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Lorsque le document est trop grand pour Atre reproduit en un seul cllchA, il est filmA A partir de Tangle supArieur gauche, de gauche A droite, et de haut en bas, en prenant le nombre d'Images nAcessaire. lies diagrammes suivants illustrent la mAthode. 32X 1 2 3 4 5 6 m»'- ,1 HO Has I when coinm is well Ii D univers used it D cases ol prostra benefit. D with de convey relieved of mind Di able hel Di insom^ Di it in pfa with the Sen furnishe charges. Pre B CAVTH CONSUMPTION. HORSFORD'S ACI D PHOSPHATE Has been used with good effect in consumption, and also when complicated with indigestion. In night sweats it has commonly given speedy benefit. It is agreeable to the taste IS well tolerated, and does not constipate the bowels. Indicated in all wasting and debilitating diseases. Dr. J. A. Meek, Glencoe, Minn , says: "It seems to be almon universally useful when there is a tendency to tubercle. I have also used it to great advantage in a diversity of cases of defective nutrition " Dr. F. C. Hawley Canandaigua. N. Y., says: " I have used it in cases of phthisis and inflammation of the lungs, where there was great prostration, constant cough and profuse expectoration, with marked benefit. . u P'\7'^ **-j^- Davison Parsons, Kan., says: "I have used it with decided and certain benefit in consumption. I do not intend to convey the impression that I have cured consumption with it, but it has relieved its distressing symptoms, such as iowness of spirits weakness of mind and body, nervous irriution," etc. ... Pi ^■, Thompson, Lowell. Mass . says: "I have found it a valu- able helper in nervous debility and incipient consumption " Dr. Thos. Phillips. Austin. Minn., says: " I have used it in the msomaia of phthisis pulmonahs, with immediate good. " w . >^;J-."- ^/!?u^;.^*"'! ^r""*' '^'='» . "ys: •• I always prescribe it In phthisis and debility, physical or nervous, and have been pleased with the results obuined." ^ ^<^^^ Send for descriptive circular. Physicians who wish to test it will be furnished a bottle on application, without expense, except express Prepared under the direction of Prof. E. N. Horsford, by the EUMFOED CHEMICAL WOBKS, Providence, B. I. Beware of Substitutes and Imitations. CAVTIOir.-Be sure the word " Hartford's " is Printed on the label. All others are spurious. Jfever sold in bulk. "'•'"• "^ penMHUMHR liHHHIII ma- — '■ ''.' r I i N SLEEP, INSOMNIA, AND HYPNOTICS. 'if E. P: HURD, M. D.. Member of the Massachusetts Medical Society; Member of the Cliinatoh\^ical Society; Memlter of the Soci^t/ lie M^tie- ciiie Pratiijue (Paris, France); one of the Physicians to the Anna Jaqiies Hos- f'ital, .Yew/iuryport, Mass. ^iffi /^. / 1891. GEORGE S. DAVIS DETROIT, MICH. f— _^ ■I m iii i w "^'^ ■^^ vVO (. .^\ Copyrighted by GEORGE 8. DAVIS. 1801. c ^^ ,V^^ TABLE OF CONTENTS. CHAPTER I. TMK l'IIYSI()I.O(;V OK SI.EKP, Page . General Considerations on Sleep— The Necessity of Sleep; Proximate Cause or Causes— Functions of the Cerebrum — Registration of Impressions- Partial Memories; Sensory and Motor Localiza- tions—The Cerebrum as an Originator of Energy —Fatigue under Exertion— Waste and Repair- Antecedents of Sleep— State of the Circulation During Sleep— The Sense of Fatigue— Predis- posing Causes of Sleep— Amount of Sleep Nec- essary— Dreams— Dreaming an Indication of Im- perfect Sleep; often a Morbid Symptom 1-28 CHAPTER II. INSOMNIA. General Divisions: i, Psychical; 2, Physical Causes —Pain as a Cause of Insomnia — In:^omnia Due to Overwork of the Brain -Treaiment— Insomnia Due to Morbid States of the Brain— Insomnia of Respiratory Origin— Insomnia of Heart Disease — Cardiac Dyspnoea— Insomnia of Gastro-intesti- nal Origin— Insomnia of Cystitis — Insomnia from Genital Irritation — Insomnia of Toxic Origin— Insomnia of Continued Fevers and Its Treatment 20-88 r*- ■% VI, CHAPTER Ml. IIVI'NOTK S. Opium and Narcotics-Alcohol and Other StimuhuUs —Bromide of Potassium and Bromides— Chloral -Sulphonal - Paraldehyd - L'rcthan - Somnal -Amylen hydrate — Chloralamid — Remeduil Measures not' Medicinal; (a) Baths, (b) The Wet Pack, (c) The Turkish Bath, (d) Shower and J?t- baths, (e) Electricity Page. S(j-II2 il- PREFACE. 'age. ij-iia This little treatise, though Ihiik; advertised Id he a trans- lation of a recent mnnoxraph of Germain S4e i" the MMrim A/, M.D. Newburyport, Mass., Dec. 1st, 1S91. i' o CHAPTER I. THE PHYSIOLOGY OF SLEEP, It has been sufficiently demonstrated that during sleep the brain is relatively an.x«mic. The observa- tions of Durham, of Hammond, of Mosso, and others, have proved this. During sleep, all the encephalic blood-vessels are under a diminished pressure, as shown by the manometer. And this lessening of the active flow corresponds with a diminution of cerebral function. This is in accordance with the facts of physiology generally: the performance of function is characterized by vascular fulness and activity; the cessation of function is attended with decrease of the vascularity and volume of a part. The immediate cause of sleep, however, is not simply the shutting off of a portion of the blood-current from the brain. The lessening of the blood-supply is rather the accompaniment than the cause of sleep. The true cause is the ionpor—e ngourdissement—oi the cerebral cells. This torpor may be the result of waste, unbalanced by repair, of the hemispherical ganglia, which become functionally inactive owing to diminution of oxidizing material, as well as to clogging of the venous and lymphatic channels by the accumulated debris of organic combustions. But this is not all. As the effete products of cell function have a paralyzing action on the cells them- selves—a truth exemplified even in the protoplasmic ^mmmmmmmmm SHcnmoMMaM -:!-^«l . ,„. o. microbe, whic. a,e now ---"X^^l'^ Prever has much probability in its favor Preyer and refers to e v ^___^,^ ^„j produced a llTomno,",' condition which was nndistinguish- abe^fomata, Sleep, But .actic acid is on y one o the toxic product. o< the ''^f .X^^^ter™ U =Alu are also destructive o! cell life, ana every rE-rrtrva:rpT-,^^^^^^^^^^ ratffl:je.«ndsthat^^^^^^^^^^^^ ::r;:tr tCTro^Ss narcosis, while the iatter ''""^"''"^.rL^nt^ir.r/ror:ChtHT;r :r=rrursir:^. Znd th. .cumulation 1 ^o h<-raiise the ehmination ot tnese s.uu takes place because uic stances by the urine goes on the more slowly *LaMidecine Modcrne, 1890, p. 183- ■■•' ft ^ ceby J— so i by reyer waste sleep, : acid ced a guish- ane of rinary ry cell 1 exer- oon as :o per- ho has inimals ;al and ay pos- e night, e latter drawn recesses by their nulation ese sub- »wly the — 3 — nearer we approach the usual period of sleep. On the other hand, during sleep, the convulsivant sub- stances which result from denutrition cooperate in bringing about awakening.f In accordance with this theory, it might be expected that there would be a definite relationship between the labor done and the amount of sleep required— that hard brain work would necessitate more sleep than muscular work, and that those who toil little would sleep little. Unfortunately, theories, like parables, do not always "go on all fours." The relationship above spoken of is not mathematically established; the coal-heavers and diggers of the soil are the best, while the brain-workers are the poorest sleepers, and those that do little or no work of brain or muscle sometimes sleep with extraordinary soundness, and even have no diffi- culty in going to sleep in the daytime. There is reason to believe that sleep often ensues from simple torpor or lethargy of the cerebral cells, a state into which some persons are constitutionally prone to lapse. The state of the foetus in utero may be regarded as one of continuous sleep, and it has been remarked that idiots and feeble-minded persons sleep much more than active-minded men. The Necessity of Sleep. — It is a law of nature that every kind of force or energy emanat- ing from the organic or inorganic world shall be the exact equivalent of some pre-existent kind of force. This is the doctrine of the correlation and equivalence and persistence of force now universally admitted. The power that drives, the piston rod of + G. S6e, /oc cit. — 4 — the steam engine existed latent in the coal as static force, originally coming in the form of dynamic force -light and heat-from the sun, that great primal source of power. . In the galvanic battery we see chemical force converted into electricity, and in the conducting wire we have the transformation of electric force into heat. In the organic world we witness the metamorphosis of light, heat and chemisra into those forces which are called vital.* # " It is now an admitted doctrine that the nervous power is Kenerated from the action of nutriment supplied to the body, and is therefore of the class of forces having a com- mon origin and capable of being mutually converted, m- Cuding mechanical momentum, heat, electricity^ magnet.sm and chemical decortiposition. * * *„ . ^'^f '" J*"!; vitality is not a peculiar force, but a collection of the orces oftorganic matter in such a way as to keep up a hvmg !,r„rture * * * * The nerve force that is drawn from tie waste of a given amount of food is capable of being transm «ed into any other form of animal life. Poured into he muscles during violent conscious effort, it increases their acivT; passing to the alimentary canal, it aids in the force o dStion; at other points, it is converted into sensible heat; whi fthe s^me power is found capable of yielding true elec Trical currents. The evidence that establishes the common b"si orichanical and chemical force, heat and electricity, namely their mutual convertibility and common origin LtTbHs'hes the nerve force as a member of the same group. —fRain- Senses and Intellect, p. 65. xLe Hfe of the highest as well as the lowest organisms is characterized by the manifestation of certain activities MAwuc^-iha^^tf^. , IS static lie force , primal ;al force ing wire ito heat, lorphosis rhich are ous power lied to the ig a com- iverted, in- lagnetistn, It is called : the forces ip a living rawn from e of being 'cured into reases their in the force nsible heat; g true elec- [le common electricity, non origin, me group." L organisms in activities . — 5 — It is a truism to say that all organs that are e^xercised must have rest. After every con- siderable effort of the muscular system, a greater or less incapacity for further exertion results, and the subjective expression of this incapacity we call fatigue. The tired muscles obtain a meas- ure of repair during the intervals of work, and such intervals may be frequent during the working hours. We often rest one set of muscles when we are working another set. Even those actions which are derivable from the cosmic environment; the energy which we expend as nerve-force, muscular contraction, thought and will is but the expression of destructive changes taking place within our bodies. How much of nerve and muscular activity is the direct product of the breaking up of ternary compounds in the organism— fats, carbo-hydrates and glycogen, which are stored up as " reserves" in the tissues— how much is due to direct tissue metabolism, it is impossible to say; it is certain, however, that parts of the body that undergo exercise waste pari passu with that exercise, and that in undergoing disinte- gration, the static force that gave them structural form and function is set free as dynamical energy, and in accordance with the substratum throughout which it is liberated, mani- fests itself as some form of vital force. Plants expend little motion, and consequently their waste is inappreciable. Actiniae kept in an aquarium diminish little in bulk from prolonged abstinence. Even fish, which are much more active than other aquatic creatures, suffer little loss of substance when kept long unfed. The same ■ remark applies with greater pertinency to cold-blooded animals and to hibernating animals. On the contrary, warm-blooded animals in a state of normal activity expend much energy and - •flM _ 6 — most continuous, as respiration and the pulsations of the heart, have distinct periods of suspension. Jt is a mistake to suppose that the heart and lungs never rest. After each contraction and dilatation of the heart, as Hammond reminds us, there is a pause of one-fourth the time of a beat in which the heart rests and is repaired. Hence the heart may be said to rest six hours out of the twenty-four. After each respira- torv act, there is a pause equal to one-third of the whole time; thus the lungs rest eight hours out of the twenty-four. But for the busy brain, there are no sufficient seasons for rest during the working hours. The latest, most elaborate, most noble product of evolution, superadded to the spinal and sensory ganglia of the animal economy ages after the auto- matic action of these centres had been established by waste much substance.f This waste must be made good by repair.and the conditions of repair are a normal supply of food a normal circulation, and opportunity for appropriation of pabulum. If this opportunity be not afforded from moment to moment; if synchronous with waste, repair cannot go on, suitable seasons must ensue when the equilibrium may be re- stored. If the system cannot in its entirety be refected while work is going on, work must stop while the system is being refected. The machine is out of repair, and business must be suspended while it is having an overhauling. These considerations give hints as to the true meaning of sleep. tVide Herbert Spencer's ?"«=>?>" ''^«|°'°«y' '^^V'' ^The onW which I have borrowed several illustrations of the law stated. The only ratlsfacto^ explanation of the phenomenon of sleep is furn.shed by such biological inductions. -mfttrntidmii^Kf ions of Jt is a i never of the ause of irt rests i to rest respira- of the t of the are no r hours, duct of sensory le auto- ished by ; good by ijr of food, riation of noment to lOt go on, may be re- eled while 1 is being ness must {. These ' sleep. , p. 170, from I. The only hed by such organization, and superadded for the greater elabora- tion of faculty and for the more complete co-ordina- tion of faculty with the conditions of existence, the cerebrum is still the latest development in the evolu- tion of the individual, and perhaps the most hetero- geneous and unstable in its molecular constitution. I do not propose to go into any lengthy con- sideration of the functions of the brain. I assume the cerebrum to be the seat of sensa- tion, thought, volition. The psycho-motor centres are located in the post-frontal and parietal regions. No such precise localization for the purely psychical centres is yet possible. "The endless variety in the character and complexity of our cerebral activities," says Macfarlane, "implies the exist- ence of a like multiplicity of centres." Localization we do indeed know in part. Ferrier's teachings with regard to the motor centres for the muscular group- ings of the face, upper and lower extremities, etc. (which are mostly located along the fissure of Rolando), are generally accepted. The visual centre is in the occipito-angular region; the auditory is in the temporo-sphenoidal convolutions. The seat of smell is probably in the tip of the temporo-sphenoidal lobe, that of taste is in the region of the subiculum cornu ammonis. The seat of cutaneous sensation— tactile, thermic, pathic— located by Ferrier in the gyrus hippocampi and gyrus fornicatus, seems the rather, in accordance - ' , , _ 8 — with a multitude of facts collected by Dana,* to be in the motor areas of the cortex. A study of cases shows that the the sensory centres for special parts of the body, /. e., face, arm, or leg, are in general iden- tical with the motor centres for those parts, but are larger and more diffuse. The tactile sensation seems to be more strictly confined to the motor areas. f The centres of the psychical operations are known to be somewhere in the cortex, but apart from the general vague division of mind into feeling, intel- lect, and volition, and the recognition of the fact that these three aspects of mind are so dependent among themselves, although characteristic in their manifesta- tions that no one could exist alone, no further division of mind is possible in the present state of science. There is, however, a sort of psychical differentia- tion with definite localization of- which we are war- ranted in speaking, and as the subject is of import- ance in connection with the physiology of sleep, I may be pardoned such digression as may be neces- sary to set forth views which may now be considered as data of science. Ribot, in his "Diseases of Memory," remarks that in physiology the distinction of partial memories is now currently received. " Memory resolves" itself into memories, just as the life of an organism resolves *" The Cortical Localization of the Cutaneous Sensa- tions," Journal of Mental Diseases, Oct., 1888. , f Dana, loc cit. V \ 1\ iT ll fl i ffi-'--'— • be in cases irts of iden- iit are seems IS are t from , intel- t that imong ifesta- ivision :e. rentia- e war- mport- eep, I neces- lidered ;marks mories i* itself ;solves Sensa- — 9 — itself into the life of the organs, tissues, and anatom- 'cal elements that compose it." . As memory is only the sum of partial mem- ones, and all our knowledge (based on memory) is primarily derived through the senses, and as all the sense-organs have their centres in the cerebrum where the residua of sensations (to use Maudsley's expres- sion) constitute the memories of each special sense so certain diseased conditions may obliterate one set of sense-memories by destroying their anatomical substrata, leaving, it may be, intact the memories of other senses. Charcot, in a recent lecture, has given us a good instance of this suppression of certain groups of memories. It was a case of loss of the mental vision of objects— forms and colors— coming on suddenly in a subject noted for great intellectual activity, but especially for the strength of his visual memory. This- individual would recall the principal features of a landscape, a painting, a play, with extraordinary ex- actness and vividness; his imagination was keen, and he excelled in perspective. He could readily recall what he had read by the mental images of words imes, sentences, etc., presenting themselves. His memory of persons and places was wonderful. After the accident to which allusion has been made, and which seems to have been of the nature of a limited embolism, he iost his visual memory of forms and colors, and was obliged in the management of his commercial affairs to have recourse to other forms of memory (the auditive, tactual, etc.), which were un- in^Tl:- ^^^ ?