jINSOMNIA 
 
 AND ITS THERAPEUTICS? 
 
 A*. W. MACFARLANE, M.D., 
 
 Fellow of the Royal College of Physicians, EdinBurgh ; Fellow of the Royal Medical and 
 Chirurgical Society of London ; Examiner in Medical Jurisprudence in the Uni\-ersity 
 of Glasgow ; Honorary Consulting Physician (late Physician) Kilmarnock 
 Infirmary ; Formerly Examiner in Medicine and Clinical Med- 
 icine in the University of Glasgow, etc., etc. 
 
 REPRINTED FROM WOOD'S MEDICAL AND SURGICAL MONOGRAPHS. 
 
 NEW YORK 
 WILLIAM WOOD AND COMPANY 
 
 1891
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PACK 
 
 The Physiology of Sleep, . . . 11 
 
 The Brain and Nervous System, 
 
 The Effects of Sleep upon the Body, . . . . . . 
 
 The Depth of Sleep, ......... 
 
 The Causation of Sleep, 
 
 Dreams, 
 
 CHAPTER II. 
 
 General Remarks on Insomnia, 38 
 
 Cardiac and Vaso-motor Centres in the Medulla Oblongata, . 46 
 
 Conditions which Influence Sleep and Sleeplessness, . . 50 
 
 CHAPTER III. 
 
 Insomnia Depending upon Affections of the Nervous System, . 74 
 
 Overwork, 74 
 
 Shock, 84 
 
 Depressing Emotions, 87 
 
 CHAPTER IV. 
 Insomnia Depending upon Affections of the Nervous System, 
 
 Continued, 95 
 
 Neurasthenia, 95 
 
 CHAPTER V. 
 Insomnia Depending upon Affections of the Nervous System, 
 
 Continued, Ill 
 
 Hysteria, .... Ill 
 
 Hypochondriasis, 114 
 
 Insanity, 118 
 
 Myxcederna, ... 124
 
 iv Contents. 
 
 CHAPTER VI. 
 
 PAGE 
 
 Insomnia Depending upon Affections of the Nervous System, 
 
 Continued, 125 
 
 Insomnia Depending upon Spasmodic Neuroses, . . . 125 
 
 Insomnia from Paroxysmal Neuroses, 128 
 
 CHAPTER VII. 
 
 Insomnia Depending upon Affections of the Nervous System, 
 
 Continued, 137 
 
 From Affections of the Brain and its Membranes, . . .137 
 Insomnia Depending upon Affections of the Spinal Cord, 
 Nerves, etc., . 147 
 
 CHAPTER VIII. 
 
 Insomnia Depending upon Affections of the Nervous System, 
 
 Concluded, 151 
 
 Insomnia Depending upon Toxic Agents, Alcohol. Morphine, 
 Chloral, Cocaine, Tea and Coffee, Tobacco, .... 151 
 
 CHAPTER IX. 
 
 Insomnia Depending upon Affections of the Alimentary Canal, . 166 
 
 Gastric Dyspepsia, . . 166 
 
 Intestinal Dyspepsia, 188 
 
 Constipation, . 192 
 
 Intestinal Worms, ' . . . . 197 
 
 CHAPTER X. 
 
 Insomnia Depending upon Affections of the Liver, . . . 198 
 
 Functional Disorders of the Liver, 198 
 
 Jaundice, 202 
 
 CHAPTER XI. 
 
 Gout, its Symptoms and Treatment, with Special Reference to 
 
 Insomnia, 205 
 
 Acute Gout, 209 
 
 Irregular Gout, 210- 
 
 CHAPTER XII. 
 
 Insomnia Depending upon Affections of the Circulatory System, . 229
 
 Contents. \ 
 
 CHAPTER XIII. 
 
 PAGE 
 
 Insomnia Depending upon Affections of the Respiratory System, 248 
 
 CHAPTER XIV. 
 
 Insomnia Depending upon Febrile and General Diseases, . . 265 
 
 CHAPTER XV. 
 
 Insomnia Depending upon Affections of the Urinary System, . 281 
 
 CHAPTER XVI. 
 Insomnia Peculiar to Females, 289 
 
 CHAPTER XVII. 
 Baths Electricity, 297
 
 INSOMNIA AND ITS THERA- 
 PEUTICS. 
 
 CHAPTER I. 
 
