REMEDIES FOR INSOMNIA.
O, true apothecary!
Thy drugs are quick.
--ROMEO AND JULIET.
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.
Heat.
Baths.
Massage.
Electricity.
Counter-irritants.
Food.
Digitalis.
Camphor.
Musk.
Valerian.
Cannabis indica.
Belladonna.
Hyoscyamus.
Stramonium.
Phosphorus.
Acids.
Opium.
NERVOUS SEDATIVES.
Cold.
Alcohol.
Paraldehyde.
Ether.
Chloroform.
Chloral.
Butylchloral hydrate.
Amyl nitrite.
Opium and opiates.
Bromides.
Hops.
Gelsemium.
Conium.
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:
Paraldehyde, Gr. 20.0
Spirit, 100.0
Syr. Simpl., 75.0
Tr. Vanillæ, 5.0
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.
_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]