake up at two in the morning, and only sleeps again, if at all, when wearied with tossing till daylight. Such patients often derive great benefit from a morning nap thus obtained between the hours of five and seven.

The most successful treatment of this variety of insomnia is that form of medication which is addressed to the particular cause of the cachexia or dyscrasia. But the palliative treatment necessitated by the immediate suffering of the patient will often tax to the uttermost the ingenuity of the physician. Usually, there is a chronic atonic dyspepsia, or a chronic catarrhal gastro-enteritis, or a combination of both conditions, to be remedied. Gently stimulating laxatives are needed for the relief of these disorders. An animal diet is most easily digested. Milk and rare beefsteaks supply this form of nutriment, to which must be added oranges, grapes and lemons, to prevent the development of incipient scurvy. The kidneys may be excited with small doses of iodide of potassium or chlorate of potassium. Only after a considerable course of elimination are “tonics” admissible. For the immediate relief of the insomnia by which the patient is exhausted, a rather complex method is needful. Such subjects often pass the day in tolerable comfort, but, as evening advances, the wearied brain becomes irritable, and bedtime finds the patient in an excited state which cannot be easily overcome by large and repeated doses of chloral. Paraldehyde is too disagreeable to be used with impunity, and only towards morning does the sufferer yield to the narcotism induced by successive doses of chloral and bromide. A night thus occupied adds nothing to the vigor of the individual, and its frequent repetition will most surely lead to starvation of the nerve-centers,—perhaps to consequent “chloral-mania.”

When the tendency to cerebral irritation becomes thus apparent, great assistance can be obtained by a resort to the use of opium, combined with tartar emetic and camphor. A pill containing one grain each of opium and camphor, with one-twelfth or one-sixteenth of a grain of tartar emetic, should be given early in the evening. This calms the brain, and prepares the way for a moderate dose of chloral at bedtime. In this way sleep can be procured with much less expenditure of nervous force and medicine than is wasted in the ordinary routine method. The rest thus obtained is followed by less depression than when it follows stupefaction with large quantities of an exciting narcotic.

Insomnia during pregnancy, and after parturition.—Closely akin to the insomnia of anæmia is the wakefulness experienced by hysterical subjects. The irritable weakness of their brains renders them peculiarly liable to disturbances of sleep. The state of pregnancy often serves to fill their nights with excitement sufficient to interfere with quiet rest. Loss of blood during parturition, by the induction of temporary anæmia, may greatly aggravate this condition.

The suppression of nervous irritability is the principal indication for treatment. This may be temporarily accomplished by the use of the bromides. But these must be reinforced by an ample dietary, with stimulant nervines and anti-spasmodics. Good wine, camphor, valerian, hyoscyamus, cannabis indica, and occasional doses of opium, will generally suffice to induce the needful repose. If confinement in bed precludes muscular movement for any length of time, passive exercise must be secured through the aid of massage.

Insomnia in spasmodic diseases.—This class of ailments will usually be encountered among patients who are enfeebled by unfavorable conditions of health, either congenital or acquired. Together with the specific treatment appropriate to the particular disorder, it often becomes necessary to make use of hypnotic remedies against sleeplessness. Thus chorea may sometimes reach a degree of inveteracy that renders sleep impossible. Alcohol and chloral hydrate must then be given in large and frequent doses. A laryngeal catarrh may excite spasmodic croup—a disorder speedily relieved with chloral hydrate. Old people of a nervous temperament sometimes experience paroxysms of a similar character, interfering with sleep whenever they suffer a catarrhal attack. Liberal doses of assafœtida and a Dover’s powder at night, associated with a course of antilithic treatment, afford great relief. Iodide of potassium, in the majority of asthmatic affections; the bromides and gelsemium in cases marked by excitability of the spinal cord; valerian, musk, assafœtida, camphor, and carbonate of ammonia, in cases of cerebro-spinal weakness and irritability; oxide of zinc, quinine, and chloral hydrate, when weariness and exhaustion are connected with a hyperæmic condition of the brain; such are the principal remedies against this variety of insomnia. Convulsions, if frequently repeated, may be subdued by the inhalation of ether or chloroform, until a sufficient quantity of the bromide of potassium can be introduced into the system.