 THE PHYSIOLOGY OF SLEEP. 
 
 "I wish I could write a chapter upon sleep; it is a fine subject." 
 " Tristram Shandy." 
 
 "Life's nurse, sent from heaven to create us anew day by day." 
 READE. 
 
 As we cannot satisfactorily study sleeplessness unless we 
 form some conception of sleep, it is proposed to review briefly 
 a few points connected with its physiology, such as .will assist 
 in illustrating- the pathology of the process. No attempt will 
 be made to examine all the varied details of the subject, or to 
 shed any new light upon the mystery in which it is still en- 
 shrouded ; our task being the discussion of sleeplessness, and 
 not the solution of the enigma of sleep. 
 
 Sleep, the familiar yet mysterious condition of repose in 
 which our consciousness is in abeyance, received attention in 
 the early days of Hippocrates and Galen; and ever since it 
 has excited the interest of numerous careful and able investi- 
 gators. Among these may be named Bichat, Binns, Blumen- 
 bach, Braid, Browne, Brown-Sequard, Brunton, Cappie, Car- 
 penter, Cheyne, Denby, Dickson, Donders, Durham, Ehrlich, 
 Ehrmann, Flemming, Fox, Foster, Granville, Hall, Haller, 
 Hammond, Hartley, Holland, Jackson, Kohlschiitter, Kuss- 
 maul, Landois, Lewis, Lyman, McKendrick, Macnish, Marvaud, 
 Mitchell, Moore, Mosso, Obersteiner, Philip, Playfair, Pfliig- 
 ger, Ranke, Richardson, Salathe, Savory, Sieveking, Sommer, 
 Tenner, Verheyen, Vulpian, Waller, and Willis. Each of these 
 observers has added his quota to the general fund of knowl-
 
 2 Insomnia and its Therapeutics. 
 
 edge, while some have advanced theories which to them ap- 
 peared to interpret the nature of sleep. No one of these ex- 
 planations is as yet recognized as affording- a satisfactory or 
 final solution of the changes that distinguish a brain awake 
 or functionally active, from one asleep or functionally tran- 
 quil. Their combined observations, however, particularly 
 those made during the last thirty or forty years, have ren- 
 dered tolerably apparent the nature of the modifications 
 which occur in the brain in the course of sleep, whether these 
 be causative, concomitant, or consequent. Notwithstanding 
 their failure to unfold definitely the constitution of sleep, a 
 careful survey of the accumulated facts will serve to indicate 
 the character of the various pathological conditions which 
 give rise to insomnia. 
 
 THE BRAIN AND NERVOUS SYSTEM. 
 
 The condition of an animal asleep has been likened to " one 
 robbed of its cerebral hemispheres," capable only of excito- 
 motor acts. The nervous system, as a whole, is in a quiescent 
 state; its functions are curtailed, and those which persist are 
 carried on in a modified manner. 
 
 The psychical centres in the convolutions of the brain are 
 functionally active during mental operations. These have 
 not, like the motor centres, been definitely localized, but their 
 physiological (if hypothetical) existence cannot be questioned ; 
 they embrace intellectual, emotional, and volitional centres. 
 Activity originating in these is coincident with molecular 
 changes in the cerebral cells, changes which are the sources 
 of thought, emotion, and volition. The nature of the molecular 
 metamorphosis is unknown, but that is no reason for doubting 
 its occurrence. During sleep this molecular activity ceases, 
 and simultaneously, mental operations are suspended, and 
 consciousness and volition are in abeyance. 
 
 The endless variety in the character and complex^ of our 
 cerebral activities implies the existence of a like multiplicity 
 of centres. These possess the most diverse functions, but all 
 communicate one with another, by means of elaborate and in- 
 tricate arrangements, and also with the special sensory and 
 motor areas, so as to enable them to co-operate in a correlated 
 manner. It follows, that during waking moments the whole
 
 Insomnia and its Therapeutics. 3 
 
 of these centres cannot be in action at one time ; on the con- 
 trary, that a certain proportion must be in a state of repose. 
 It seems probable that during sound sleep they are all at 
 rest; if a limited number are active, light sleep and dreams 
 are the result; if any considerable number are in function, 
 sleep is rendered impossible. 
 
 The motor and sensory centres likewise subside into tran- 
 quillity; the latter becoming incapable of perceiving slight or 
 ordinary sensations, while their corresponding nerves trans- 
 mit impressions in a slow and imperfect way. 
 