^y ^''"^ ^« "^«'l' his very home, and the faces and forms of the members of his family were at first strange to him; he recognized nobody •except by the voice; he could only find his place of IfW lO — §'■• i business by inquiry. Little by httle us visual mem- ories returned, but never completely. He had lost the faculty of drawing; could no longer sketch the form of any object which he had once seen. His memory of colors was gone; he could not form the mental image of black, white, red, etc., and when any- thine of a bright hue was presented to him he could not recognize the color. The larger part of what he had learned by reading was forfo"en, whi^ the memory of what had been acquired by the auditory sense was as vivid as ever. This gentleman wrote to Charcot that his in- terior vision," once so active and perfect, "had com- pletely disappeared." He could no longer represent to himself the forms and feat"'-«t.°^h'«.,T:'^^jri children, or any other person or object with which he had been familiar. His dreams were completely changed; he now no longer dreamed of persons and places, but of voices and words. A remarkable con- sequence of the loss of this mental faculty was the change of character which he had experienced. He found himself much less prone to sorrow, sympathy and moral emotion than formerly Having rccen ly lost a valued relative, he felt much less poignant grief than we would have felt could he have represented to himself by the interior vision the physiognomy of thi^ relative, the phases of the disease through which he had passed, and especially, if he could have pictured to himself the external effect produced by this death on the members of his family. He concludes his let- ter by the remark that he is now obliged to say ta himself the things which he wishes to retain in his memory, whereas, before the occurrence of his cere- bral lesion, he had only io photograph them by sight in order to remember them. HiMi« mem- id lost :h the His m the n any- I could hat he le the iiditory is "in- d corn- present ife and which ipleteljr ns and )le con- iras the d. He mpathy recently int grief ;nted to iT of this rhich he pictured is death 5 his let- say to in in his lis cere- sight in — II — Charcot concludes some very judicious and in- structive comments on this interesting case, of whose details we have given but an imperfect idea, by the followmg observations: " It cannot now be denied that the possible and actual suppression, in numerous instances, of an entire group of memories, of a whole category of commemorative images, without the par- ticipatioh of other groups, of other categories, is a capital fact in pathology as well as in cerebral physi- ology; It leads necessarily to the admission that these divers groups of memories have their seat in certain determined regions of the encephalon, and adds an- other proof to those already existing that the hemi- spheres of the cerebrum consist of a certain number of ditferentiated organs, of which each possesses its proper function, while remaining in the most intimate con- nection with the others. This last proposition is moreover, to-day generally admitted by those who study the functions of the brain, not only in animals, in the laboratory, but also, and especially, in man, by the procedures of the anatomo-clinical method." To sum up, then, the cerebrum is the great centre of sensation, perception, and ideation, of con- scious, emotional, voluntary activity. Pulses of mole- cular motion from the brain are being continually diffused throughout the body, and the healthy per- formance of its office by every part of the body de- pends largely on these gushes of nervous energy. There are differences in molecular activity between nerve fibres and nerve cells. " While the matter com- posing a cell is built up of enormously complex ag- gregates of molecules, wholly unshielded from ex- — 12 ternal disturbance, the nerve matter of a fibre is pro- tected throughout its entire length by a membranous sheath. And while it is probable that the action go- ing on in a cell consists in the continual fall of un- stably arranged molecules into a state of more stable equilibrium, from which a fresh rush of blood is con- tinually raising them to their unstable state, it is probable that the action going on m a fibre consists m the successive isomeric transformation and retrans- formation of the system of molecules which make up the fibre " " The cell is the place where nervous energy is liberated, while the fibre _is a path along which nervous energy is transmitted."* The amount of molecular energy locked up in a nerve centre is proportionate to the amount of unsta- ble nerve matter awaiting decomposition; and the » This view is well brouglit out by Virchow. He be- lieves that all function (or activity of all kinds in tissues is due to changes of place in the minute particles o the cell contents. This change of place is almost '"^t^Tn^r n transmitted through all the cells in proximity. ^ change n the electrical state of the part is connected with it. Vir- chow's view that restitution of function does not always de- pend on a fresh absorption of nutritive material may per- Lps seem novel. Rest alone, he says, is often sufficient t_o enable the cells in a very short space of time to renew the r activity The molecules which had quitted their usual posi- Z gradually revert to it. and hence are ready for function again. Virchow seenis to have proved this by e'^P"""*"" on nerves which have been cut out of the body.-[Cellular Pathology, p. 327- s prc- ranous on go- of un- : stable IS con- 5, it is ' isists in etrans- ake up '.ervous 1 along up in a E unsta- ind tiie He be- Issues) is ■ the cell taneously hange in it. Vir- Iways de- may per- fiicient to new their sual posi- • function periments -[Cellular — '3 — greater the (juantity of motion liberated, the less of material remains for the liberation of motion.* Hence the diminished readiness with which the nervous cen- tres respond to stimuli after a few repetitions of the disturbance. The amount of explosive material is lessened with each explosion. The enfeeblement of nerve-centres when caused by moderate action is in- conspicuous, for the disintegrated mass speedily re- integrates itself from the materials brought in the blood.f But if the stimulation and consequent dis- charge are violent, or very often repeated, then repair falls so far in arrear of waste that the nerve centres become partially or completely incapacitated. "All the unstable substance within easy reach of the incoming disturbance has been decomposed, leaving only such part as is most removed from ordinary disturbances and can be affected only by excessive ones." As ex- amples we need only to be reminded of the tired horse that needs persistent urging and the continued and often excessive use of the lash to make him con- tinue his pace. Also of the effect of friction of the skin in causing paralysis of the vaso-motor nerves and cutaneous congestion. The familiar experiment of the effect of irritating the web of the frog's foot is to the point. The arteries are at first contracted under the stimulus; "the strong impression conveyed to the vaso-motor centres there liberates an excessive dis- * Spencer's Psychology, vol. i, p. 89. t Herbert Spencer, loc. cit., p. 89. . ""F= — 14 — Charge along the fibres supplying those arteries, caus- ing spasmodic contraction of their muscular coats. The second result is that these arteries dilate, losing their normal contractility; they become distended with blood, and the part is congested. That this is due to extreme prostration or temporary paralysis of the vaso-motor centre has been clearly proved, for if the nerve-trunk containing the vaso-motor fibres be dissected out and artificially irritated, the dilated ar- teries instantly contract."* Mr Herbert Spencer, from whom I have bor- rowed these illustrations respecting the vaso-motor nerves, has hardly done more than gather up into a complete whole the generalizations of his leading sci- entific contemporaries. Virchow, for example, in his Cellular Pathology, p. i49, has said substantially the • same respecting the action of vaso-motor nerves under stimulation, and the readiness with which they are exhausted. In the smaller vessels, with few mus- cular fibres, the exhaustion follows so speedily the stimulation that it seems as if the irritant had pro- duced no contraction, so soon does relaxation follow. These familiar truths explain why the brain needs the rest of the night. Repair and waste are not evenly balanced during the waking hours. Waste has got in excess of repair. Not that no repair has been going on during the working hours-nutntion is actively going on at all times, and in the spinal cord * Loc. cit., p. 87. If' ,, caus- coats. losing tended this is jTsis of I, for if >res be ;cd ar- fe bor- )-motor I into a ing sci- :, in his ally the nerves ch they >w mus- lily the ad pro- i follow, e brain aste are Waste ipair has trition is nal cord — '5 - and medulla oblongata it is probablp tl.at repair ever keeps pace with waste, or falls but l.ttic in arrear, equilibrium being quickly restored. The peniliar functions of these lower centres are of an automatic kind, stimuli always producing responsive discharges along established lines. It would certainly be for the advantage of every species in the struggle for e.xist- tence that those automatic functions should be per- formed at such an even, uniform rate that repair and waste should be in equilibrium. Such is the condi- tion of these nerve centres. From minute to minute brief pauses occur, when waste is made good by re- pair. This was shown to be true in respect to respira- tion, the pause after each respiratory act giving the bulb sufficient time for repose and repair. With the cerebrum the case is somewhat different. " Its substance is consumed by every thought by every action of the will, by every sound that is heard, by every object that is seen, by every substance that IS touched, by every odor that is smelled, by every painful or pleasurable sensation, and so on. Each mstant of our lives witnesses the decay of some por- tion of Its mass, and the formation of new material to take its place."* Hence the need of that periodical repose we call sleep. Sleep becomes emphatically "tired Nature's sweet restor er," "balm of hurt minds," "chief nour- * Hammond. " Sleep and its Derangements." p. 12. r ,_-,«B^****« ■"*" • _ 16 — isher in life's feast." In this adaptation of organisms to the waste of the day and the repair of the night Herbert Spencer sees an example of the prmc.ple of survival of the fittest. "An animal so constituted that waste and repair were balanced from moment ta moment throughout the twenty-four hours, would other things being equal, be overcome by an enemy or competitor that would evolve greater energy dur- ing the hours when light facilitates action, at the ex- pense of being less energetic during the hours of darkness and concealment. Hence there has neces- sarily established itself that rhythmical variation ,n nervous activity which we see in sleep and waking. (Principles of Psychology, vol. 1, p. 88). Antecedents of 5/../.-There is every reason to believe that one of the antecedents of sleep is a cer- tain change in the composition of the ^ood circula - ing in the capillariesof the pia mater,where by the nutri- tion of the cortical cells is diminished. This change may be regarded as an accumulation of waste extrac- tives There is also doubtless another factor, as staged by Pflugger; the brain is extremely sensitive to the want of oxygen, e.g., when frogs are deprived of this element for any length of time, they fall into a condition resembling sleep. Some experiments of Pettenkofer and Voit make it apparent that oxygen accumulates in the blood during sleep to be utilized during the waking hours; deficiency or absence of this "change-compelling" element may well cause janisms ! night, ciple of istituted ment to would, I enemy rgy dur- ; the ex- hours of IS neces- iation in waking."^ •eason to ( is a cer- circulat- the nutri- is change te extrac- [actor, as sensitive deprived J fall into •iments of at oxygen )e utilized absence of well cause _ 17 _ that lethargy of function whose full expression is sleep.* Another antecedent of sleep is lethargy of the circulation. There are probably several factors in this change. Less blood is attracted to the cortex by the cells becoming functionally inactive, and the tired brain sends diminished energy to the heart, and there is a slowing of the circulation. With a diminu- tion of vaso-dilator influence in the higher ganglia there may be an augmentation of vaso-dilator in- fluence in automatic ganglia lower down (the inhib i- tory agency of the hemispheres being withdrawn), hence a narrowing of the calibre of the cerebral arterioles and a lessened blood supply. During sleep, then, it is believed that the proper functions of the cerebrum are mostly suspended, nutrition only being active; the constricted arterioles supply- ing just enough blood to the nerve cells that the requisite reparative processes may be performed. * These experirr.enters, by an ingenious laboratory con- trivance, were enabled . . measure the amount of oxygen inhaled and of carbonic acid exhaled during the 24 hours. A healthy man was put into the test chambers with the light occupation of taking to pieces the works of a watch. Of the total quantity of oxygen inhaled by him, 33 per cent, was absorbed during the day, ?nd about double. 67 per cent during the night. This goes far to prove that night is the time for storing up oxygen to be used during the day in the production of work.— [North British Review, June, 1868 p. 269. ' ~=^-'-^-^*--^r\ \ '\- T i ur ii inm iti lr^ i Twr ii fp" i II — i8 — This relatively anaemic condition of the cerebrum during sleep has been proved by numerous well at- tested observations, as those of Sir Astley Cooper, Pierquin, Donders, Durham, Hammond, Mosso, and others. The experiments of Hammond were made on dogs from whose crania portions of bone were trephined, exposing the brain and its membranes. The details of these experiments are now sufficiently known since their publication in his book on " Sleep and its Derangements." Durham's observations, which were several years prior to Hammond's, also pertained to dogs. Pierquin's case is recorded by Dendy in his " Philo- sophy of Mystery." and elsewhere.* A girl in Montpellier had lost a large portion of her scalp and skull. The brain could be seen for a considerable extent of surface. When she was in dreamless sleep, her brain was motionless and low within the cranium; but when her sleep was imperfect and she was agitated with dreams the cerebrum moved and beat; more blood coursed through the vessels of the pia mater, and the brain protruded through the holes in the skull. • * • When she was awake and in vigorous thought, the brain swelled, and protrusion was very observ- able. Professor Mosso, of Turin, had the rare oppor- ■ tunity of making similar observations on three per- sons, each of whom had lost a portion of the skull. His studies of the cerebral circulation during sleep * Combe's Physiology, p. 143- Jarvis' Physiology, p. 432. American Annals of Phrenology, No. i, p.^37- Jlfii'-nri^T*-^ rebrum ell at- ^ooper, lO, and : made e were branes. iciently " Sleep irations, I's, also " Philo- ntpellier he brain When iless and mperfect >ved and the pia s in the vigorous y observ- ; oppor- ree per- le skull, ig sleep iology, p. 7- - jil '■« » « — 19 _ and during the waking moments have been the most thorough, and go to show; " i. That in the act of gomg to sleep a dilatation and relaxation of the ves- sels of the forearm occur, with a corresponding con- traction in the vessels of the brain, this change be- commg most pronounced during deep sleep. 2. That all external stimulation, however slight, such as a ray of light falling upon the eye, a noise, etc., is attended by contraction of the vessels of the forearm, greater blood pressure, and an increased flow of blood to the brain. 3. That these changes are accompanied by a modification of the respiratory rhythm, and an ac- celeration of the pulsations of the heart. 