Insomnia in childhood.—According to Vierordt,[55] the duration of sleep in the first week of life is only interrupted by the act of nursing. During the first month the infant should sleep at least two hours after each meal, waking only three or four hours out of the twenty-four. This period gradually increases; but, when a year old, the healthy child still sleeps more than he wakes. During the second and third years, he should sleep for ten or eleven hours at night, besides a nap of two hours in the daytime. After the fourth or fifth year, the daily nap may be discontinued. The fifth and sixth years require ten hours of sleep at night. From the seventh to the eleventh year, nine hours are needed. After the twelfth year, eight hours are sufficient.

The causes of wakefulness are as numerous among children as among adults. Jacobi[56] insists upon the importance of attention to the ventilation of the bed-chamber, and to the quality of the bed. Everything must be light, airy and cool. He gives utterance to universal experience when he asserts that great heat can be endured by day without harm, if only the night brings coolness and rest.

Hunger is sometimes a cause of wakefulness among young children. Partial starvation endured for a considerable time induces somnolence. The opposite condition of repletion may also excite wakefulness through painful distension of the stomach and bowels. Earache, terminating in abscess, often prevents sleep, sometimes without discovery of the cause until a discharge of pus enlightens the diagnosis. Persistent wakefulness without evident cause should arouse a suspicion of incipient tubercular meningitis. Slight elevations of temperature at night sometimes occasion sleeplessness, which may be overcome with quinine in doses of two to five grains at bedtime.

Wakefulness sometimes occurs merely as the result of a bad habit. This is usually observed among delicate children of a nervous temperament, whose inclinations have never been thwarted. Such patients have been sometimes cured, after the failure of a long and expensive course of treatment with homœopathic globules, by the adoption of a systematic moral training reinforced by an occasional forcible application of the parental hand to the gluteal region of the child. Of course such a method must not be recommended without certain knowledge that no lurking disease of the nervous system has escaped detection. Fretfulness and wakefulness are not associated with proper living and good health. Their cause must generally be sought upon the surface of the body and in its internal cavities.

Much relief in the insomnia of children can be obtained from the use of lukewarm baths at bedtime. Supper should be a light but sufficient meal. Every disorder of digestion should be regulated as it occurs. Painful affections may be quieted with Dover’s powder. Feverish and irritable conditions yield frequently to aperients, or to gelsemium and quinine. Night terrors and screaming fits should be calmed with chloral hydrate and the bromide of sodium. As a general sedative and hypnotic for children hyoscyamus has an excellent reputation. It may be given in considerable doses with perfect safety and the best results. For patients in early life it seems to fill the place occupied by cannabis indica in the medication of adults.

Insomnia in old age.—The highest physical perfection is reached before the fortieth year of life. Between this age and the forty-fifth year man’s vigor begins to decline. The power of accommodation diminishes, necessitating the use of spectacles; adipose tissues begin to load the body; the hair grows thin, and begins to bleach. The processes of nutrition and of disassimilation become more sluggish; the appetites and passions gradually subside. Sometimes the moderation of nervous excitability thus effected permits indulgences of the appetite for food that were impossible during earlier years—the nervous dyspeptic can tolerate dainties which would formerly have been unendurable. Less disturbed by the solicitations of sense, the powers of reasoning and of judgment enlarge their authority. Under favorable circumstances this period of life may continue for about twenty years, when old age develops. From the sixtieth to the eightieth year the progress of decline is rapidly accelerated, and life is normally terminated between the eightieth and eighty-fifth years of existence. The rare examples of greater longevity are too few in number to warrant the assumption that a century of years is the physiological complement of life.

As old age advances, the time of sleep is slightly abridged. The moderated activity of the body requires only a diminished rate of repair to make good the waste of the tissues. Less sleep, therefore, is needed. But the liability of age to the incidence of arthritic diseases, rheumatism, and disorders of the heart, blood vessels, digestive apparatus, and urinary organs, renders the period of decline particularly subject to those varieties of sleeplessness which depend upon such derangements of health. The nutrition of the brain suffers under such circumstances, and the substance of the organ becomes morbidly irritable. Insomnia among the aged often owes its cause to these unwholesome conditions. The biography of the celebrated Carlyle affords numerous illustrations of this variety of wakefulness. Disease of the cerebral blood vessels sometimes originates a series of changes differing only in degree and intensity from the classical type of chronic periencephalitis. This is characterized by many of the minor phenomena of general paresis, only occasionally rising to the level of that disease. Wakefulness is one of the most troublesome symptoms of this disorder. Its management requires attention to all the details of excretion and nutrition. The diet must be carefully selected with reference to failure of the digestive function. Milk and water should be preferred for drink, and the great emunctory organs of the body must be carefully stimulated and sustained. A judicious choice of climate may accomplish much for the comfort of the patient. The mild, insular climate of Florida, or of New Providence, or of the Sandwich Islands, affords superior advantages for the relief of sleepless sufferers in the northern temperate zone of the American continent, who need the soothing influence of a continual open air bath.