 The great nervous centres in the medulla oblongata which 
 are mainly concerned with the carrying on of respiration and 
 circulation, are, so far as is compatible with life, asleep. 
 
 The spinal cord also is less active, and reflex movements 
 can only be produced in response to more powerful excitations 
 than would be required during waking moments, and these 
 movements are slowly performed. This is probably due to 
 the fact that spinal nerves transmit impressions during sleep 
 in a languid and incomplete manner. Reflex impulses always 
 bear some relation to the intensity of the excitation and to 
 the depth of sleep. 
 
 The condition of the sympathetic nervous system during 
 sleep is uncertain. It has not, as yet, been definitely ascer- 
 tained. 
 
 Briefly summarized, during sleep the brain, ganglia, me- 
 dulla, and cord are in a state of repose ; and the work of the 
 economy is conducted with the smallest possible expenditure 
 of energy. 
 
 A good illustration of the extent to which this elaborate 
 system is involved is to be found in the following remarks of 
 Mr. Erichsen : " Those who are asleep at the time of the acci- 
 dent very commonly escape concussion of the nervous system. 
 They may, of course, suffer from direct and possibly from fatal 
 injury to the head or trunk; but the shock or jar, that pecu- 
 liar vibratory thrill of the nervous system arising from the 
 concussion of the accident, is frequently not observed in them, 
 while their more wakeful and less fortunate fellow-travellers 
 may have suffered severely in this respect." 
 
 Sleep the Time favorable for Recuperation. Nervous 
 activit}-, of whatever form it may be, is invariably attended 
 by the consumption of the potential energy which exists in
 
 4 Insomnia and its Therapeutics. 
 
 .nervous tissues; and also by a deposition of detritus in these 
 parts, in quantities corresponding 1 to the- amount of work 
 done. This activity is followed in a longer or shorter time by 
 a feeling- of exhaustion, which suggests repose, and is only re- 
 lieved by sleep. So that during- sleep, in addition to the fact 
 that the functions of the nervous system cease, so far as it is 
 possible, the products of its metabolism are excreted, and its 
 potential energy is recuperated. 
 
 Onset of Sleep Gradual. Bichat long- ago pointed out, 
 that " Sleep general was made up of many particular sleeps ;" 
 that it did not invade the whole of the organs at once, but 
 that the cerebrum, sensorium, spinal cord, and the various 
 organs and muscles must jointly and severally repose for 
 sleep to be sound and complete. Excitability of one or more 
 of these systems disturbs the repose of the whole body, and 
 insomnia results. In this way we comprehend the importance 
 of using daily all the separate parts in something 1 like equal 
 proportion if good sleep is to be secured. 
 
 Sleep is preceded by a series of indefinite and obscure sen- 
 sations, which, collectively, are universally recognized as pre- 
 monitory intimations that it is required by the body. It 
 usually comes on gradually, one set of centres in the brain 
 being obscured after another, generally in definite order, until 
 all are involved. 
 
 The Motor Centres are first Invaded. These are local- 
 ized by Ferrier in the parietal and post-frontal regions. We 
 find that one group of muscles after another becomes relaxed 
 until the body assumes the horizontal posture; and finally 
 real slackening of the muscular fibres is produced, nowhere 
 better seen than in the diminution of tension which occurs in 
 the firmly contracted muscles of a hemiplegic limb during 
 sleep. The only exception to this rule is in the case of the 
 sphincters, which remain contracted, although those of the 
 eyelids occasionally fail to contract firmly, as some children 
 sleep with their eyes partially open in health, and they more 
 frequently do so when they are ill. (In disease, even in tetanus, 
 the muscular system relaxes during sleep; although Professor 
 Gairdner, of Glasgow, recently recorded, in a case of severe 
 chorea, the remarkable, if not unique fact, that " the opistho- 
 tonic attitude was maintained even during sleep/' " Lancet," 
 1889.)
 
 Insomnia and its Therapeutics. 5 
 
 The motor centres in the brain fall asleep before those in 
 the spinal cord, so that the normal inhibitory influence exer- 
 cised by the former is for the time being in abeyance; and 
 prior to the subsidence of activity in the cord itself, there is a 
 tendency to spasmodic action of the muscles, causing exag- 
 gerated acts, and slight convulsive movements in the limbs 
 or in the whole body. Sleep is the time most favorable for 
 the exhibition of many of the vagaries of the nervous system 
 which involve muscular movements; epileptic seizures, con- 
 vulsive attacks, and certain reflex acts being of frequent 
 occurrence. 
 