4. That during sleep, the quantity of blood in the brain is sub- ject to fluctuation without any apparent cause 5 That all mental activity is attended by an increased quantity of blood in the brain." ♦ These facts seem to teach that the sleep state is attended with relative anaemia of the brain, and that the amount of blood supply to that organ is in ratio with the mental activity. Hammond regards this diminution of the quantity of blood circulating in the brain as the immediate cause o f sleep, and aflirms that whatever cause is * " Insomnia and its Therapeutics," Macfarlane. p. 16 Mosso devised special instruments by which he took tracings of the movements of the brain, the pulsations of the heart etc.; he also invented the Plethysmograph. for estimating the quantity of blood in the forearm and hand. 20 — capable of lessening the quantity of blood in the brain is also capable of inducing sleep. To this view has been opposed the fact that pa- tients suffering from general ---- (;[«";^';X; rhace chlorosis, cachexia, etc.), are often the victims fTs^mnia, ani that conditions of Plethora are ot attended with troublesome somnolence. Ligature of the carotids in animals does not produce a state re- semS true sleep, and faradization of the cephahc ends o? the two divided cervical sympathetic cords m animals while it produces considerable cerebral an- ^mTa dols not Sring about the least tendency to '°%te"sro*bjectionsappeartometo be well taken, and it seems probable that the vascular and cardiac Lod cations'are, as Vulpian says, '' only accessory and adjuvant," " concomitant or consecutive, play- ing no essential role in the Phy^'^^^^y f ^tfi. ^^^ht At the same time, there is no doubt that slight and gradual anemia of the brain is conducive to s^eep •' and therefore we see the utility, m some cases of insomnia, of hot pediluvia, cold, wet cloths to the """"^'m Sense of ira/^«..-Subjectively, sleep is pre- ceded by a sense of fatigue, which is the more pro- Tounced'the greater the labor which ^^as Produced^^ Fatigue may be regarded as an expression of waste i^i^T^ese objections forcibly stated by Vulpian in his Lemons sur VAppareU VascMoteur, t. ). p. 150. pf^ " in the at pa- laemor- victims e often ture of ate re- ephalic ;ords in ral an- ;ncy to 1 taken, cardiac :cessory e, play- p." " slight ucive to tne cases ,s to the ip is pre- aore pro- iduced it. of waste )ian in his 21 — unbalanced by repair; according to Preyer, lactic acid and creatine accumulating in the blood cause this sensation by their paralyzing action on the cells of the cortex. "Fatigue," says Benedikt,* "is a property inher- ent in all the nervous and muscular tissues; but the almost unlimited duration of certain automatic move- ments of pathological nature proves that the fatigue which supervenes after voluntary movements has its origin in the motor centers of the cortex. • • • * The sensation of fatigue is in a certain sense a guar- anty of safety for the muscular apparatus. In certain pathological states;, often even by the energy of the ^ will alone it may he overcome. But there then fol- ' lows a still greater realization of fatigue, which may be the result of complete exhaustion." Normal fatigue easily leads on to a condition of sluggishness and languor known as sleepiness. The eyelids feel heavy, the muscles relax, there is an in- stinctive disposition to shirk work, an inability to fix the attention on anything which requires thought, a sensation of supineness and enervation, a considerable obtuseness of the senses. Yawning is a phenomenon " indicative of a wearied attention. " " The head nods and droops upon the breast, and the body assumes that position which is most conducive to ease, com- fort, and entire muscular inactivity." Another subjective antecedent of sleep is failure *La M/decint Moderne, 1891, p. 67. — 22 — Of the attention. To this end, absence of sensorial impressions is an important condition of sleep. 1 here are certain influences which are predisposmg causes, such as darkness and silence and muscular rest. Habitual sensations, as the continuance of an accus- tomed sound, are of the same class. It is ow.ng to the power of habit that some persons can sleep more soundly in the neighborhood of noisy mills and cata- racts, than elsewhere, the attention of the individual being more attracted by the suspension of the sound than by its continuance; for as the exercise of the attention implies an awakened and concentrated con- sciousness, during such exercise sleep is, in the nature of the case, impossible. Other predisposing causes are gentle tranquilizing sounds, such as the piping of crickets, the rustling of foliage, the hum of bees, hearing a dull book read, etc., which conduce to sleep by making on the sensorium a series of monotonous impressions which are neither interesting enough nor powerful enough to keep the attention aroused (Car- ^^"*Ovid places the cave of Somnus in the country of the Cimmerians, the fabled 'and of shadows, of silence, and of gloom. The river of Lethe flows there, and invites to sleep by its murmur, and poppies luxu- riate before the cave of the drowsy god. Spencer locates the palace of Somnus in a dull and darklmg part of the earth. Archimago sends a little spirit down to Morpheus to fetch him a dream: iii '-■III, sorial rhere luses, rest, iccus- ing to more 1 cata- vidual sound of the d con- nature causes )ing of bees, o sleep )tonous gh, nor d (Car- country lows, of s there, ;s luxu- Spencer larkling tie spirit — 23 — " He making speedy way through spersed ayre. And through the world of waters wide and deep, To Morpheus' house doth hastily repaire , Amid the bowels of the earth full steepe. And low, where dawning day doth never peepe, His dwelling is. There Tethys his wet bed Doth ever lave, and Cynthia still doth steepe In silver dew his ever drooping head, While sad night over him her mantle still doth spreade. And more, to lull him in his slumber soft, A trickling stream from high rock tumbling down, And ever drizzling rain upon the loft, Mixed with the murmuring wind, much like the soune Of swarming bees did cast him in a swoone. No other noise, nor people's troublous cries. As still are wont to alarm the walled towne. Might then be heard, but Careless Quiet lies Wrapped in eternal silence far from enemies." Amount of Sleep Necessary. — As sleep is a con- structive process, it would seem that the amount of sleep taken should be proportionate to the mental and physical e.xercise of the waking hours. The reparative value of sleep, however, is more depend- ent on the depth and intensity of the sleep than on its duration. The invigoration which follows sound, dreamless sleep is remarked by every one; a little sleep of this kind is worth many hours of disturbed, dreamy sleep. It would seem that absolute quies- cence and suspension of function is that condition of the cortical cells most favorable for nutrition and repair. The principle of making up for lost sleep is a correct one; persons habituated to six or seven — 34 — hours' sleep a day may pass without inconvenience a night or two without sleep, provided they can make up for this loss by a more prolonged sleep afterwards. It is by dint of the habit of sleeping profoundly when they do sleep, that some persons sleep but few hours out of the twenty-four, and yet continue in health. Frederick the Great and John Hunter are said to have required only five hours' sleep a day, Pitt used to restrict himself to three hours. The briefest sleepers are generally men of the greatest mental activity. The best scholars, thinkers and lite- rary men, according to Carpenter, do not spend more than one-fourth of the diurnal cycle in sleep. Persons of lymphatic temperament are said to be the greatest sleepers, from natural lethargy of the nervous centers. Hard, muscular toil promotes somnolence more than hard brain- work; the husbandman and day laborer sleep longer and more profoundly than the student or professional man. The waking state of such persons is characterized by great activity; the wear and tear of the muscular system is iipmense, and long seasons of rest are needed, during which the physical and vital energies shall be largely occu- pied with the work of muscular reparation. Blood goes from the brain to the muscle, and there is rela- tive anaemia of the cortex, a condition favorable to the inertia of sleep. Moreover, the cerebral activity of even the humblest day laborer is not inconsider- snce a make wards. )undly ut few lue in er are a day; The reatest id lite- 1 more 1 to be of the e more d day an the tate of ty; the imense, : which y occu- Blood is rela- able to activity )nsider- — as — able — the sensorv, perceptive, and voluntary faculties are kept constantly employed during their daily occu- pations. They often toil for hours in obedience to a painful exercise of the will, amid an almost overpow- ering sense of muscular weariness. Now, a purely voluntary act fatigues the brain more than an involun- tary or automatic one. Hence, the protracted sleep of the day laborer must be due in a considerable degree to cerebral waste. The relationship of muscular exercise and muscu- lar fatigue to the intra-cranial energies and circula- tion may not be demonstrably clear, but the fact is none the less certain that muscular exertion is one of the most powerful promoters of sound sleep. Dreams. — Dreams, from a psychological point of view, constitute the most interesting phenomena con- nected with sleep; from a medico-physiological point of view, they are chiefly of interest as indicating that the sleep is not sound, /. e„ only partial. In dreams, the cerebrum is in part awake; the automatic (earliest evolved, most organized) centres of mind resume a measure of their activity, while the will* is still dor- * I use the term as expressive of the sum of the higher metital activities. These may be regarded as the latest evolved, most consummate results of evolution — the last developed in individual biological history and the soonest lost. The effects of physical tire earliest manifest themselves in modifications of the functional efficiency of the organic substrata of these faculties; the truly automatic substrata are more stable and capable of more prolonged, unresting I ■ : — 26 — mant. A limited area of brain is brought into a con- dition of waking excitement; certain ideas and emo- tions result, which, not being modified by comparison, and reflection by other ideas and feelings which are asleep, present a phantasmagorical succession of images to the consciousness. Hammond suggests that the cause of that sus- pension of the judgment which characterizes sleep resides in some alteration in the circulation of the blood in that part of the brain which presides over the judgment, whereby its power is suspended and the imagination left free to fill the mind with its incon- gruous and fantastic images. And yet, judgment, like volition, is a very com- plex phenomenon. It implies the possession of one's principal mental acquisitions, one's stores of experi- ences; it implies comparison, choice. The experi- ences themselves may not be actually present to the consciousness, but certain residua — unconscious gen- eralizations—from these experiences, most be there that judgment may be exercised on the c-isc at issue. It is plain that the imperfect sleep consciousi'-js i» inadequate to such exercise of comparison. We have not time to linger on this interesting topic covering which volumes have been written. It is perhaps better to leave this domain to the poet and activity, as is shown by abundance of pathological facts. (See Hughlings Jackson's Lectures on Evolution and Dissolu. tion in the Nervous Centres.) con- emo- rison, h are n of t sus- sleep if the over id the ncon- com- one's xperi- speri- to the gen- there issue. ^>s is esting n. It it and facts, lissolu* — a? - the metaphy.sician, to whom, as rightful property, dreams belong. We may remark, in passing, that the loss of association of ideas prevails as much in dreams as in the waking state. " Lulled in the countless chambers of the brain Our thuuKhts are linked by many a hidden ch.iin. Awake but one, and lol what myriads rise. Each stamps its image as the other iiies. Each thrills the seat of sense, that sacred source Whence the firm nerves direct their mazy course, And through the frame invisibly convey Their subtle, quick vibrations as they play." The dream images that "thrill the seat of sense" are a revival of registered sense impressions rendered peculiarly vivid because the natural channels between the outward world and the sensorium are closed. Hence, not being corrected by an incoming torrent of objective impressions, they engross the relatively meagre and imperfect sleep-consciousness, and seem realities. The same brain tract which is excited by the objective sense impression is occupied by the revived subjective image (Carpenter, Bain, Spencer), If we dream of things seen or felt or heard, it is the centres of those respective senses that are called into action, with such portions of the hemispherical (cor- tical) ganglia as have organic connections with them. It is remarked by Macfarlane that when many cen- tres are active, dreams are consistent and coherent, while when few centres are working, they are unreal ~I WHMWIUH*' mmn0f — 28 - and extravagant, /. r, tlie difference in the quality of the dreams depends on the depth of the sleep.* Dreams are principally of interest to the phy- sician as being an indication of unsound sleep. The dreaming period .seldom comes on in health till the time for waking approaches. Then the centres that are most automatic one by one recover their functional activity, those which represent the higher mental powers still remaining dormant. It is doubtless true that in sound sleep we never dream. If anything has been settled by the labors of physiologists during the past forty years, it is I think this, that the vascular and other conditions of perfect sleep forbid any men- tal manifestations. The condition of sound sleep is one of complete psychical inertia. A transcendental philosophy which teaches that the mind is always conscious and always active must have some higher foundation on which to rest than common sense and experience. If the dreaming period coihes on early, it Is evi- dence of some irritation in some part of the body which is disturbing the rest of the brain. Thus, un- seasonable dreaming is often symptomatic of indiges- tion, teething, a febrile condition, the influence of some toxic agent (tea, coffee, alcohol, etc.), and when dreams become pathological, it is a part of the phy- sician's duty to discover the cause and remedy it. * Loc. cit., p. 31. ty of phy- The 1 the that ional ental I true g has J the cular men- ep is ental I ways igher e and s evi- body s, un- diges- ice of when phy- t. ♦ CHAPTER II. INSOMNIA. If the essential condition of sleep be torpor of the centres of conscious mentality, everything which excites these centres and keeps them functionally active will promote insomnia. In discussing the causes of insomnia I shall adopt in part Professor See's classification, and shall con- sider these cases as: I. Psychical; and, II. Physical. I. Under the head of I'sychical Insomnia are included cases of sleeplessness due to to mental emo- tion, to thought, worry — /. /•., internal causes not di- rectly dependent on organic states or outward excita- tions. This kind of insomnia is that with which the author of "Night Thoughts" was (presumably) affected: " From short, us usual, and disturbed repose, I wake. How happy those that wake no more! I wake emerging from a sea of dreams Tumultuous, where my wrecked despondent thought From wave to wave of fancied misery At random drove, her helm of reason lost!" Insomnia of the psychical order is illustrated in the student who is anxious about his examinations and cannot obtain rest till the result is known; in the candidate for political honors who cannot sleep till the election is over and his fate is decided; in the mother who will watch over her sick child night after — 30 — night, not closing her eyes till the crisis of the sick- ness is passed. Multitudes of such instances happen in daily experience. In order that natural sleep may occur, the mind must be tranquil; on this point it is useless to enlarge. The pure hypnotics— chloral, paraldehyd, ure- than, sulphonal— are generally quite efficacious in the insomnia due to emotional causes, the intensity of the insomnia being of course proportional to the intensity of the disturbing cause. Business cares and anxieties of all kinds, and, I may add, homesickness and disappointments, often produce a most obstinate wakefulness, which hardly yields to even large doses of chloral; sulphonal is almost without effect. In such cases the therapeutist is almost without re- sources. " Who shall minister to a mind diseased, Pluck from the memory a rooted sorrow, Rase out the written troubles of the brain, And with some sweet oblivious antidote Cleanse the stuffed bosom of that perilous stuff Which weighs upon the heart?" Under the head of psychical insomnia may also be classed sensorial disturbances of an unusual, in- tense, or persistent nature, whether of sight or of hear- ing, which prevent sleep. But these causes are so familiar to everybody that it suffices simply to men- tion them— illustrations are innumerable. Prof. St'e alludes to the effect often produced by prolonged le sich- happen ep may )int it is yd, ure- is in the y of the intensity inxieties 3SS and )bstinate je doses ect. In lout re- stuS may also usual, in- r of hear- ts are so y to men- Prof. St e jrolonged — 31 — application of the eyes to reading and to the micro- scope, especially in the evening; this frequently pro- vokes subjective excitations— "phosphenes"— whose constant reappearance prevents repose. It is useless to say that this kind of insomnia, being caused by physical agents, might properly come under the next division. II. Under the head of Physical Insomnia, I shall, I, take up the group of physical causes, fore- most among which are organic conditions productive of PAIN. If an irritation emanating from any organ or tissue may keep consciousness aroused and the cortex active when not painful, how much the more will it be likely to produce insomnia when raised to tha!