TREATMENT OF INSOMNIA IN PARTICULAR DISEASES.
Take thou this phial, being then in bed,
And this distilled liquor drink thou off;
When presently, through all thy veins shall run
A cold and drowsy humor, which shall seize
Each vital spirit.
--ROMEO AND JULIET.
Excluding from consideration all cases of insomnia arising from painful
injuries or diseases of the external portions of the body, which belong to
the province of surgical therapeutics, we may profitably commence with the
variety of wakefulness that is excited by disorder of the brain and its
membranes. This includes the different forms of meningitis, the cerebral
disturbances which constitute insanity, cerebral exhaustion, and chronic
alcoholism.
_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:
℞ Morph. Sulph. gr. ¼
Chloral Hydrat,
Sodii Bromid. ā ā Ʒiv.
Tr. Aconit., rad. gtt. xxv.
Tr. Cardam. Co. Ʒi.
Aquæ, q. s. ad. ℥i.
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:
℞ Ammon. carb., gr. v.
Spt. chloroform, gtt. xx.
Aq. camphor, ℥ ss.
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.