 Sleep next extends to the centres for psychical operations 
 in the hemispheres of the brain; the will ceases to control the 
 working of the intellectual faculties, and the powers of per- 
 ception grow less ; the mind, no longer inhibited from within 
 or corrected from without, revels in absurdities, until at length 
 all intellection terminates, or, at least, no knowledge of it is 
 retained. 
 
 The centres for the special senses, each in its turn, and 
 usually in the order enumerated below, become progressively 
 inactive, failing to perceive sensations of an ordinary kind, 
 while their special nerves transmit impressions feebly. 
 
 Professor Ferrier has thus localized the various sensory 
 centres. 
 
 Vision. That of vision is situated in the occipito-angular 
 region. The eyelids close ; the e3 7 eballs turn upward and in- 
 ward in the orbits, as if to exclude the light; and the pupils 
 contract, the extent of this contraction being an indication of, 
 and in ratio to, the depth of the sleep. External excitations, 
 either through the skin or other sensory organs, cause the 
 pupils to dilate to some extent, and that although the stimu- 
 lation be so slight as to fall far short of awaking the sleeper. 
 This phenomenon varies at different periods of sleep. An 
 excitation, which during light sleep would suffice to awaken 
 the sleeper, only causes dilatation of the pupils, during deep 
 sleep. 
 
 According to Plotke, the pupils dilate widely in the act of 
 awaking. 
 
 Oscillating movements of the eyeballs are common in chil- 
 dren during sleep. 
 
 Hearing. The centres for hearing, which are situated in
 
 6 Insomnia and its Therapeutics. 
 
 the superior temporo-sphenoidal convolutions, only respond to 
 very pronounced sounds during sleep. This sense has been 
 utilized for the purpose of estimating 1 the depth of the process. 
 Noises frequently, though not necessarily, prevent sleep; and 
 loud noises often fail to arouse a sleeper, while an accustomed 
 or expected noise or sound readily does so. For example, if 
 an alarm-clock rings out, by accident, hours before it should 
 do so, it awakens the sleeper at once. This is probably due to 
 the channels and centres which convey and perceive familiar 
 sounds offering less resistance to their transmission and re- 
 ception, than those which conduct and register other sounds. 
 Certain it is, that a sleeping dog will awake at the casual 
 mention of his name in the course of conversation, which had 
 not previously attracted his attention. 
 
 Monotonous sounds are not perceived after a time, the 
 centres for hearing either getting accustomed to them, or 
 their receptivity becoming lessened. Their cessation alone 
 attracts attention : for instance, in night travelling it is usu- 
 ally the stopping of the train, or the interruption of the noise, 
 that interferes with sleep. Such monotonous sounds as read ing 
 slowly in one tone of voice, the dropping of water, soft music, 
 a pleasant murmur, have all been recommended as aid's to 
 sleep, and are of undoubted efficacy. Singing a lullaby and 
 monotonously patting a child are the popular methods of woo- 
 ing sleep. It has been proposed in America to court sleep by 
 means of a humming-top worked by clock-work. 
 
 Smell, The seat of this sense is probably in the tip of the 
 temporo-sphenoidal lobe. For the keen perception of odors 
 it is necessary that the fragrant particles should be dissolved 
 in the mucous secretion of the Schneiderian membrane. Mu- 
 cus is n'ot secreted in any quantity by this membrane during 
 sleep, and in consequence of its absence, the sense is so enfee- 
 bled that even offensive materials held to the nostrils fail to 
 waken many sleepers, although cases have been recorded 
 where abominable odors have awakened persons who were 
 slumbering soundly; the stimulus, however, must be a power- 
 ful one. Upon awaking, the secretion of the Schneiderian 
 membrane reappears, and the centre for smell resumes its 
 function. Odors of various kinds prevent sleep; excessively 
 minute particles of a volatile substance being capable of per- 
 ception by the radicles of the olfactory nerve. In the case
 
 Insomnia and its Therapeutics, j 
 
 of musk, for example, Kirke quoting- Valentine states that 
 TTfFTro <nnnr f a grain can be so detected. 
 