During the latest stages of decline, when the cortex of the brain has become considerably atrophied, the opposite of wakefulness is experienced. Intellectual operations become less vigorous, and the patient passes lengthening periods of time in sleep. This is a genuine relapse into the apathy of infancy. The apparatus of thought is worn out, and the old man sinks gradually into the sleep from which there is no awakening.

The treatment of insomnia, therefore, resolves itself into the removal of all special and temporary causes of wakefulness, with attention to the general hygiene of the patient, and careful regulation of his diet, habits, and occupation. Pain must be quelled with anodynes. Cerebral excitement must be calmed, in sthenic cases, with anti-spasmodics and sedatives—in asthenic subjects it must be overcome with food and nervous stimulants. Since many patients present a combination of these apparently opposite conditions, there is room for a great display of penetration and tact in the management of complex cases. While seeking for the immediate relief of present suffering, the ulterior consequences of treatment must always be kept in view, and the particular cachexia or dyscrasia must be thoroughly appreciated by the physician in his choice of remedies.

CHAPTER V.

The harmonious activity of all parts of the nervous system is indispensable to the highest exercise of the conscious mind. Healthy intellectual life is the perfectly balanced outcome of the complex polygon of forces which has its seat within the brain. In the waking condition this “moving equilibrium,” as it has been happily termed,[57] is sustained by the convergent impulses which are continually entering the brain through the pathways afforded by the several senses. Our waking hours are occupied with the ideas and with the associated trains of thought which are thus projected upon the field of consciousness. As a consequence of the harmonious function of the organs of sense, each one supplementing and correcting the information furnished by the others, a continuous process of perception and logical thought is maintained. But, along with the procession of ideas which are clearly conceived by the mind, the field of consciousness is also invaded by a cloud of half formed perceptions, which are too imperfect and fleeting to occupy the attention. As in the act of vision, though the periphery of the visual field is crowded with a whole world of objects dimly perceived without challenging particular attention, only the center of that field furnishing clear images to the brain, so the eye of the mind comprehends only a few of the impressions which enter the sphere of consciousness. The swarm of unnoticed perceptions, however, is none the less the result of abiding sensory impressions graven in the substance of the brain, from which, through the action of memory, they may at any favorable moment reënter consciousness. Sleep does not wholly arrest this process. A certain amount of projection into the field of consciousness continues, even during profound repose; and the ideas thus aroused form the material of our dreams.

It has already been remarked that the invasion of sleep is not an instantaneous process. One by one the senses fall asleep, and long before the final cessation of their activity, sleepiness hinders their function. Hence a progressive narrowing of the range of external perception; hence a reduction of the vividness of impressions derived from the outside world; hence, also, a simplification of the actions and reactions which constitute the “polygon of forces” active within the brain. But the suppression of certain lines in this polygon does not suppress life, nor does it necessarily destroy consciousness. It only occasions a redistribution of force, and a proportionate narrowing of the stream of related ideas. Since this process of suppression, just mentioned, is not an absolute quantity, but a variable factor, the polygon of physical forces within the brain and the corresponding succession of ideas in consciousness must necessarily be in a state of continual change. Consequently, our dreams must be as variable as the clouds that drift upon the currents of the air. As, on a hot day in summer, when the equatorial draught has ceased to guide the wind, we may observe all manner of local tides among the masses of vapor which arise from the earth, so, in sleep, when the guiding influence of the senses is withdrawn, the ideas that still arise are chiefly dependent for their origin and association upon the automatic and endogenous activities of the brain. Undisturbed by impulses from the external world, the brain seems then to become more sensitive to impressions that have their origin within the body. An overloaded stomach, an enfeebled heart, a turgid sexual apparatus, or an irritable nervous ganglion, may become the source of irregular and uncompensated impulses which, without disturbing the organs of special sense, may invade the cerebral cortex, and may there set in motion a whole battery of mechanisms whose influence upon consciousness would remain quite unnoticed were the external senses in full operation.