* degree of intensity known as pain ? Pain implies a peculiar e.xcitation of the sensory cortical centres and an awakened consciousness, and its very exist- ence is inimical to sleep. It is not necessary to dwell long on the causes of pain. It maybe peripheral or visceral; may be due to inflammatory states of the nerve centres or their membranes, or to functional disturbances of nerves, contituting neuralgia; to conditions of anaemia or hyperaemia; to inflammation and suppuration; to ul- cerative processes; to the pressure of tumors, exuda- tions, etc. The leading therapeutical indication is to remove the cause. This may be easy of accomplishment, as ■when the pain is from a carious tooth, or an abscess. s ^ ^ ■J to. i i* * * »»'»« .ii^-tf"^ _ 32 — or it may be impossible to meet, as in many cases of locomotor ataxia with douleurs fulgurantes, m the pam of internal. cancer, etc. The pain of migrame offers this peculiarity that it generally yields to the desire for sleep; other forms of neuralgia are apt to be worse at night. Often the causal indication must be kept in abeyance; the first thing to attend to is the inciicatio morbi. A hypodermatic injection of morphine may be imperatively required, and it may be waste of time to attempt to relieve the pain by other remedies. In the insomnia due to cancer, to acute inflammation (pleurisy, pneumonia, peritonitis, pericarditis), abscess, the lightning pains of ataxia, to severe neuralgic at- tacks, it will not always be possible to obtain the relief requisite for sleep without recourse to opium or morphine. It is undeniable, however, that in anti- pyrin, phenacetin, acetanilid, and other of the new analgesics, we may often find good and comparatively harmless substitutes for opium or morphine. Thus there is a large amount of testimony to the benefits obtained from phenacetin, antipyrin, etc., in the pams of acute rheumatism, facial neuralgia, hemicrania, lumbago and pleurordynia, neuritis, zona, sciatica, and even in the douleurs fulgurantes of tabes. The analgesic action of belladonna, cannabis Indica, hyoscyamus, is sometimes sought in insomnia due to pain; not much reliance, however, can be placed on any narcotic but opium. There will always be one objection agamst opium r ses of e pain offers desire to be lust be is the )rphine ■aste of medies, imation ibscess, Igic at- ain the pium or in anti- he new ratively , Thus benefits he pains licrania, sciatica, cannabis nsomnia can be St opium — 33 — when used for hypnotic intent; it is not a good hyp- notic, as it produces and long keeps up, in many per- sons, a cerebral excitation incompatible with sleep; hence where other analgesics, as antipyrin, acetanilid, prove to be sufficient to quell the pain, they should always have the preference. 2. /nsomnia due to ovenvork of the brain is the insomnia of cerebral hyperaemia. Prolonged study, constant application to business, literary undertak- ings, speculative enterprises, etc., demanding vigilant thought and entailing much worry and anxiety are fruitful sources of insomnia. At the same time, ex- haustive mental toil may be carried on with impunity provided the hours of sleep be not interfered with; provided also that suitable seasons of relaxation and diversion be snatched during the working hours. It is unremitting mental toil and worry that kills. The theory that during mental work certain dis- tricts of the brain are flushed with blood is consonant with all the experiments and observations whereby we have acquired a knowledge of the physiology of the brain. It is also know., that the blood supply to the brain is controlled by the vaso-motors, and it is a legitimate inference that in the insomnia from mental overwork the blood vessels of the cerebral cortex are overfilled from exhaustion of these nerves, or, what means the same thing, from exhaustion of the tonicity of the blood vessels. Doubtless the age in which we live is peculiar in 3 BBB .»^M .imini»«,.mu - _, ' ^ i jD 4,1,11 - '. '?v » j..' ! i M M I >*.«i Mana- — 35 — c^ine * has traced the causes, effects, and remedies of mental over-pressure in modern life. She lays great stress on the want of gymnastic training in schools, and the numerous unhealthy conditions of our civiliza- tion. The besetting infirmities of the age are " cere- bral anaemia " and " nervous exhaustion." The causes are complex, but they all act similarly, " by producing irregularities in the vascular sphere," /. e., by impair- ing the tonus of the cerebral blood-vessels. " When once the tone of the blood-vessels is lost, when their nutrition is disturbed and the circulation no longer responds to the exigencies of normal life, phenomena of dissolution begin to manifest themselves." Doubt- less Mile. Manac^ine is right in regarding the stimu- lants (tea, coffee, alcohol, tobacco, etc.) in which the people of this age are prone to indulge as being large factors in producing a toneless condition of the cere- bral vessels, but exhaustion by overwork, and especi- ally by worry, are doubtless still more important factors. With regard to the influence of physical over- work in producing insomnia, the explanation may not be so easy. A state of great physical fatigue is cer- tainly favorable to sleep, but over-fatigue is attended with a painful aching of the muscles, which causes an excitation of the cerebrum. Germain S^e adds as a factor the accumulation of the products of denu- *" Le Surmenage Mentaledans le Civilisation Moderne," Paris, i8go. X ■ M*M _ 36- trition, which being in excess in the blood, act as toxic agents and" excite the cerebrum. With regard to the treatment of insomnia by mental overwork, the indicatio causalis first demands attention. The student must curtail his studies, his hours of work; must be content with a less honorable standing in his classes, must take more rest, more recreation, more exercise. These injunctions are especially imperative when the subject of insomnia is a growing youth; in fact, the appearance of insomnia, or dreamy, restless, unrefreshing sleep m children should generally be the signal for removing them for a time from school and prescribing suitable sports and recreations, a course of gymnastics, and other measures calculated to invigorate, subdue rest- lessness, and procure natural sleep. Dr Dukes, of Rugby, is of the opinion that boys under ten years of age require eleven hours sleep and those under thirteen need ten hours and a half set apart for this purpose.* The same causal indications are applicable to the man of business, who, when once he finds himself unable to sleep of nights is on a downward scale, which will end in ruin unless he can pause and reform lis habits. Even then he will realize the /a«/» descensus Averni, while to retrace his steps-/«. /a&or, hoc opus est. One of the most annoying forms of in- somnia among business men is this: The patient goes ♦Quoted by Macfarlane, loc. cit. ill ict a? ia by Hands 8S, his orable more IS are iumnia ice of leep in moving ;uitable cs, and lie rest- at boys i' sleep, i a half able to himself ■d scale, 1 reform B facilis hie labor, is of in- ent goes -r*x\ — 37 — to bed and falls asleep to wake up in an hour or two with his mind full of the care and worry of the day, and then there is no more sleep all night long; or if sleep returns after several hours of wakefulness, it is a disturbed, dreamy sleep from which he awakes tired, jaded, and miserable. This kind of insomnia is called by Germain S^e true insomnia. The following table is modified by Macfarlane from Friedlander, and contains his views as to the best division to be made of the twenty-four hours in the matter of rest, work, and sleep : APE. HOURS FOR Exercise. Work. Leisure. ■ Sleep. 7 7 3 4 lo 8 6 4 4 10 9 5 5 4 • 10 10 5 6 4 9 II 5 6 4 9 IS 5 6 4 9 13 4 7 4 9 14 4 8 3 9 »5 4 8 3 9 Besides making the endeavor to pursue a course of life the reverse of that which he has been pursuing, the victim of insomnia from overwork will naturally for a time seek relief from some of the safer hypnot- ics, preeminently among which is sulphonal. From nnfiiriiwiiiiiiiriii Jif - 38 - my own experience, I would say that sulphonal is the king of hypnotics, conferring a sleep which is the most like natural sleep with the least after-discomfort. Nor does the continued use of this drug seem to be attended with real harm— at least with any such evils as follow the prolonged use of morphine or chloral. I know one business man who has been in the habit of taking ten grains of sulphonal every night for six months, nor has he yet found it necessary to increase the dose. Chloral was formerly regarded as the ideal hyp- notic, and in many cases it produces a sound refresh- ing sleep of several hours. The late Dr. J. R. Nichols, of Haverhill, told me in 1873 that chloral had been a boon to him— that one dose of ten grains taken at bed time would quite banish his insomnia for a whole week, the effect not wearing away for several nights. In 'comparatively tractable cases of insomnia from overwork, a tablespoonful or two of old whisky at bed time will often work like a charm; sleep speedily ensues and lasts many hours; with many, a glass of bitter ale has a still better effect. As natural sleep may be hypothetically regarded as brought about by certain toxic products of exercise^ and as muscular exercise is known to be more pro- ductive of these hypnogenous substances than intel- lectual, so the medical adviser may very properly urge his patient to perform some severe muscular work 01 Iftifmi'aliiiiii IMIWKtiiWiaWlW is the is the )mfort. to be h evils ihloral. e habit for six icrease il hyp- efresh- J. R. chloral 1 grains isomnia way for isomnia whisky ; sleep many, a egarded ixercise^ )re pro- an intel- srly urge ar work — 39 — before going to bed— a long walk in the open air, dumb-bell exercise, etc. Many a victim of insomnia has found a remedy for his' infirmity in garden work, joinery, wood-sawing, or even in such active sports as base-ball and lawn-tennis. Sleep is much more certain to follow muscle-tire than brain-tire. As the leading indication is to induce that cere- bral torpor which is the necessary antecedent of sleep, it is well to advise the insomnic patient to avoid all cerebral excitants in the evening. He should not in- dulge in tea, coffee, tobacco or spirits, with the excep- tion, perhaps, of an occasional draught of old whisky on going to bed, as above stated; he should refrain from reading, writing, and other mental labor. Even novel reading (recommended by some as a diversion) is of questionable utility; listening to the reading of a dull book is a much more rational expedient. If one can succeed in breaking the train of thought by fixing the attention on any series of monotonous souhds (the singing of crickets, the roar of a distant waterfall, the whistling ot the wind down the'chimney, etc.), he will often before he is aware of it be caught in the toils of Somnus. The sleep state being one in which the cerebral arterioles are contracted, with lessened circulation in the encephalon, the artificial production of this con- dition would seem to be favorable to sleep, and much account has been made of cold applications to the head made with the intent to exsanguinate the brain; ■: 'i LH.JJLUIJ . .tw ff^iKrtMiiiaiw MIMMVMM^W- ill — 40 — hot foot baths to determine blood from the head, and the general warm bath as a powerful means of deriva- tion. Hammond states that he has seen the applica- tion of the cold douche to the heads of refractory prisoners bring on a deep sleep. I believe, however, that cold to the head, as a means of provoking sleep, oftener fails than succeeds, and I have even known it to aggravate the insomnia. Of more efficacy is bath- ing the trunk and limbs with cold water, followed by a brisk rubbing to induce a reactionary glow; stand- ing naked on the cold floor a few minutes, then a hasty rub-down with a coarse towel or flesh-brush, often does good in the same way by derivation. The warm bath or wet-pack may be resorted to in desper- ate cases. Macfarlane gives some excellent hints for the rational treatment of this kind of insomnia. To re- store tone to the vaso-motor system, he advises a combination of nux vomica with hydrobromic acid. 9 Acid hydrobromic 3 vi. Tinct. nucis vom 3 ii. Aquam ad- 5 vi. M. Sig.— A tablespoonful in a wineglassful of water twice a day, before meals. To calm and strengthen the nervous centres, the patient should cultivate the habit of going to bed at a regular hour, and of rising with punctuality. The bed-room should be well ventilated, and the head raised upon a high pillow. The hours for eating and i If !| •mm , and eriva- plica- ictory vever, sleep, 3wn it bath- ed by stand- :hen a brush, The lesper- ■>T the ro re- nses a cid. f water es, the bed at , The e head ng and — 4t — drinking must be laid down with precision, the diet being adapted to the temperament and digestive powers, the last meal being taken some three hours before going to bed. The plethoric, whose vascular tension is high, do best without alcohol in any form, while the anaemic are often benefited by a moderate quantity taken with the food to promote digestion and a " night-cap " of brandy or whisky with warm water and sugar. On account of its stimulant and derivative action, turpentine in thirty-drop doses at bed-time is a powerful aid to sleep. It is easily taken in capsules. If it is found necessary to resort to hypnotics, the bromides are especially serviceable, the only contra-indication being great anaemia. Mac- farlane prefers the bromide of lithium, as it contains a half more bromine than the potassium bromide. Its dose is from lo to 20 grains. The bromides of so- dium and potassium, which are in most frequent use in this country, are given in doses of one-half to one drachm. They are best prescribed in syrup and water, a full dose being taken a few hours before bed-time and another at bed-time. If these doses do not succeed in procuring sleep, they may be asso- ciated with ergot of rye and digitalis, both of which are stimulants of the vaso-motor centres. Macfar- . lane's favorite prescription is as follows:* ^Macfarlane, Insomnia and its Therapeutics, page 88. " . — 4a — Q Bromidi llthli «^- «'• F.xt. cfRot liqulil 5 »• Tinct. digitalis '^'"'• Aqu« chloroformi 5 xv. M. siR.— Take one-half two hour* before going to bea and the other half at bed-time. 3, To the third group belongs insomnia con- nected with a disordered state of one or mot ■ organs. {a) Morbid States of the Brain.-Thcs^ cause insomnia by interfering with cerebral nutrition. The changes taking place in the brain during cerebral hyperamia are more of a katabolic than of an anabo- lic character, i>, are characterized by excessive waste rather than normal repair, hence are antagonistic to conditions which produce sleep. This hypersem.a may be active or passive. Active hyperemia is due to overwork of brain (see preceding paragraph), to alcohol or other toxic agents, to arterial degeneration, to exposure to intense heat, the irritation of teethinji, to tubercles, syphilis, etc. The passive kind is gene- rally due to organic diseases of the heart and lungs. Active cerebral hyperaemia is characterized by flush- ing of the face, throbbing of the temporals, conges- tion of the retina, suffusion of the conjunctiva, irrita- tability, restlessness, giddiness, confusion of ideas, loss of memory, etc. In passive congestion, stupor is the most marked symptom. In the active form, the indication is to lessen the quantitv of blood in the brain; in the passive form, to increase the force of the circulation and lessen the tV 10 bed con- •gans. cause The rebral inabo- waste Stic to raemia is due )h), to ration, ething, ! gene- lungs. f flush- ;onges- , irrita- ideas, ;upor is isen the [orm, to sen the 1 — 43 — venous supply. The first indication is fulfil led by cold to the head, saline purgatives, leeches to the temples or outside the nose, mustard to the epigas- trium, the constant galvanic current for two minutes— the positive pole being over the sympathetic, the nega- tive on the nucha (Hammond). In this form of in- somnia, it is necessary to prescribe the bromides, or, these failing, chloral. In the passive kind, diuretics, saline purgatives, and opiates rather than bromides are called for. Alcohol, which is contra-indicated in active, is of great use in passive hypertemia. The cerebral hyperoemia with which wc are most familiar either soon ends in recovery — the patient gving up his severe tasks or his excesses in eating and drinking, and living more rationally— or it is the ava/U coureur of some severe and generally incurable brain affection. I have seen children suffer from flushed, hot head, vertigo, headache, irritability, peevishness (i.e., the symptom— cortege of hyperemia) for weeks before becoming the victims of hydrocephalus. I have seen it the precursor of apoplexy in the aged, being the first manifestation of atheromatous degene- ration. It may be the first symptom of general paralysis of the insane (periencephalitis). If simple hyperaemia be inimical to sleep, h fortiori inflammatory states of the cerebrum or its membranes must be so. The insomnia of acute meningitis, of periencephalitis, of cerebritis, is sufficiently familiar, '*Jfc rf ii. i « «» .-.