 Taste. This is localized in the region of the subiculum 
 cornu ammonis. It seems probable that this sense is modified 
 during 1 sleep, though it is difficult to determine this with ac- 
 curacy, as the conclusions are apt to be vitiated by the sense 
 of touch. The secretion of saliva is arrested, and, if the nos- 
 trils are unobstructed, the mouth is closed. 
 
 Touch. This sense is located in the hippocampal and 
 neighboring- temporo-sphenoidal regions. The centre being 
 deeply situated in the brain, retains its activity longer than 
 any of the others. Reflex acts can always be excited ; their 
 vigor depending upon the strength of the stimulus, the degree 
 of sensitiveness of the part stimulated, and the depth of sleep. 
 
 The centres in the medulla, which are not entirely oblivi- 
 ous, work at the lowest rate of tension compatible with life. 
 
 Sleep having progressively included these various portions 
 of the nervous system, it is said to be profound, and no act of 
 volition can modifj 7 or terminate it. 
 
 If the inception of sleep be considered, it will be apparent 
 that the centres situated highest in the cerebrum are the first 
 invaded, while those at a lower level are successively included. 
 This may depend upon the centres growing inactive consecu- 
 tively (according to their position), and ceasing to attract a 
 working supply of blood ; or it may arise from the vascular 
 supply of the centres becoming lessened, relatively to their 
 distance from the heart. 
 
 THE EFFECTS OF SLEEP UPON THE BODY. 
 
 The Circulation. From the days of Hippocrates it was 
 believed that the heart pulsated with greater force and fre- 
 quency during sleep than in the waking state. But the re- 
 verse is the case. The pulse beats more slowly and less 
 strongly while one is asleep, the number of contractions de- 
 creasing on an average from ten to twenty per minute; the 
 same phenomenon is noticed in those who sleep by day and 
 work by night. The recumbent posture accounts in part for 
 this. Dr. Wilks, writing in Hilton Fagge's " Principles and 
 Practice of Medicine/' quotes Tufnell as having found that, in 
 one patient, the difference in the frequency of the pulse was
 
 8 Insomnia and its Therapeutics. 
 
 thirty-five beats per minute, equal to fifty thousand in the 
 twenty-four hours, in the lying as compared with the sitting 
 posture. The realty important factor, however, in the causa- 
 tion of the slowing- of the pulse during sleep, is to be found in 
 the weakened functions of the centres in the medulla, leading 
 to diminished innervation of the heart, the arterial tension 
 being at the same time lowered. This is more marked in 
 children than in adults. The pulse is sometimes irregular in 
 healthy children during sleep. 
 
 In pathological conditions, the pulse rate is diminished 
 during sleep, the exceptions being in cases of great prostra- 
 tion without elevation of temperature, when its frequency may 
 be accelerated. Owing mainly to the depressed state of the 
 circulation, palpitation frequently comes on during sleep, and 
 hemorrhages of various kinds are also apt to occur. 
 
 Respiration. During sleep, the respiratory centres being 
 in a comparatively inactive condition, the respirations number 
 on an average four less per minute than at other times, the 
 inspirations being shallower, and chiefly thoracic, owing to 
 the inactivity of the diaphragm. On application of a stimu- 
 lus which, though interfering with sleep, falls far short of 
 awaking the sleeper, the respirations change in character, ap- 
 proaching more nearly those of the waking state; and when 
 sleep actually terminates the breathing becomes deeper, 
 quicker, and abdominal. The depth of sleep can be gauged, 
 by noting the character of the respirations, and occasionally 
 the rhythm becomes that known as Cheyne-Stokes without 
 its having any special significance. 
 
 In diseases, the respirations decrease in frequency during 
 sleep, though in cases of prostration, similar to those referred 
 to in the last paragraph, they may become more rapid. Sleep 
 is the favorite time for the onset of asthmatic seizures, and of 
 croup, true and false. 
 
 It is always advantageous, when it is possible in illness, to 
 estimate the pulse and respiratons during sleep, that the 
 fallacies which are apt to vitiate the observations in the wak- 
 ing state may be avoided. 
 
 Landois and Stirling mention that the elimination of car- 
 bonic acid is diminished one-fourth during sleep, and ascribe it 
 "to the constant heat of the surroundings (bed), darkness, 
 absence of muscular activity, and the non-taking of food."
 