Still another cause for the production of dreams is to be found in the more or less complete suspension of the power of volition which accompanies sleep. Every act of attention is the result of exercise of the will. But the perfect exercise of the will is dependent upon the perfect development and wakefulness of the brain. So soon as sleep begins to invade the brain, the will begins to lose its normal incitement to action, and finally it becomes almost wholly disconnected from the muscular organs. In this state the sleeper may desire to perform some act—he may wish to move his limbs or to cry out aloud, but he can move neither hand nor foot, he cannot utter a sound. In other instances a partial connection between the will and the locomotive organs persists, and various orderly movements can still be produced. In like manner the control of the will over the succession and association of ideas may be either wholly, or only partially, lost in sleep. The deeper the sleep the more complete the loss of such control; hence the greater incoherence as well as feebleness of impression which is characteristic of dreams when sleep is profound. The vivid and panoramic succession of visual conceptions which constitutes a “vision,” occurs during light and partial sleep, when the will is still capable of in some measure guiding the procession of ideas.

For a similar reason the higher faculty of judgment, and especially the power of arriving at moral conclusions, is in great measure suspended during sleep. Like the power of volition, the activity of the moral sense is dependent upon a certain functional perfection in the brain. When the capacity of the brain is depressed by drugs or by disease, or by sleep, the moral sensibilities are the first to disappear. Hence the non-moral character of the impressions usually experienced during the act of dreaming. We feel neither surprise nor regret at the incidents of ordinary dreams. It is only when the border line of wakefulness is reached that the dreamer feels ashamed of walking naked in his dream, or feels compunction for an act of crime, or experiences emotions of joy or sorrow in connection with the incidents of his vision.

A dream may, therefore, be defined as the occupation of the field of consciousness during sleep by a succession of ideas more or less completely withdrawn from the guidance of the senses and from the control of the will. A great variety of dreams may thus be admitted, ranging all the way from those products of mere absence of mind which constitute revery, down to the faintest and feeblest stirrings of consciousness which have been always observed during the act of waking from the profoundest sleep.

Considerable light may be thrown upon the production of dreams if we consider attentively the manner in which illusions and hallucinations are excited by the use of drugs or by disease during the waking state. When engaged in experimenting upon myself with different medicines, I once took a dose of hasheesh sufficient to produce the peculiar effects of the drug. Sitting quietly in my chair, the first unusual sensation was an agreeable feeling of coolness diffusing itself over the surface of the body, as if some one were gently fanning me on a hot day. A feeling of causeless amusement began to occupy my mind. I seemed to be smiling all over without any apparent reason for hilarity. Then the walls of the room in which I sat seemed to recede to a vast distance. My attention became riveted upon a little picture which hung against the wall before me. It was a sunset scene, painted upon a canvas scarcely larger than my hand. As the wall upon which it was placed seemed to recede, the canvas expanded until I beheld a glorious landscape bounded by a range of snow-capped mountains flushed with purple light from the setting sun. As I sat, admiring this splendid scene, the gilded frame of the painting became alive with winged fairies and cherubs, peeping out from behind the moulding, and bending over its margin to look into the picture. Then the ceiling of the room and the sky of the picture seemed to blend in one common expanse of ethereal blue; the sunlight faded from the mountain peaks; stars began to appear in the firmament; the little imps and fairies disappeared; and, presently, everything resumed its natural appearance.

In this experience the departure from healthy cerebral function consisted in an exaltation of certain forms of sensibility while others were depressed. The succession of visual images was initiated by the visible objects around me, but it was enriched by the association of ideas furnished through the stimulation of memory. The sunset glow, the snow-capped mountains, the starry sky, were familiar objects, suggested from memory by the items grouped in the picture. In like manner, the cherubs who climbed upon its gilded frame were merely the glorified products of memory, probably suggested by the fact that it was a picture upon which my attention was fixed—one picture reminding me of others which I had seen. The loss of proportion in the view—the exaggeration and distortion of all the relations of time and space, which made the unreal seem real, and conferred grandeur upon commonplace objects, was undoubtedly occasioned by a modification in the molecular structure of the organs of special sense and of perception under the influence of hasheesh. The change thus effected was of a character to diminish the force of sensory impressions derived through the aid of the muscles and nerves of the eye and the ear and the skin, while at the same time exaggerating the processes of memory and association in connection with impressions originating within the brain. In this way was produced a sort of confusion between the external world and the ideal world within, rendering it difficult to distinguish the one from the other. Hence the impossibility of estimating aright the relation of time and space to the visual impressions upon which attention was fixed. The result was a waking dream which differed from ordinary revery chiefly in the intensity of the impressions that occupied the mind.