^. ■^ifWif^hrif y — 44 — and even when the usual restlessness, agitation and delirium give place to the .quiescence of coma, it is the repose of paralysis and death, rather than refreshing sleep, that is witnessed. In tuberculous meningitis, among the first symp- tom.s of the hyperemia which precedes the developed disease, is a restless, dreamy sleep, which next gives place to complete insomnia. In the treatment of sleeplessness due to inflam- matory conditions of the cerebrum, the general prin- ciples laid down under cerebral hyperemia are to be carried out. Full doses of chloral with bromides sometimes give brief seasons of quiet, if not product- ive of real sleep. I have found a combination of sulphonal with antipyrin more or less efficacious in the restlessness and delirium of meningitis. 3 Sulphonal Antipyrin Sa gr. x. M. Sig.— One powder. To be repeated every hour till sleep or quiet is produced. This combination is especially indicated in hyperpyrexia. Cerebral tumors are a cause of sleeplessness, both from the inflammation which they excite and the pain which is a constant attendant. Anaemia of the brain, whether produced by ex- cessive loss of blood, profuse discharges from the intestines, from chronic abscesses, etc., by insufficient food, by exhausting diseases or other causes, gives ^-'"•■"■^'•— T-rrrn igitation )f coma, ler than St symp- ;veloped xt gives ) inflam- ;ral prin- ire to be bromides product- lation of acious in y hour till icated in ness, botli i the pain ed by ex- from the nsufficient ises, gives ^'^ — 45 — rise to sleeplessness or imperfect, dreamy sleep. The explanation of this insomnia is that in the anemic there is not only an exsanguinous state of the brain, but a vice of nutrition resulting from insufficiency of arterial blood. Germain See adds another cause which applies to certain cases; the local oligiemias are generally due to emboli or obliterations of arteri- oles, and the failure of nutrition goes on rapidly to ramollissement, the initial symptoms of which are always those of excitation. The following case illustrates the general treatment of sleeplessness due to anaemia: Mrs. M. B.; aged fifty; mother of eight children; con- sulted me in May, 1883, for a uterine trouble whose principal manifestation was excessive haemorrhages. I found her weak and anaemic, obliged to keep her bed the most of the time. The heart's action was feeble; there was a systolic (anaemic) bruit; exertion, excitement, even ordinary food, would often bring on palpitations; walking or an attempt to work caused breathlessness. The face was frequently flushed (paresis of the vaso-niotors^; there were ringing noises in the ears, flashes of light before the eyes, and other perversions of the special senses; it required but little exercise of the eyes to tire them— reading, sewing, etc., after a few minutes became painful. There was an almost constant headache, with mental enfeeblement, and inability to apply the mind more than a few minutes to any subject. The insomnia was marked. I found a uterine polypus to be the cause of the profuse haemorrhages; this I removed by an ecraseur, thus arresting the loss of blood, but Mrs. B. suffered for months from the anaemic symptoms just mentioned. The distressing insom- [ ■ ■..i.ijii.j.'a i _ 46 - nia would only yield to opiates with draughts of whisky or bitter ale. A hypodermic of morphine always gave most relief but this was seldom resorted to through fear of forming the morphine habit. A mixture of equal parts of red laven- der and ammoniated tincture of valerian, dose a teaspoonful in water, often had a marked soothing effect Chloral was avoided; when taken formerly while Mrs. B. was under the care of another physician it had always produced excitement rather than quiet. A cordial frequently prescribed consisted of compound tincture of lavender, one drachm; tincture of valerian, one drachm; deodorized laudanum, twenty drops; this was taken at bedtime. After a few weeks had gone by, I omitted opiates altogether, giving °">y/''«'7''f J,;^,^!" at night; this also was eventually abandoned, a little beef tea or fluid beef being given instead. A course of physical exercise had been commenced-walks, rides in the open air. parlor gymnastics which powerfully promoted natural sleep. Throughout the treatment, nutrients were admin.stereQ day and night in as large quantities as could be assimilated; thus always between meals a cup of beef tea or «f -•*;«> •»'»'' with bovinine was given; an egg-nog was taken the first thing in the morning and a cup of milk with Mell.n s food and a spoonful of bovinine at midnight. Eventually the recovery was as complete as could bo desired. I have on record numerous cases of a similar kind where the distressing insomnia brought on by long-continued discharges has yielded to suppression of the cause and the plentiful administration of stim- ulants and nutrients. . The cerebral anaemia accompanying aortic-val- vular disease finds expression in an obstinate insomnia, in frequent attacks of vertigo, in intellectual disturb- ances and in a profound irritability which has been 11 t^MMWBaaawaBWfe-^^wp'^ whisky e most orming laven- poonful ral was der the itement )nsisted cture of ' drops; one by, y or ale tie beef physical pen air, al sleep. ;red day ed; thus rm milk the first in's food lally the similar t on by pression if stim- •rtic-val- isomnia, disturb- las been — 47 — •described under the flame of irritable weakness. A similar line of treatment to that above indicated is needed, but the main reliance must be in opium or hypodermic morphine, in alcoholic stimulants, and in nitro-glycerin. It is hard to draw the line between anaemia and passive congestion, but it must be re- membered that in aortic disease the brain is in- sufficiently supplied with arterial blood, and hence is anaemic. It matters not if the cerebral substance is charged with venous blood, unless the subject is sup- plied with plenty of arterial blood and there is a free circulation, the condition of the cortical cells is none the less one of anaemia. (i) Degeneration of the cerebral arteries is a cause •of haemorrhage or softening, and one of its common symptoms is troublesome dreaming or insomnia, though some cases are characterized by morbid som- nolence. Dreaming in advanced life is generally regarded as suggestive of pending apoplexy (Mac- farlane). In the treatment of this kind of insomnia, the general principles applicable to cerebral anaemia are to be observed. Macfarlane speaks well of a mixture of henbane and camphor, and of sumbul and hops,* and professes to have obtained good -esults *His formula are as follows: 9 Spts. chloroform |ss, Tinct. sumbul, J gs. Tinct. lupuli 31. M. Sig. — Two teaspoonfuls in water every hour till -sleep is procured. ■I ■;: t f'i i • ii'i li^ . -48- 9 Tinct. digitalis •' ^^''• Tinct. sumbul ^J; Tinct. lupuli 5 ')• Aquam ad ' '5- M. Sig.— Take one-half at bedtime in water, and repeat in two hours if required. from sponging the nape of the neck with hot water and from the application of mustard plasters for a few minutes over the epigastric region or the upper part of the spine. (mitted e grain sible at use an maybe e tubes phlne, ■ft is one to — 53 — are emptied, a dose of urethan (gr. xxx) of paralde- hyd ( 3 j.), or even a Dover's powder (gr. x) may be administered. The general principles of treatment of neurosal dyspnoea are the same, whatever name may be appli- cable to the particular manifestation. Antispasmodics and anaesthetics are always indicated; in attacks of spasmodic asthma and laryngismus stridulus, a few drops of the anaesthetic mixture A. C. E., inhaled from a sponge or towel, always give relief. ' ;^lcohol ,p^„ J'!'"™^"^'" 2 parts. Ether „ . Mix. 3parts. Nitrate of amyl, gtt. iii, inhaled from the palm of the hand frequently gives instant relief; chl, ral hydrate with potassium bromide in full doses is slower m .ts action, but more permanently reduces inordi nate reflex excitability. With some patients hypo- dermic morphia is a necessity. In laryngismus stridu- lus or spurious croup an emetic is generally sufficient speedily to relax the spasmodically tightened air- tubes Of all emetics the turpeth mineral is the one which in my practice has yielded the most satisfactory results. Parke, Davis & Co. make tablets of this salt containing two grains, which are very convenient. A more frequent cause of insomnia is cough I have not space to review the various pathologi- cal conditions productive of cough and supplement \r — 54 — such review by therapeutical hints. The most that I can do is to touch upon a few points of practical im portance in connection with the relation ( < insomnia to cough. u .• ♦ In the early stages of consumption, the patient may be tormented with a teasing cough which is for the most part dry. Every physician is familiar with such cases. The physical signs are obscure; at the most there is a slight dulness under one or both clavi- cles, but there is a little febrile movement every day with failure of appetite and strength. This cough indicates an irritation of the respiratory organs by bacilli and tubercles, and is not alleviated by the ordinary expectorants. Here calmatives and seda- tives with counter irritation do little or no good. A pill of codeia, one grain, at bedtime will sometimes effectively allay irritation and produce sleep. Chloral, bromide of potassium, cannabis Indica, hyoscyamus and belladonna may all be tried, with doubtless sonie alleviation at first; while nothing will so promptly relieve and so thoroughly as morphine. The latter medicament may be combined with dilute hydrocyanic acid, chloroform, and tolu, as follows: 9 Chloroform g". xvj. Morph. sulph •' 8'- »)• Acid hydrocyanic, dilute gtt. xxj. Syrup tolu 5 ')• M. Sig.-A teaspoonful at bedtime and at midnight when the cough is troublesome. \r :hat I i\ im jmnia atient is for r with at the clavi- ry day cough ins by by the i seda- od. A letimes Chloral, cyamua is some romptly i latter ocyanic midnight — 55 - A spray of liquid albolene and menthol used by a hand atomizer will sometimes allay the tickling in the upper air passages which seems to be the point of departure of the cough. . 3 Liquid vaseline t: Menthol ,' J S8. M. For the spray-producer, Such patients are often benefited by full doses of Rock and Rye " on going to bed. I have seen good results from small blisters ap- plied to the upper part of the chest, or from painting the upper thorax with tincture of iodine till the skin begms to peel. Of the various cough troches, there is one made by Parke, Davis & Co. and other of the pharmacists, contam.ng a little cubebs with extract of licorice which has given satisfaction in my practice. I have seen somewhere the advice to paint the throat with liquor cocaine; this expedient I have never tried, but I should think that it might produce some temporary alleviation, ■' In the later stages of phthisis when expectora- tion IS profuse, it is not always safe to arrest the cough by narcotics given at bed-time; there is so much secretion from the vomicae and inflamed mucous membrane that frequent fits of coughing are neces- sary to remove muco-pus and prevent asphyxia In such cases an emetic of sulphate of zinc sometimes / -56 - has a salutary effect in clearing the bronchi and per- mitting a few hours' quiet sleep. I have found bella- donna serviceable in restraining secretion; this may be prescribed in the form of a pill of atropine, jU^\\ grain, night and morning. Senega, turpentine, tar, sulphur, and carbonate of ammonia have a reputation when there is copious expectoration, and the spray of ipecacuanha wine, as recommended by Murrel, may be tried to advantage. The syrup of tar, with carbonate of ammonia, and the Compound Pine Expectorant of P., D. & Co., are preparations which have become popular. The catarrh is a product of bronchial congestion provoked and kept up by the presence of tubercles, and cannot be much modified while active tuberculiza- tion exists. In the teasing, paroxysmal cough of pertussis, full doses of antipyrin or acetanilid have proved of great efficacy. Q Acetanilid 3»8. Divide in cliart, No. vi. Sig. Give one powder every four hours night and day, and keep up the treatment for a week or even a fortnight. For a child of lo years, the five-grain tablets are very convenient. The one- grain tablets (one every 4 hours) may be prescribed for infants. Antipyrin, phenacetin, or exalgin in equivalent doses may be given instead of acetanilid. I have given infants two years old grain doses of antipyrin / nd per- l bella- lis may ne, tar, utation pray of el, may imonia, . & Co., igestion bercles, srculiza- ertussis, oved of and day, tnlght. blets are • every 4 >juivalent I have antipyrin — 57 — «very two hours in whoopintf-cough, and seen the paroxysms markedly diminish in fredable inten- sUy These purely mechanical causes are: Disten- sfon of the stomach, and the forcing upward of the dia- phragm which notably diminish the respiratory area, Sy'irsufficient for h.matosis. Add, as acce^ory causes bronchial catarrh and frequent concomitant Tphysema, and you have the entire -t « ^gy o ^[^^^ oxysmal dyspnoea linked to affections o the hea^t The dyspnoea due to dilatation of the heart, ac cording to Professor S6e, is ■ no.t always continuous though there are paroxys: :. .acerbations, and that due to fatty degeneration is „«,• ^.«.m," presenting som^^mes r'eal paroxysms of distress and suffocation at the same time that careful examination of the Igs does not reveal any morbid signs; there is not. the least acceleration of the breathing, or any appar- -^S;r:rS^^-espiratory plexuses •Maladies du Coeur. etc., 1883. p. 30. -*i»^,-.>;^^,,,,^^ ^ in the mation as sat- rhich is 5lf gen- [ by de- bts first 1 toward respira- e inten- Disten- tbe dia- Dry area, iccessory comitant jr of par- beart." * lieart, ac- ntinuous, and tbat iresenting uffocation m of tbe ere is not iny appar- y plexuses -63- ^f nerves, as Peter, Trousseau, etc., teach, has been beheved to have some share in the respiratory dis- tress; and the magical relief conferred by a hypodermic injection of morphine or other calmative before even the pulmonary congestion or oedema is mitigated has been cited in confirmation of this doctrine Henri Huchard has of late written much and ucidly on the paroxysmal dyspnoea of aortic regurgi- ation and aortitis. The dyspnoea of ao.litis is, liL that of mitral disease, at the first a dyspnoea of effort coming on during rapid walking, lifting, etc • it is paroxysmal and often intense, rarely spontaneous Later on in the disease the attacks come on in the night time, often reproducing themselves with great ST'h'" '""V^" P'^'^"' '^ obliged to pas? the night in his arm-chair. Huchard regards this " aortic pseudo-asthma " as due to arterial hypertension which augments by the recumbent posture and under the nfluence of sleep, as also by walking, and under the influence of movement." The cause of the dyspnoea .s " mechanical," as Professor S^e taught, butToHn the same sense as he taught, for in Huchard's view we have to do with "peripheral resistances," and "spasm of the blood-vessels. If, says Huchard distension of the stomach has anything to do with th^ paroxysmal dyspnoea, abstinence from the evening meal or a very frugal repast ought to keep the patient free from his nocturnal attack; this is, however, sure to come, whether he eat little or much. If — 64 - This dyspnoea, Huchard amrms, is also of toxic origin. Experiments like the following seem to demonstrate this: He injects under the sVm of a guinea-pig normal urine; death ensues m several days He injects the same quantity of urme from a woman affected with arterio-sclerosis of the heart and aorta, and the guinea-pig scarcely suffers any detr.^ ment. This proves, he says, that the blood of h.s patient was poisoned by the products of d'sassimilar tion which the kidneys, already impermeable by the fact of the aortitis and a commencing arteno-sclero- sis could but incompletely eliminate. These v.ews, he' urges, are not simply theoretical, they are con- firmed by practice. In fact, blood-letting, purgatives, nitrite of amyl, nitro-glycerin, etc., which depress arterial tension, contribute in large measure to dimin- ish the intensity of the attacks. But nothing works so well as an exclusive milk diet, which acts marvel- ously in combating these attacks of aortic dyspnoea, often keeping them completely in abeyance. Now milk diet, according to Huchard, acts m two ways and meets two indications: First, by the abundant diuresis which it provokes, the milk diminishes the arterial tension and promptly eliminates the toxic principles contained in the blood; then it acts by yir- tue of its very harmlessness and because it does not contribute to the blood in circulation, like other ah- ments, and meat in particular, materials which, not being completely eliminated, become rapidly toxic to the economy. [ toxic em to n of a several from a art and y detri- of his ssimilar by the )-sclero- » views, ire con- rgatives, depress dimin- ig works marvel- lyspnoea, B. Now wo ways abundant ishes the :he toxic ts by vir- does not other ali- rhich, not y toxic tO' - 6s _ INSOMNIA OF GASTRO-INTESTINAL ORIGIN. Writers have dwelt much on the cerebral hyoer- -rn.a attending disordered states of the stom'a'ch Ihat mdigestion causes insomnia by exciting the cerebrum is a matter of common experience. Vith many persons, even, the active exercise of digestion 1 p' Suet '"h ''ff ' '^ '"^^""P^^'^'^ ^^^ s^ep. Such md.viduals refrain from lunching or par- takmg of a hearty meal before going to bed CerfaTn valetudmarians cannot drink a glasf of milk or eat a biscuit late in the evening without atoning for ^le md.scret.on by hours of sleeplessness Such inhibition of the cerebrum by the stomach s of frequent experience in the nursery. The fim thmg the physician thinks of when consulted S reference to insomnia in a young child is the proTa b.htyof .nd.gest.on as the main factor' in the case tkvld : '"''? °' ^'^ '°°^' "^^^ ^b-^ the quan." At[;nH ^ .;' "^^ '°"^'''°" °f '^' d'«««t've organs ? Attention to these points, in the absence of objective s.gns o .mportance, as fever, will generally pi one on the track of the cause and suggest the remedy «nH .r *"^'f '*.'