 Insomnia and its Therapeutics. o 
 
 Pettenkoffer and Voit stated that of the total carbonic acid 
 eliminated during 1 twenty -four hours, 58 per cent is given off 
 during- the twelve hours of the day, and 42 per cent during 
 the twelve hours of the night, while the quantity of oxygen 
 taken in, during the twelve hours of the night, far exceeds 
 that absorbed during the twelve hours of the day. 
 
 Temperature. The temperature undergoes modification 
 during sleep, both in children and adults, falling from 0.5 to 2 
 Fahr. : chiefly for two or three hours after midnight. It falls 
 similarly during the day, in the case of those who sleep by day 
 and work by night. Helmholtz states that a man weighing 
 about tAvelve and a half stone gives off 40 calories of heat 
 every hour while he is asleep, and 112 calories in the same time 
 when he is awake. 
 
 The Secretions. The secretory organs are less active dur- 
 ing sleep. The conjunctiva! secretion and nasal mucus are 
 greatly diminished in amount; if they are not, as in conjunc- 
 tivitis and nasal catarrh, the eyelids are gummed together in 
 the morning and the nostrils are occluded with mucus. The 
 salivary and other secretions concerned with digestion are 
 only formed under the influence of suitable stimuli, and these 
 being absent during sleep they are not secreted. Absorption 
 is slowly effected, consequently the action of medicines and 
 poisons is retarded. The gastro-intestinal movements are 
 either wholly in abeyance or greatly lessened. 
 
 The urine is secreted in smaller quantitj', the amount being 
 about a fourth of that secreted when awake; and the urea 
 formed is decreased one-half during sleep. 
 
 Mendel found that urine secreted during the night con- 
 tained a larger quantity of phosphoric acid than that secreted 
 and passed during the day, showing that sleep is the most 
 favorable time for the nutrition of the brain tissue and the 
 removal of its waste products. 
 
 Bouchard, writing upon the toxicity of human urine, says 
 that the urines of \vaking and sleeping differ not only in in- 
 tensit}', but also in quality ; the urines of sleep being always 
 really convulsants, while the urines of waking are only nar- 
 cotics. 
 
 The secretion of milk continues during sleep. 
 
 Considerable difference of opinion exists as to the secretion 
 of sweat; many eminent physiologists holding that it is de-
 
 IO Insomnia and its Therapeutics. 
 
 creased during 1 sleep nearly 50 per cent, while Sir Dyce Duck- 
 worth and others, on the contrary, believe that it is increased 
 during the night, on account of the greater quantity of blood 
 found in the viscera and integument at that time. This would 
 well explain the liability to ca'tch cold from sleeping in a 
 draught. Sleep is the chosen time for the profuse sweats of 
 phthisis and frequently also of rickets. 
 
 THE DEPTH OF SLEEP. 
 
 The depth of sleep varies considerably, even during different 
 periods of the same night. It may be so light that conscious- 
 ness is only momentarily obscured and the sleep terminable 
 by the slightest external disturbance ; or it may be so pro- 
 found that activity in all the cerebral centres is suspended, 
 and only the strongest external stimulations can interrupt it. 
 External excitations acting on the sensory surfaces and cen- 
 tres have been made use of to determine the depth of sleep. 
 Kohlschiitter, by means of sounds of graduated intensity, 
 found that this increased very quickly at first, and afterward 
 more slowly until the end of the first hour, when it reached its 
 maximum. It subsequently decreased quickly, and afterward 
 more slowly, fluctuating from time to time until waking oc- 
 curred. Several other observers have made experiments on 
 this subject, but their conclusions do not differ materially 
 from those of Kohlschiitter. Attempts have also been made 
 to estimate the depth of sleep by the modifications which the 
 reflexes undergo. Rosenbach found that in the first period of 
 sleep, when it was yet light, there was weakening of the re- 
 flexes, and contraction of the pupils ; in the deeper sleep which 
 followed, the abdominal, cremasteric, and tendon reflexes be- 
 came abolished, and the pupils were fully contracted. Dr. 
 Lauder Brunton writes: " In ordinary sleep reflexes disappear 
 in the same order as in chloroform narcosis, but in mesmeric 
 sleep the reflexes are increased as in narcosis from ether." 
 He also writes : " According to Eulenberg, in chloroform nar- 
 cosis the patellar reflex is abolished first, then reflex from the 
 skin, then from the conjunctivas, and lastly from the nose." 
 "Narcosis by ether differs from that of chloroform in the 
 much greater increase of patellar and other tendon reflexes, 
 both in extent and duration." The writer can confirm these
 
 Insomnia and its Therapeutics. II 
 
 observations, excepting that which refers to the state of 
 mesmerism. 
 