A somewhat similar process is sometimes experienced as a consequence of cerebral disorder unconnected with the effects of drugs. During the invasion of measles, having taken no medicine but sage tea, I remember, as night approached, a strange succession of illusions. My head seemed to expand to the size of a bushel basket; then it would slowly contract again. My body seemed to grow out of shape into the most distorted forms of rickets. Audible sounds seemed to come from the most remote distances. Impending shadows of a great darkness hovered over the bed. Waves of heat, and tingling darts of numbness traversed my limbs. These singular and rather uncomfortable sensations continued until relieved by an ordinary Dover’s powder.

In this experience the confusion of ideas, though less agreeable, was essentially similar to that occasioned by the action of the hasheesh. In both cases there was the same diminution of the intensity of external sensation accompanied by an exaggeration of internal impressions. The brain and the nerves were in a condition of irritable weakness, caused by disease, which interfered with the normal generation and association of ideas. Having thus partially escaped from the control of the senses and the will, the mutilated succession of ideas which reached the field of consciousness could only be perceived as a series of illusions. Here, again, was a waking dream, of origin and course analogous to the illusions and hallucinations which accompany every form of delirium.

It is not alone under the influence of disease or of drugs that the automatic action of the brain furnishes ideas for the inspection of the mind. Riding, one day, in a street-car, and reading a philosophical work, I came upon a paragraph devoted to a discussion of the doctrine of the association of ideas. Immediately, out of memory, flashed a momentary vision of the quarter deck of the old frigate, United States, upon which appeared the figure of a very small midshipman, talking to a gigantic personage, the captain of the ship. This was an incident which I had actually witnessed forty years before. I was, at first, somewhat puzzled in the attempt to account for the occurrence of a vision so apparently incongruous with the subject matter of the book; but a little reflection convinced me that the exciting cause of this seemingly involuntary act of memory was really the idea of association suggested by the book. This had unconsciously aroused the apparatus of association in the brain, and the particular scene thus brought before the mind had been further suggested by the circumstance that the last object, external to the printed page, upon which I had fixed my attention, was a large ship, lying in the river, near the bridge, just crossed by the car in which I rode.

Numerous other examples of a similar character might be related to illustrate the fact that the brain is a reservoir of sensory impressions, some of which, at the moment of their original incidence, have aroused the mind to a greater or less degree of conscious attention, and have then all lapsed into a latent or potential condition. But, though latent, they are none the less persistent, and only await the suppression of other inhibitory forces to become once more capable of arousing attention. Such inhibitory impulses are continually furnished by the action of the sensory organs on the one hand, and by the energy of the mind upon the other. So soon, therefore, as the organs of sense and of voluntary impulse are sealed with sleep, if the remaining portions of the brain are still operative, and are left to their own unrestrained activity, a more or less disorderly series of ideas occupies the mind. This constitutes a dream. The difference, therefore, between waking thought and a dream is analogous to the difference between a page upon which the words have been arranged in a rational order, and another page upon which some of the same words have been set down at random. Inasmuch as the majority of our sensations are derived through the organs of sight, and since the larger portion of the sensory region of the cortex of the brain is concerned in the act of vision, it is no more than might be expected that the ideas suggested in sleep should generally proceed from the visual apparatus of the brain. The superior power of visual impressions to attract attention may also serve to explain the fact that the majority of dreams are composed of images that were originally perceived in the act of vision. Hence our dreams, for the most part, constitute a series of pictures undisturbed by sound, or by other forms of sensation. But this is not always so. It is highly probable that when the organs of external sense are allowed to sleep without disturbance, our dreams consist of visual impressions alone. But, if any unusual sound, or smell, or other sensation is experienced during sleep, it may penetrate the field of consciousness, and may become the starting point of a dream quite filled with sounds. Thus a young lady, who had passed the evening at a musical concert, was aroused, soon after retiring, by the striking of a clock which had been recently placed in her chamber. At the moment of waking, she was dreaming of an orchestral performance of Wagner’s music. Doubtless the dream was suggested by the unaccustomed sound of the clock.