°" ™ay be functional or organic Hkelv to'bl ''"' '°"''"°"^ '' '"^^ ^^°™-' are likely to be accompan.ed by insomnia. Structural diseases, as gastritis, ulcer, gastrectasis, cancer. cauTe skeplessness, both by the pain and discomfort and the consequences of indigestion which attend them — 66 — „rlc« are often formed by the mal-elaborat.on of ^poTs; .Use irritate .h. nervous centres and n'.t*;::trotre?rpeTof.He<,„^^^^^^^^^^^ ^r he Bushing of the stomach-at the expense of the to the fl"s»^'"g ° necessary condition of its func- ZTme^^no^Z^Zrs without attracting tion. Uigesuon j ^^^^^^ ^^ ^n the conscousness and her .s ^^^^^^ ^ ^^^^^^ 'TLlTrweUas'in carnivorous animals. It is ""ot trueThat durUig sleep the digestive functions are :■! „^, the .-rnrr^srr-^'h": :r^^nd in" X'LinL, so accurate .s • Insomnia and its Therapeutics, p. iQ^- ion t» ormal ed by jmach g the Toxic ion of s and >n. In arterial 3 sleep. I, espe- ributed B of the ts func- tracting why on I hearty is. It is tions are ive said: ;heir act- le move- :, if not with an curate as - 67 _ tiT/r''".' I^' ''"""''^ ^"^ '"^^«""«« continue he,r function dunng sleep, though with lessened act- ZJr. '^%*^"«"«"«.^'-« "ot suspended, the unstriped muscular fibre continues a constant though dimin- .shed action; the spinal cord even seems prfternar. ally active the inhibiting restraint of the cerebrum being withdrawn. In reality, in sleep all the essential functions continue to be exercised. Those most indispensable to life, circulation, respiration, diges .on. etc., are performed as during the waking per bd fo'Tv r'' ''T^'^''^- ^''"'' '''' ""'''' belts more slowly during sleep. " J^u/sus in somno parvi Ian- gmd, ran;' says Galen. With the retardafion ^f the circulation, there is diminished activity of the secret ing glands (gastric, intestinal, pancreatic, etc.), but in healthy persons these organs are adequate to the work imposed upon them, as is proved by the fact that mul- titudes can eat a full meal-on going to bed, sleep soundly, and be ready for another meal on awak ng' Nor can It be said that the peristalsis of the gastro mtestinal canal ceases during sleep, any more than the contraction of other unstriped muscles (the arteri- oles, for instance), which are not under the will Germain S^e, who refers most cases of digestive insomnia to d fficulties attending the secondaryTr „! lane) hus defines this kind of insomnia: "Intestinal digestion generally begins three hours after a la and ends in seven or eight hours. The patient, we _ 68 — . .. f. o'clock P.M. At 10 o'clock ho will MppoM, sups at '<>>='''';"; (,„ midnight. goes to l,ed,b„. 77 '7Xl°ic intestinal diges- r;:::iro:"ertri,«ni.Hca, the patient -« ;c^t.at . - 'i- -i'r»;:« - ■- insomnia, let •'•' P"^' ^t / JcLk in the after- ronrdVe':mr<.:hath/wiiuotosi«patt.e ^-!^r;Ln,en.;n;-ni^^^^^^^^^^^^^ irrrtH. --- "' - .o^acn. ^.^- tines, and the ^''^^^1°'f'Z^,^y committed as to (,) Errors are most '"^»f"^, ^e competent to ,„antuy, -r-'f'f ^:,rSnrpl 0° Simculty. dispose of a certain bulk «''»° J" ,h, stomach; while an excess 7»«J„^:;X und" ""'"°'""'' decomposition and ««nl=nce se .^ microblc rule-, pntrid ""^ J"' " ..bilious" condi- ,nd ptomaines are f-""','''". has experienced a. tion supervenes, such js every o ^^^^ „^ times. " is ''"""''^""ttrtd by excessive eat- ?;trCa:^nr Cm^^. -^^^^^^^ i^ri:rbSS strHiU ^not let the brain rest. — ■ ,,r Second edition. Paris, 1883. • Des Dyspepsjes, etc. seconu sas***''-^*" A , ck he night, diges- latient of the at the after- at the jestion, * taken I, intes- :d as to letent to ifficulty, itomach; molested :ic gases " condi- ienced at udes are ssive eat- lly comes and over- 3t let the rl», 1883. - 69 ~ The proper remedy for sleeplessness arising from this cause is apparent; it is to curtail the daily rations to the physiological standard. The necessity of eat- ing slowly and deliberately with thorough mastication of the food, IS apparent; those that " bolt " their food are sure to eat to excess. (2) Food of poor or insufficient quality produces anaemia and starvation of vital organs, including the cerebrum, and hence engenders insomnia. Physicians cannot too much insist on the necessity of a full diet that IS, of an adequate admixture in the daily fare of albuminoids, fats, and carbo-hydrates. Food of in- digestible quality produces essentially the same evils as excessive alimentation. Under this head may be included food improperly or insufficiently cooked (good cookery under our civilization has become in- dispensable to healthy digestion), and foods that most persons of sedentary habits find hard to digest as unripe fruit, pastries, hot bread, fried pork, confec- tionery. Of course, butcher's meats should be selected that are tender and juicy, and in the light of recent discoveries (Gautier, Selmi, etc.), it is doubtful if meat or game that has become high {faisandd) is fit tor food. Foods of themselves sufficiently digestible may become indigestible if too many kinds are eaten at a meal. But this brings us again to the evils of excess- ive eating. It need not be repeated that he who would sleep ■/ — 70 — well must avoid those articles of diet which have been found to be indigestible, or should indulge .n them sparingly. Much depends, of course, on the muscular work done. Horace speaks of the Jura ilia me^sorum The hay-makers on the salt marshes need food hard of digestion, that is, food that is :r/tw/y digested, yield- ing up force for many hours; food that m common . parlance "stays by," such as baked beans and pork» boiled beef and cabbage, and mince p>e. Such per- sons sleep well, despite their hearty fare; it is especi- ally the "brain-workers," the men of sedentary habits^ that are upset by a rich diet. • (i) A healthy digestion presupposes a healthy state of the stomach, intestines, and accessory organs, and any derangement of these viscera must be cor- rected by suitable medicinal and dietetic means before normal sleep can be enjoyed. To enter on a consideration of all these derange- ments would take more space than we have at our command. The hygienic treatment of indigestion in- cludes dieting, exercise, recreation, cold bathing etc. The cold shower-bath in the morning is sometimes a powerful aid to digestion. Exercise promotes a more vigorous circulation and favors peristalsis and chymi- fication; equally necessary are change of *cene, diver- sions, and the cultivation of a contented, cheerful frame of mind. Among the medicinal means are: (i) Such as favor gastric digestion, namely, alka- — 71 — Ohi.'^f'"' '"'"'\""' '''''^' ^'"^ I'^'l'-". after, value. Small doses of strychnine are u.seful (a) For ac.c!(iyspei).sia full doses of bicarbonate of soda are naturally ind.cated. Profe.ssor S6e ad V. es dyspepfcs with excess of acid secretion to take a drachm of b.carbonate of .soda in hot water on go .ng to bed. It .s certain that in certain morbid states of he stomach and intestines, whether due to " A^ s da^if '; r .'V''' "^ '""-«' ^he beneficial sedative effects of alkalies are pronounced. (3) Constipation is another recognized cause of insomnia, whether by the reflex irritatfon of re ai ,ed TZTco/ ^''^^^^"'-- -^-^ f-q-ntiy attrd a loaded colon. Here the remedy is obvious; such laxatives as rhubarb, Glauber salts,' cascara. enema a of hot water, etc. Persons who sleep poorly from th.s cause often find a hot water enema on going to bed a sovereign remedy. ^ fif th?'" T^^"^ ^"«^*''"'"' * ^°^P'd "^«'-. '« at fault (.f this can be determined), of course a blue pill a dicLl'"""^™*" "' P^^^P'^y"'" *«"'d seem to be'in There is an acidity of the stomach which depends smo'n ofT' f ' '""^"^^' ''^ P^"'^-'^ °^ ^-oCo- s.t.on of starches or sugars in the food. In these cases, washing out the stomach by means of emet!;I and copious draughts of warm water every nigrtfor three or four nights, as Macfarlane recommends •" ' :" _ 7« — often proves very efficacious. The same writer ad- vises ferro-alumen in three-grain doses for pyrosis along with three drops of dilute hydrocyanic acid, and turpentine in ten-drop doses for flatulence, as most effective remedies. j „ Gastralgia and gastrodynia demand anodynes and anti-spasmodics. In the experience of many authorities, a pill of opium, or an equivalent of the deodorized tincture is more efficient in gastralgia. than morphine hypodermically or by mouth. In the treatment of gastric neurasthenia, the fol- lowing therapeutic regulations may be carried out : 1 The patient may take with each meal s grains each of salicylate of bismuth, magnesia, and bicarbon- ate of sodium. , „,» 2. He may take, on going to bed, a dessert- spoonful of compound licorice powder. 3 Every day he may have a cold jet-douche of IS seconds' duration applied along the vertebral col- umn; energetic dry friction with a flesh-brush after the douche. 4 Walks in the open air, muscular exercises (fencing, opposition gymnastics, etc.,) are beneficial ' 5 There should be only two meals a day, the one at lo a.m. and the other at 7 p-m. The diet should consist chiefly of eggs, cereals, green veget- ables and fruits; the eggs to be nearly raw, the starchy foods and vegetables to be thoroughly cooked, the fruits to be stewed. Drinks to be water '•^^, ter ad- pyrosis ;id, and ■s most lodyncs many of the stralgia , the fol- out: 5 grains icarbon- dessert- )uche of ibral col- ish after exercises ineficial. day, the The diet en veget- raw, the loroughly i be water — 73 — or a light white wine with ordinary water; no gaseous waters, no pure wine, no whiskey or other distilled hquors. Such patients often do best on a dry diet* Intestinal indigestion is to be treated mainly by i» w|^ ,ii M^ i r ,fm p i) am imiti-sttiij:^-„ make- ended f the ate or lid be e can- liative ay, or titisep- rogen, lended gives d been made ,ble io ing the or this useful. French se with lerit of left to [leter is- ne and i aloMg tes that der, the is filled — 75 — with the antiseptic solution, is introduced into the mouth of the catheter and the contents injected into the bladder; the solution is then allowed to run out, and more is injected till the water flows off clean and free from mucus. Too much pains cannot be taken to have the catheter always clean and aseptic; obstinate cystitis has been more than once started by the use of a foul catheter. Suppositories of morphia, of opium, of hyoscya- mus, etc., are often advantageous. The following prescription is frequently employed in the Jefferson Medical College Hospital of Philadelphia: 5 Pulv. opii gr. xij. Camphorae gr. xxx. Ext. belladonna gr. iij. Cacao q. s. M. et in suppos. No. vi, divide. S. One each night on retiring. A teaspoonful of the tincture of hyoscyamus at bedtime sometimes proves to be a useful hypnotic in cystitis. The ordinary hypnotics (chloral, sulphonal, paraldehyd, urethan) are of little or no benefit. INSOMNIA FROM GENITAL IRRITATION. In this connection it is necessary to allude to the insomnia which attends genital irrittLion. While excess in venery sometimes causes insomnia by impairing nervous tone, there is another frequent . - 76 - cause in individuals otherwise healthy, viz., contin- ence. Every physician is now and then consulted by vigorous young men who have at some time given loose reins to their passions, and who afterwards m consequence of prolonged continence have trouble- some erections at night which waken them and keep them awake. In such cases, in the event of the physiological satisfaction of an imperative want bemg impracticable, recourse must be had to sedative medi- cines, to anaphrodisiacs. The suppository of camphor and opium (see above) may be given to advantage, or a full dose of chloral, or of bromide, has a great reputation in in- somnia due to genital irritation. It should be given in large doses and followed up for some time. 5 Pot. bromide 5 '^• Tinct. hyoscyatni 5 ss. Mist camph 5 v*^- M. Sig. A tablespoonful three times a day and at bed time. Lupulin, which may be given in drachm doses stirred into a small cup of hot water at bedtime, is of ancient repute, and the same may be said of full doses of camphor. Not much can be said in favor of cold douches to the perineum, which would be likely to aggravate the trouble. The patient should sleep on a hard mattress, not on feathers, and should accustom himself to sleep with very few bedclothes over him. .-*'^i»tu. ;ontm- ted by given rds in ouble- 1 keep of the t being : medi- m (see lose of in in- ; given r and at m doses le, is of [11 doses douches rgravate ■ess, not eep with — 77 — The utility of avoiding romances of a certain character as well as everything else that can stimu- late the sexual passion (and under this head come tobacc3 and alcohol) is sufficiently obvious. INSOMNIA OF TOXIC ORIGIN. The natural effect of alcohol on the cerebral functions is to impair healthful sleep. It excites the cerebrum by increasing the heart's action and the blood-flow, and by directly stimulating the cortical cells concerned in conscious activity. This is the ordinary action of alcohol when taken moderately, the effects of liquors being, as a rule, the less baneful the less impurities they contain, and the nearer they approach by rectification or by age to the type of pure ethyl alcohol. It is possible that the stimulant effect of the alco- hol on the stomach, rendering that organ hyperaemic, may sometimes promote sleep by temporarily ansemi- ating the brain. On the whole, however, alcohol is a most unsatisfactory hypnotic, and the sleep which attends its ingestion is generally brief, and followed by a period of wakefulness later on. It is by no means proved that alcohol in any form ever fulfils the prime requisite of a hypnotic, that of lessening the amount of blood in the brain! The stupor which follows smaU medicinal doses is regarded by many authorities as a minor degree of that narcosis which comes on after excess. Into this _ 78 - narcotism enter as factors the toxic effects of the alcohol on the cerebrum, vasomotor paresis, and tae paralyzing action of blood poisoned by carbonic acid, whose retention is due to interference with the respi- ratory function. Jaillet, moreover, has shown that the blood globule, when impregnated with alcohol, loses the property of transforming all its hemoglobin into oxyhemoglobin; for the oxygen of respiration unites at the same time with the alcohol and the hemoglobin of the corpuscles; in other words, the alcoholized blood becomes too poor in oxygen to pro- perly subserve either the nutrition or function of the cerebral cells. These considerations show how com- plex is the action of alcohol on the brain, and the necessity of caution in prescribing it in derangements of sleep. Certainly the continued use of alcoholic stimulants, even in moderate doses, for hypnotic effect, is likely to defeat the purpose for which the remedy is given, by producing in the end a very ob- stinate insomnia, if we can trust some recent authori- ties- and this it does by inducing a permanent loss of tone in the cerebral blood-vessels, if not by favoring arteriosclerosis. "The effect of alcohol on the brain " says B. W. Richardson, " is to produce and maintain the relaxation of its vessels, to keep them chafed with blood, and so hold back the natural repose Under thi^ divergence from natural life, the sleepless man lies struggling with unruly and uncon- nected trains of thought. . . . The more he tries. i«w«ite**««s*«K^ '■- of the nd fae ic acid, respi- n that ilcohol, jglobin jiration ind the •ds, the to pro- of the >w com- and the gements ilcoholic lypnotic dich the very ob- authori- it loss of favoring on the luce and ep them 5 natural 1 life, the id uncon- ■ he tries, — 79 — the less he succeeds, till the morning dawns " Rich ardson affirms that arterial atheroma is a" frequent consequence of even moderate indulgence in alcoholic beverages and doubtless there is much testimony in support of this contention. As for the effects of Ion? contmued mtemperance, there is no doubt that this is one of the most prolific sources of arterial degenera- tion. Nor .s even beer exempt from harm of the same kmd, and there is warrant for the belief that "the use of beer m many instances produces a species of degener- ation of a^l the organs, profound and deceptive fatty deposits, diminished circulation, conditions of conges- tion and perversion of functional activities; local in- flammations of both liver and kidneys are always present •• Intellectually, a stupor amounting almos to paralysis arrests the reason, changing all the higher faculties into a mere animalism, sensual, selfish, slug- gish, varied only with paroxysms of anger that are senseless and brutal. A writer in the Scientific Amer- ican, who makes this assertion, claims a wide observa- tion of the effects of beer-drinking among the various •civilized nations, vauuus U fh^^lu^^ ^f"' '"'''"'' """ *''*^ ^^'^ t° emphasize «s, that the moderate use of alcohol in any form may produce insomnia by its exciting action on the heart and circulation, and on the cerebral cells; that the use r. H f ^' ^^yP"°''" '"^y- *» the long run, defeat the end for which it is given; and that prolonged, immod- erate indulgence, even in the milder intoxicant bever- ,,,.^;:>: _ 80 — ages, may produce grave cerebral disturbances and such as are incompatible with healthful sleep. The remedy for alcoholic insomnia is that ot ai- coholism in general-the most complete abstinence from the toxic cause. Prolonged mental rest, the natural vaso-motor tonics, out-door air, massage, in- vigorating exercise, cold bathing, and perhaps sea- bathing, are indicated, and a nutritious diet adapted to the enfeebled state of the digestive organs. These patients are often benefited by a prolonged course of strychnia. One-thirtieth of a grain may be given three times a day, or ten drops tincture of nux voni- ica, just before meals. Hypnotics will be temporarily needed-chloral or paraldehyd. The combination of twenty grains of chloral with twenty drops of tincture of capsicum, in two fluid ounces of chloroform water. is a good one. Physicians are seldom called upon to treat insom- nia due to tea-drinking or coffee-drinking. The num- ber of those who abuse these beverages is probably .mall, and the congenitally feeble and neuropathic early learn by experience to indulge sparingly in them The tea-drinking malady is characterized by » sleeplessness, or sleep disturbed by dreams or night- mare, headache, irritability of temper, depression, hypochondriasis, disorders of special senses, auditory and visual disturbances, neurosal palpitation, dyspep- sia, intestinal torpor (with the accompanying flatu- lence and constipation), neuralgia, muscular enfeeble- ment and tremor." (Macfarlane.) s and of al- inence it, the ge, in- )s sea- dapted These urse of given X vom- )orarily ition of tincture 1 water, t insom- le num- >robably ropathic ingly in rized by )r night- pression, auditory dyspep- ng flatu- enfeeble- — 8i _ ^^ Insomnia is a frequent consequence of excesses m the use of tobacco. This is brought about, partly by the digestive and circulatory troubles which char- acterize chronic nicotinism. But the nervous centres are most violently smit- ten, especially the medulla oblongata, whence the car- diac, circulatory, and respiratory disturbances. The direct excitant influence of nicotine on the cortical . centres IS considerable; the existence of vaso-motor paresis is undoubted. Entire abstinence is the only remedy; the poison «s quickly eliminated. It has been found that the wakefulness is lessened by four-gramme doses of monobrom.de of camphor at night (Macfarlane), but any of the milder hypnotics may be administered The only other toxic agent necessary to allude to IS opium. Opium and morphine may almost be said not to deserve a place among true hypnotics, so little do they bring about the conditions of normal sleep It IS known that they render the cerebrum hyper^mic- they paralyze the vaso-motors, and act upon the nerves which supply the respiratory muscles so as to interfere with the process of respiration (W A Ham- mond); hence the sleep which results from their use is more like stupor than natural sleep attenir'' *?^'''"^^^ *"'' unmanageable insomnia attends the opium or morphine habit, for the cure of which special treatment is necessary (especially in aggravated cases), and, generally, isolation in an insti- _ 82 — tution possessed of properly trained nurses, and where restraint can be exercised. The literature of morphinism is now quite exten- sive; prominent among worics devoted to this subject . are two treatises lately published, one by Regnier, the other by Oscar Jennings. . , , In breaking off the habit, Jennmgs declares in favor of the gradual method; and in conjunction with Professor Ball he has made some careful experiments on the power of sparteine and nitro-glycerin to com- bat the circulatory disturbances which attend the period of amorphinism. INSOMNIA OK CONTINUED FEVERS AND ITS TREAT- MENT. In typhus and typhoid fever, sleeplessness is a frequent, troublesome, and often dangerous symptom. Dr Murchison, writing of the necessity of sleep m tvDhus says: "The practitioner cannot be too forci- bly impressed with the fact that loss of sleep at any stage of typhus, if it continue for two or three nights, is of itself sufficient to kill." . In typhoid the necessity of sleep is no less ur- aent One of the first symptoms of approaching dis- soluiion is a restlessness which forbids sleep, and the return of refreshing sleep is hailed by physicians and attendants as a presage of recovery. In the earlier stages of these fevers, insomnia s pretty certain to accompany the hyperthermia, while f. 3 , and ;\len- ubject it, the ires in n with iments com- id the rREAT- ss is a mptom. ileep in 10 forci- ) at any ! nights, less ur- ling dis- and the ians and amnia is lia, while - 83 _ sleep often attends a fall in the temperature It would seem that over-heated blood is itself inimical o sleep by excitin, the cerebrum. Certain it IZ^ disturbances and promote sleep. Hence, for the rest- essness and msomnia of typhus and typhoid feve there .s often no better treatment than a cold bath o/ about fteen minutes- duration, the tem? lure o th water being from 60° to 75^ F., and during the bath cold water may be poured on the head in case! wh!iefif:;e.r"^'^ "'' "^^'^^^"««« -^ ^«"'i- r the fehrT". " °"^^' ^° '^ '°"^ ^"°"K'' '° de- cases ^hVi: ' "' u "'"'^ '''' "°^'"«'' '" ^ome cases the bath may be of longer duration. "The earher the stage, the higher the fever, the more robust the constitution, the colder should the ^at be. The later the stage, the weaker the constitution .nH f^""^ 7"'^? '''^''" '° ^*^« f°""d cold sponging bath oThlrH %"'^'""^ ^"'^^'^"^« ^- 'h« - d bath Others havp derived only a temporary refresh- mg from these milder means. -^X reiresh- Where the cold bath is impracticable, from diffi cuUies on the part of the patient or his su'rround.ngs" .^me^f the new antipyretics may be tried. There *J. C. Wilson. i ._ 84 - , is much lesfM-iony in favor of acetanilid as a ncrvou^ sedative in fevers. Fivegrainseveryhourforth.ee or fo^r doses (in an adult) will generally lo.er the febrile temperature two or three degrees, and one o two hours of quiet sleep (..pecially «f /he med.dne b. given in the night-time) is almost certa.n to follow. TK-nany practitioners an-' hospital phys.c.ans, anal- gLin is regarded as the preferable hypnotic; the dose should be double that of acetanilid. These antipyretics, though they undoubtedly have a marked action on the the^.-nogenetic and thermotaxic heat-centres. which are under abnormal irritation by the fever-poison, an action which is ex- .vu'cd to the hi,-., r cerebral centres, certainly do no aft..tthe infectiou' agent, and hence the course of the fever is not influenced by them. Their prolonged use is probably attended by some cardiac depression ?an e.\\ to be especially shunned in fevers), and the best clinical authorities are shy of them, seemg no permanent advantage in the continued admrnistra- tion of these medicaments, but possibly mischief At he most th'.ir employment is restricted to the obten- t!:.n of s'ch sedation L is needed for the nervous dis- '"''' Among the pure hypnotics, chloral still des.. vedly takes the lead in the treatment of the insomnia of \^ll It calms the delirium, saves the forces mod- erates the fever, and produces a sleep ^-^J^ natural sleep in its refreshing effects (l.iebre.ch, i ._J ^%, «>, ^!^^^o. IMAGE EVALUATION TEST TARGET (MT-3) i^j^ "/a ^/ 1.0 1.1 l^y^S |25 y. 1^ |2.2 Ktuu |l.25 II . .4 ,,.6 .4 6" ► Photographic Sciences Corporation \ SJ <^ 23 WEST MAIN STREET WEBSTER, N.Y. 145S0 (716)872-4503 »■ CIHM/ICMH Microfiche Series. CIHIVl/ICIN/IH Collection de microfiches. Canadian Institute for Historical Microreproductions / lnstit?it Canadian de microreproductions historiques st the CHAPTER III. HYPNOTICS. The limits of this treatise will allow of only a brief consideration of the leading agents that properly come under this head. I shall take up first the med- icmal hypnotics, then the remedial agents not med- icinal. I. OPIUM AND NARCOTICS. * Opium is the most ancient and still the most universally employed hypnotic. The narcotic prop- erty of opium is the result of its morphine, codeine, papavarme, and cryptopine— all somniferous alkaloids. Opium IS far from being a pure hypnotic; in small doses Its action is that of an excitant of the cerebrum, and generally it is only in tolerably large doses that It IS hypnotic. Many persons find opium, and espe- cially morphine, powerful promoters of wakefulness, sleep only following many hours after the ingestion of the narcotic. Opium is par excellence the hypnotic where the insomnia is due to pain. Opium undoubtedly exerts Its power by a stupefying action on the cortical cells, rather than by any changes which it effects in the circulation. . " It is the peculiar virtue of narcotics," says Still^, "to blunt the senses and steep the mind in forgetfulness, in spite of pain, of nervous irritabil- ity, or of tormenting thoughts." — 90 — The combination of opium or morphine with the pure hypnotics, as chloral, sulphonal, paraldehyd, urethan, is often highly efficacious. The following formula are recommended: (These prescriptions are designed for adults only.) CHLORAL ANU MORPHIA. 9 Morphina sulph gr- ij- Hyd. chloral 3 ij. Syrup tolu 5 U- M. Sig.— A teaspoonful when needed to induce sleep. PARALDEHYD AND TINCTURE OF OPIUM.' 9 Paraldehyd 31. Tinct. opiideod g«- "*• M. For one dose. To be taken in a little old rum and water. Valuable in the insomnia of melancholia, in deli- rium tremens, incipient paralytic dementia, etc. SULPHONAL AND MORPHIA. Q Sulphonal 3ss. Morph. sulph gr. X • M. One powder, for a hypnotic effect where there is great nervous irritability or pain. MORPHINE WITH CHLORAL AND BROMIDE OF SODIUM. (From Macfarlane.) B Liqui morphin acet f3i. Hyd. chloral 3i. Bromid. sodii 3ij- Syrup tolu 3iv. Aquam add 3'*. M. Sig.— Take one-fourth part in water before bedtime, and repeat in two hours if required. th the lehyd, owing ptions ; sleep. um and in deli- there is SODIUM. bedtime,. — 91 _ Other narcotics-belladonna, hyoscyamus, Indian hemp, stramonium— have but feeble hypnotic power They are not absok.tely devoid of this power, as some writers have affirmed, but they are not to be depended on. In insomnia due to genital irritation (such cases as sometimes come before the notice of the physician in connection with habits of masturbation and at- tempts at reformation, or in continent young men who are kept awake by troublesome erections), also m the insomnia produced by gonorrhceal chordee, hyoscyamus is often of real efficacy. The camphor and hyoscyamus pill is # convenient formula: 8 Pulv.carnph g^. i. Ext. hyoscyam gr. iij. M. For one pill. To be taken ^t bedtime. A supposi- tory of ext. hyoscyamus, 3 grains, and pulv. opii i grain, with cacao butter, may be often used to advantage. In chordee, I have given teaspoonful doses of tincture of hyoscyamus three times a day without producing any troublesome dryness of i he mouth and throat or dilatation of the pupils, ard seen quiescence and sleep follow. Lettuce and hops possess true hypnotic virtues, with mildly stupefying properties, and do not produce any arterial or cerebral excitement or delirium, or any subsequent paralysis of nervous or muscular function like other narcotic agents, and particularly opium and belladonna; they act in this respect more like chloral — f)2 — and paraldehyd than like opium, engendering a calm which soon passes into natural sleep. I know certain aged patients who sleep poorly in consequence of cerebral arterial degeneration, but who affirm that when they are able to indulge free y in lettuce as an article of diet, they sleep very well. I have not, however, seen the least hypnotic benefit from any pharmaceutical preparation said to contam lettuce. HOPS-LUPULIN. I have known simple insomnia from neurasthenia, from care, worry, overwork, etc.. temporarily relieved by teaspoonful doses of lupulin on retirmg. I say temporarily, for I have never known the effect to last longer than two or three nights. The doses must be rather large. Hop tea can be of little use, as hops do not yield their active principle to water. Lupuhn is a yellow powder formed on the surface of the scales of hops; it is obtained by rubbing or threshmg or sifting the strobiles, of which it constitutes from one- sixth to one-tenth by weight. It contains a volatile oil and bitter principle which are readily soluble in alcohol. Lupulin may be given in pill form, or be taken in the form of a paste, mixed with water or syrup. . . . . , Doubtless in cases of insomnia from irritable bladder, and from genital irritation, nearly all practi- tioners have occasionally found lupulin in teaspoonful doses useful. I I calm jrly in n, but freely f well, benefit contain ithenia, elieved I say to last nust be IS hops Lupulin e scales hing or >m one- volatile luble in 1, or be water or irritable 1 practi- spoonful — 93 - It will not do in closing this topic to omit to men- tion the hop pillow, which has sometimes proved beneficial in allaying restlessness and producing sleep in nervous disorders. The pillow should be moistened with spirits before being placed under the head of the patient (Dr. Geo. B, Wood). Pills for Satyriasis {Dujardin-Beaumetz). ''"P"Hn 2 grammes. Bromide potassium 2 grammes. Ext. nymphaea (water lily), q. g. For 2o pills. Sig. Take two pills every two hours. II. ALCOHOL, AND OTHER STIMULANTS -EUPEPTIC AGENTS. Alcohol sometimes acts as a hypnotic, and is in fact frequently resorted to for that purpose. It pro- duces sleep, not because it is a vascular stimulant, clearing the over distended blood-vessels, but because it is taken in a sufficient dose to have a narcotic effect. Ale is especially chosen for hypnotic effect; the hops with which it is impregnated undoubtedly aid the calm- ative action. Whiskey or brandy to have a soporific effect should be of pure quality, and the older the better. The theory that liquors long mellowing in the cask get rid of fusel oil and other alcohols notethylic, and develop soothing ethers, seems actually sustained by facts; certain it is, moreover, that new liquors adulterated with the higher atomic and more fiery alcohols are excitant, and therefore antagonistic of ') "I' l I iiii ' iii I r ii iii tiM iii il i t;. -— ««»^^«.«' f ife — 94 — sleep. A tablespoonful or two of pure whiskey taken on going to bed will often relieve the insomnia of the exhausted, the irritable, the nervous; the insomnia due to mental overwork or worry will often promptly yield to the alcoholic potion. It is weP to administer the spirit in a tumbler of hot water -as hot as can be drunk— as the heat favorably excites the stomach, and through that organ reflexly soothes and inhibits the cerebrum. U nfortunately, the sleep produced by alcohol is often of short duration; the patient awakes after a couple of hours but little refreshed, and may lie awake much oi' the night without being able to go to sleep again. The combination of whiskey with a little sulphonal may, however, remedy this. The sulphonal may first be taken in fine powder, well stirred, till it is about the thickness of cream, into a little water; this is fol- lowed by the draught of whiskey. When the effects of the alcohol begin to subside, those of the sulphonal (which is slow to undergo absorption) are just com- mencing. I have known a dose of only lo grains of sulphonal, followed by a tablespoonful of old whiskey in a little hot sweetened water, to oe succeeded by eight hours of sound sleep. Ginger, peppermint, camphor, lavender, carda- mom, and other gastro-intestinal stimulants and "carminatives," taken with hot water, occasionally prove hypnotic. Even hot water alone may induce sleep if drunk freely on going to bed; in such cases I taken I of the somnia omptly ninister can be ich.and aits the lis often juple of TlUCh Ok ) again, ilphonal lay first is about s is fol- ; effects alphonal ist com- jrains of whiskey ;eded by r, carda- ints and ;asionally y induce uch cases — 95 — it may be supposed that the insomnia is the result of a dyspept.c state, and that the increased vasculariza- tion of the stomach may cause diminished vasculariz- at.on of the brain, thus producing one of the condi- tions of sleep. A few drops of the aromatic spirits of ammoma, of the ammoniated tincture of valerian, of he fluid extract of skullcap, will sometimes enable the mdiv.dual speedily to pass the barrier which sep- arates the waking from the sleeping state. Many a person rendered sleepless by a disordered stomach- the seat of acrid fermentations-has been enabled to realize immediate quiescence of both stomach and brain by a dose of rhubarb and soda, a drachm of Carlsbad salt in a cup of hot water, or even the same quantity of bicarbonate of sodium taken in the same wsy, m. BROMIDE OV POTASSIUM AND I.ROM.DES. hrnmtTT "l' "'''"' ''^P"°'''' '""^^ ^e mentioned bromide of potassium, which still has a great reputa- tion as a remedy for chronic insomnia. It probably produces its effects, as Vulpian taught, not by an«mi ating the cortex,* but by the influence which it directly exerts on the anatomical elements, "it «|mply less- ens the functional activity of the brain, without dis- m '"^1 '■'^'"°" °^ °"' P^" *° ^"°'her" (Brunton). ,W K r?' ' u"'"°" '' '° ^'™'"'«h cerebral or spinal '"'^^^"'^y' ^'^^^^ th« brain is hyper^mic from excess *I.e(ons sur les Vaso-moteurs, t. ii, chap. i. _ 96 - of mental toil, from prolonged watching, from abuse of stimulants; in nervous erethism characterized by emotional excitability, exaggeration of the reflex activity in the insomnia of fevers, and m genito- urinary insomnia, bromide of potassium (at least till the discovery of chloral) has been the best hypnotic known to the profession. It depresses innervation generally, and is a debilitant of the heart; hence, m the feeble, asthenic, and cardiac, it is to be prescribed with caution. It may often with advantage be asso- ciated with chloral and morphine; if given with whiskey its depressant action is less marked; the com- 'bination with calisaya, with simple elixir, with anise cordial, makes it often more acceptable to the stomach. I^ Pot. brom grs. xxx. Anise cordial 2 '• M. For one dose. 9 Pot. bromid S^s. Elix. calisaya, 1 fta 5 it). Sherry wine, ) ■, u a M. Sig.: Ateaspoonfulthreetiinesadayandatbed- time. . 5 Poi. bromid., ) aa3ij. Hyd. chloral, ) • Tinct. valerian 3 ^*' Spts. lavend. co 3 vi. Aquaecamph q. s. ad 5 vi. M. Sig.; A tablespoonful everytwo hours till sleep js> induced. The above formula has been of great use to me in the treatment of alcoholic insomnia. abuse ed by reflex renito- ist till pnotic •vation nee, in scribed ; asso- n with le com- ' 1 anise omach. d at bed- 11 sleep is 56 to me t — 97 — BROMIDE OF LITHIUM. The bromide of lithium, according to Macfar^ ' lane, is the best hypnotic of the bromide salts as it contains a half more bromine than the potassium bro- mide. Its dose is ID to 2o grammes. Macfarlane recommends the combination with ergot of rye and digitalis, both of which are stimulants of the vaso- motor centres. ^ Bromidi lithii , ^^ ^^j Fluid ext. ergot [ 3 i. Tinct. digitalis n, xx. Chloroform water 3 xv h-i ^" u^'^'i ^"^^ one-half tv;o hours before goitiK to bed, and the other half at bed-time.* IV. CHLORAL. The discovery by Liebreich, in 1869, of the hvo- notic properties of hydrate of chloral may be regarded as one of the most important therapeutic discoveries of modern times. The experience of the past twenty-two years has more than justified the first conclusions respecting its actions and uses, and chloral may still be regarded as, on the, whole, the best hypnotic we possess. Its principal advantages are: i. It is speedy and generally certain in its action. 2. There is no pre iminary period of excitement. 3. Its effects are ' prolonged, and the sleep wnich it produces is calm tranquil, and refreshing; the patient wakes out of the • Wmnia and Its Therapeutics, p. 88. ■| ■iMiiniii j.'mi w? I: -98- chloral sleep as out of natural sleep. 4- It can be eiven with good results in cases where opium is not tolerated S. There are seldom any unpleasant or m- urious after-effects; it does not disturb the secretions ir excretions, as do many other hypnotics. 6. It has a wide range of usefulness besides being simply a sleep-producer; in all morbid cerebro-spmal condi- tions attended with excitation, delirium, or spasm, it is markedly beneficial; in the insomnia due to delirium tremens, alute mania, general paralysis of the insane puerperal mania, chorea, tetanus, etc., it is of great ''*^" Among its disadvantages are: i. It is a cardiac depressant, and therefore must be given with great caution, or withheld in organic affections of the hearty , It is a dangerous remedy when long-contmued, its effects on the brain, and consequently on the .cental functions and disposition, being deplorable. The .Moral haUt is, doubtless, quite as bad as the morphine habit " Its employment," says Mucfarlane, "is so fraught with risk that its use, except under medical advice, is much to be deprecated « At first the mental depression and melancholia, from which the patient suffers »J« ^"^'^'^'^^^^y J . doae of the drug; after a time it fails to soothe, and may even excite. The victim gravitates into a pitia- ble state of mental weakness and demoraluation, be- coming childish, vacillating and untruthful, some- t^es dejected, at other times excited, and having K- EJ^CT^ :an be is not t or in- retions It has mply a condi- )asm, it lelirium insane, f great cardiac h great le heart, nued, its ! mental le. The norphine ;, "is so medical ancholia, ted by a othe, and 3 a pitia- ation, be- ul, some- d having — 107 — and almost everybody has experienced the difficulty of going to sleep when the feet are cold.* ' The Wet Pack.~i:\i\$, is a very active hydro- therapic method, being a "derivative or calmative of the highest order" (Macfarlane).f A sheet is wrung out of cold water, and the patient is enveloped in it from neck to ankles, the head and feet not being included. Several dry blankets are wrapped around the patient, a hot water bag is applied to the feet, a cold wet cloth to the forehead, and the patient is allowed to remain in the pack from half an hour to an hour. At »he end of the process he is rubbed down with dry cloths to promote vigorous reaction. The Turkish Bath.— The Turkish bath is highly recommended in many cases of insomnia. It relieves cerebral congestion, and promotes circulation and *Hemmond employed with success, in a young girl whose extremities were habitually cold, electrization of the sciatic nerve. t Experiments of Weir Mitchell have shown that the effect of chilling the cerebrum is a brief sedative action. Then phenomena of motor excitation are developed, sensi- bility is lessened, and if the application of cold is continued, the animal falls into a profound stupor, and surgical opera- tions may be performed on him without the least movement. When cold is applied to the medulla oblongau, the respira- tory movements are first tumultuous, then they are slowed, and finally cease altogether. (Quoted from " Clinical Theral peutics," by Dujardin-Beaumetz. Published by G. S. Davis, Detroit, Mich.) ^\f' •:m N- II — io8 — irterial tone, as well as digestion and assimilation. The Turkish bath consists of three rooms. The tem- perature of the first, or dressing room, is moderate, that of the second is higher, that of the third is higher still. In the first room, the bather, after dressmg, , winds one towel around his loins and a second around his head in the form of a turban. If he has any tendency to cerebral congestion, the second one may be wet. He then passes into the second room, where he waits a short time before passing into the third room. Some people, however, go directly into the third room. In both the second and third rooms the bathers partake freely of cold water. A few minutes' stay m the warmest room is usually sufficient to make the bather perspire freely, and he then returns to the second or cooler room, where he may remain half an hour or more, according to circumstances. He may then be shampooed, the surface of the body bemg rubbed, the muscles kneaded, and the smaller jomts extended. He is then washed with a lather of soap, and sluiced with basins of tepid or warm water. For some people^ it is most agreeable after this to be simply wrapped in warm towels and allowed to repose in the dressing-room. Others prefer to finish up with a cold douche before proceeding to the dressing-room. Here they remain resting for a considerable time be- ' fore they again dfess.* *Brunton*8 Pharmacology and Materia Medica. ition. tem- ;rate, igher ssing, scond IS any • may ivhere third : third others tay in ;e the o the alf an e may being joints soap, For to be repose ip with [-room, me be- — 109 — Hot Compresses, consisting of layers of flannels wrung out of hot water and covered with dry flannels, are sometimes of benefit in insomnia when applied over the abdomen. In an interesting lecture recently published in the Dietetic Gazette (Dec, 1891), Dr. C. L. Dana, in speaking of the benefits of hydrotherapy in nervous diseases, regards the wet pack as a most useful seda- tive in neurasthenia and insomnia, and a good sub- stitute for medicinal sedatives, like the bromides. It should be given three or four times weekly, or for a short time daily. The tepid bath ranks next in its sedative efficacy. The shower and jet baths are a most valuable meaps for securing tonic effects. In weak, sensitive and anaemic women, he pre- scribes, first, dry hot packs for a week, then wet packs, and, finally, the drip sheet or cool shower. The Turkish bath and the hot Sitz bath (the patient sitting for twenty to thirty minutes in water at blood heat) have also been found to have excellent sedative effects and to be promotive of sleep. • Electricity.— M.y experience, like that of most general practitioners, has been confined to faradism; I have resorted to this form of electricity for the re- lief of obstinate insomnia. I have never applied the current to the head, but have sought to obtain a powerful derivative effect by applications of the wet sponge, or the metallic brush, to distant parts of the body. I have seen neurasthenic patients quieted and ■}!■!(■ _■ ^ — no — made able to sleep by faradization up and down the spine about bed-time; also by a general electric mass- age, given with the hand, which is made to communi- cate the current. Stills (Therapeutics and Materia Medica) speaks of obtaining success " by passing a fine secondary or primary current from the cervical vertebrae to the epigastrium, and from the dorsal vertebrae to the en- tire front of the chest." " Drowsiness," he adds, " is not uncommon in anaemic and debilitated persons during the use of a generally applied direct inductive current. It has occurred only under the influence of a fine interrupted current of the second order, with a low intensity. In old persons who are restltess and sleep badly, a current of this kind passed over the forehead, while the negative is carried over the shoul- «ers and down the arms, quickly promotes sound and prolonged sleep." Doubtless cutaneous faradization produces that anaemic condition of the encephalon which is favora- ble to sleep; in confirmation of the view that this is the case, we have the observation of Nothnagel that " cutaneous electrical stimulation is followed by a re- flex contraction of the vessels of the pia mater." Central galvanization has proved efficacious in the experience of Berdet, Meyer, Erb, Skene, Keith, Macfarlane, and others. According to the experi- ments of Legros and Onimus, currents of descending direction (positive pole over the forehead, negative — Ill i.the nass- nunl- )eaks ry or ) the e en- s, "is Tsons ictive ice of vith a s and er the shoul- d and s that avora- this is el that y a re- »» ous in Keith, experi- ending egative pole to the neck) determine contraction of the vessels of the pia mater; reverse the poles, and a directly contrary effect is obtained. Doubtless electro-therapeutists, by their ready control (through the proper currents) of the vaso- motors, are able to modify the intra-cranial circula- tion at will, and if sleep were only a circulatory phe- nomenon, they would be able to give us infallible recipes for all kinds of insomnia. Unfortunately the laws of natural sleep are not exactly the same as the laws of the vaso-motors: sleep is, as has before been said, something more than a plus or minus of blood in the brain. If galvanism is a remedy for insomnia, it is by improving the tone of the vessels, and the nutrition of the cerebral cells, rather than by any transient influence on the circulation, that it does good. The subject is one on which a long chapter might be written, but such a chapter would be inap- propriate for this treatise. The successful treatment of insomnia by galvanism presupposes, on the part of the practitioner, a knowledge of technical details and a skill which can only be acquired by a study of the best special treatises on electro-therapeutics and by long practice. Moreover, the range of usefulness of electricity in insomnia is largely limited to neuro- pathic or neurasthenic cases. Lewancjowski and Eulenburg state that they have obtained very favorable results with franklini- km — 112 zation. The head plate is used, and the electricity if, conveyed in the form of breezy currents which are both agreeable aud soothing to the patient. By means of the discharging hand electrode, the patient is also electrified through his clothes; the stances last about half an hour, and the patient goes to bed soothed and ready to go to sleep. At the Adams Nervine, Jamaica Plain, much account is made of static electricity in the treatment of nervous insomnia, and my friend Dr. B. W. Bartlett, of Rowley, informs me that he relies principally on this form of electric- ity (along with other hygienic means) in the treatment of neurasthenia and its accidents, insomnia included. To conclude the chapter on Hypnotics— if drugs have had the greatest prominence among the thera- peutic means, it is not because they are really the most important. I think that physicians should >e very chary in prescribing the medicinal hypnotics. We still know too little about their action on the delicate cells of "the brain and on the vaso-motors. Many of them, by constant or frequent use, become positively baneful It is, therefore, with a caution agamst the careless employment of hypnotics that I close this book and with an exhortation to physicians first to try fully (when possible) all available hygienic resources before resorting to medicinal hypnotics. :ity If. h are . By atient •8 last 3 bed idams de of imnia, iforms ectric- itment luded. ■ drugs thera- lly the luld be ics. We lelicate lany of isitively inst the }se this first to lygienic lotics. INSOMNIA. S^Se^o?^i^''P'■""'^• J' "^''«'« ""f«« «"» from V . 'ISY*" *° create us anew from dav to dav " ir •« i„ deed " Tired Nature's sweet restorer." ^ ^" '' '"" Insomnia may be dependent upon deraneement of thi. .ar7S,T'S' '"""""°7 r,"''""" -"«'"'"« -li" " lary tract, the liver, or upon febr e or eeneral diooae* t» i'SJ^tn^ih '""!?' ^y ""^J'*'*"'^ condition"" heangHigh ing, ventilation, diet, or occupation "^-''''K. "gni Whatever its cause, which must be sought for and as far as^po^sible removed, resort must often be^ad to medicinal .nH S"*Pf **'ons Of the Bromides, Chloral, Gelsemium Ooium and Henbane are most universal y employed. ^ undelt'hSriVSf'' *" ^°"^'"^^'°" '" '-0 different formula, CEREBRAL SEDATIVE COMPOUND (Formula A, with Opium; Formula B, with Henbane sub«ti Sat'eJ)'"''"""' ''*' '*"" ^^^ '^'^'^ •" *»'-•' Opiu "i: cotra: istratkllf: ^°"°'''"« prescription is an eligible one for admin- 9 Cerebral Sedative Compound, Syr. Sarsaparilla Compound, aa ? iv P.. D. A cc's. , Sig.: Dessertspoonful when indicated. on re^S?"" "'"""" °' °°' ''""''^' '"" "> Phy'ician. PARKE, DAVIS & COMPANY, DETROIT AND NEW YORK. 'I 1 — i «. Mnnthlv Journal or t»ny»i"'"w A Monthly C.M..«.- ^:-;J;/i!;S« ;rn,«cr.os o. DR. JOHH S. BILHN08 Sur,.on^a a,^A^. pi^BXCHER. M^R. C. H.. En,. 9UB9CH.PT.ON PH.CE. ''OOO PER YEAR. THB AIMRIOAN LANOWT. ' "••;s;iWRTT7o'-N°p";:rcr."o; p.« v«». TBB MBDICALi AQB. 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TM Inftotlout DlMMO*. Vol. •• By Karl LlebormolMtr. Tht InfooliOM OiMiMt. Vol. H. By K»fl l.l«b«rmelit«'. 8BB1ES III. D. AbdemintI •iirftry. By Hal C. Wyman, M. OlttawtofthoUvor. By Dujardln-Boauowti, M. u- By J. teooard Corning, M. O. OlWMiofthoKldBiy. By DuJ»rdln-B««um«ti, M. D. Th. Thoory and Praetio. ot th. Ophth.l- •"BrrH.rb«rtCUlborn..Jr..M.D. Nlod.rn Tr.atm.nt of Bright'. Ol.w... ByAlfr.dU. Looml., M. D. Ollnloal L.ctur.. on C.rtain Oi..a».. of "VfJo'Tm. Charcot. M.D. •"'"stwSV Ha«-ond. M. D. •"'•'flTmnk Woodbury. M.D Th. Tr.atm.ntof th. Morphia Habit. By Erlcnm*y.r. Th. Itlology. Olagnoii. and Th.rapyof TuborouloM ,., __,_ By HroJ. H.Ton Zl.BiM*n. SERIES IV. , and Oultur. ••.ear'*'**?'* *' fthand Dl«.a*.*of Wom.n. •••TH*''£!"w;od. M. D. '^'^•Ut crsioneTM. D. ^^%*k. H. smith. M D. ATr.atl..onF'aotur.j. Bt Armand Dwpr*., M. u. ingtyplllH».„ „ r» Tiy E. L. Keyta, M .D. Hypodarmio M.dlcatlon. ™ y BoumoTllle and Brlcon WMa..»of OWldr.n. By I. N. Lot., M. D. N.urali^a. „ . „ n Rhaumatitm and Oo"*; „ « By F. Le Roy Saiwrl.., M. u. SLctricity. It. *PP"!«''»" ';,'*D*'*Tvrt 11 By W.Utaron Adam., M.D. L*™-'" CLctrlcity, It. Appllc«t'o« '" •^•'* ^^1 jll ByWelUogtonAdamt,M.D. ivoi.ui AuioMltatlon snd P.rcu..lon. By Fredwck C. Shaituck, M. D. ,| •tdaoiiM. Iltoo, M. D. Plturtty M* t. t. M. D. lon> M. U. I.I. i.n. I. M. D. A. M., M. D., onrf, M. D. M.D. rphi* Habit. «nd Thtr»P)f of kMca. Management oi flea, M. D. M,M.D. [Vo».Il on In Mtdljlna. ini,M.D. IVol.ni iMion. Mituck, M. D- flRfllES V. Tahlnc Oolct. By P. W. Hoiworlh, M. u Praotloal NotM on Urinary An«ly Hy William H. CinHtld, M. D. Fraotloal Intaatlnal Sursary. Vol. i. '^raotloal Intaatlnal Bursary. Voi.ii. »V K H Koblnton, M D. 'kaoturaa on Tumora. By John H. Hamilinn, M. D., LL. D. 'Pulmonary Oonaumptlon, a Mmf voua Olaaaaa. By Thoaa» J . MayH, M D . ^aaaona in tha Olagnoala and Traatmant of Bya Olaaaaaa. By Catty A. Wood, M O. •laaaaas of tua ■maaarand ^roa* Ur H» r Wyman. M. D. Artlflolai Anaaatnatla ana An«ia« thatloa. Hy ncKoreit Wizard, M. 0..and tit Lewi* H. Adicr, Jr. Oanoar. By Danlal t.twit, M. O. Tha Modarn Traatmant of Nip Ola* aaaa. By Charin P. Stillman, M. D. < Inaomnia and Nypnotloa. By Ganaain it* . Tranilattd by B. P. Hurd, M, D. BOOKS BT LEADING AUTHORS. SEXUAL IMPOTENCE IN MALE AND FEMALE ti oo By Wm. A. Hammond, M. D. " '■' PHYSICIANS' PERFECT VISITING LIST , ,o By G, Archie Stockwell, M.D. • • • . • . ju A NEW TREATMENT OF CHRONIC METRITIS .o By Dr. Georges Apostoll. ' CLINICAL THERAPEUTICS . oo By DujardinBeaumeiz, M. D. MICROSCOPICAL DIAGNOSIS , „„ By Prof. Chaa. H. Stowell, M.S. PALATABLE PRESCRIBING , no By B. W. Palmer, A. M, M. D. UKTOWARD EFFECTS OF DRUGS ,00 By L. Lewin, M. D. SANITARY SUGGESTIONS (Paper) -, By B. W. Palmer, M. D. ' SELECT EXTRA-TROPICAL PLANTS ,00 By Baron Ferd. von Muller, TABLES FOR DOCTOR AND DRUGGIST a qo By Ell H. Long, M. D. *^ GBORGE S. DAVIS, Publisher, O. 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