 THE CAUSATION OF SLEEP. 
 
 As the causation of sleep from the earliest times has been 
 supposed to depend in some manner upon alterations in the 
 blood-supply of the brain, it will be useful to consider prelim- 
 inarily some points in connection with these vascular arrange- 
 ments, more especially as the cause of so man}*- forms of in- 
 somnia is to be found in some interference with the normal 
 blood-supply, either as regards quantity or quality, or both 
 combined. 
 
 The nutritive arteries of the brain are divisible into two 
 sets, the central and the cortical. The central arteries are 
 vessels coming- off from the main arteries near their origin and 
 supplying the basal ganglia. The cortical vessels are distri- 
 buted to the gray matter on the surface of the brain, and to 
 the underlying subcortical substance, where they approach 
 but do not anastomose with the central nutritive arteries. 
 The gray matter is provided with a rich capillary plexus which 
 brings to it a blood-supply five times as great as that of the 
 white substance. All these arteries are terminal vessels 
 that is, they do not anastomose one with another, but each 
 supplies independently a portion of the cerebral substance, thus 
 providing for the simultaneous vascularization of separate 
 limited areas according as they are called into play by the 
 association of ideas. 
 
 During activity of the cerebral centres, the blood-supply of 
 these centres, under the influence of the vaso-motor nerves, is 
 increased the increase in some cases, it is said, being from 30 
 to 47 per cent ; on the other hand, when activity is lessened 
 the blood-supply decreases. In other words, the blood-supply 
 is coincident with, and in ratio to, the work being performed : 
 ubi irrita tio, ibi affluxus. 
 
 Many have doubted the possibility of increasing or dimin- 
 ishing the quantity of blood in the brain. The second Monro 
 raised the question as to whether the brain could be congested 
 at all; maintaining that, as it was shut up in a closed bony 
 cavity which was quite filled (i.e., with no vacuum), it could 
 not be compressed. This led to the inquiry, Could the brain, 
 be depleted? Upon this point the observations of Monro,
 
 12 Insomnia and its Therapeutics. 
 
 Kellie, Bonders,- Burrows, Reid, and others, are well worthy 
 of study. There is no longer any doubt that the quantity of 
 blood in the brain varies very considerably under different 
 circumstances, and that its distribution can be modified in 
 divers manners; for example, the capillaries must necessarily 
 become obstructed when the veins and sinuses are engorged 
 with venous blood. 
 
 Variation in the quantity of blood in the cerebral vessels 
 is made possible by the fact that the brain does not completely 
 fill its bony cavity, part of the space being- occupied by the 
 ventricles and the subarachnoid and perivascular spaces 
 which contain the cerebro-spinal fluid. These communicate 
 freely with each other and with corresponding structures in 
 the spinal canal, so that when the brain receives an increased 
 amount of blood, a certain quantity of cerebro-spinal fluid is 
 displaced and compression of the brain avoided. 
 
 Luys went so far as to believe that the brain changes its 
 position in the different postures assumed by the body. 
 
 The pressure of blood in the brain is so considerable that 
 it causes movements, of the brain, which give tracings similar 
 to those obtained by the sphygmograph from direct pressure 
 over arteries in other parts of the body. 
 
 Meynert, in his work on psychiatry, discusses fully the 
 movements of the brain. Briefly stated, they are Those com- 
 municated by the large blood-vessels at the base of the brain, 
 and varying from sixty to eighty in the minute according to 
 the pulsations of the heart. During systole of the vessels the 
 organ is thrust upward toward the vertex and inward toward 
 the ventricles, causing displacement of lymphatic fluid. Those 
 which coincide with the movements of respiration, the brain 
 rising with expiration and failing with inspiration. These 
 movements, numbering fifteen to twenty per minute, operate 
 mainly upon the sinuses, and, by compressing them, drive 
 along. the venous blood toward the heart. Those connected 
 with the vaso-motor centre, and appearing as peristaltic 
 movements occurring in the arteries at the rate of two to six 
 per minute. These are the most powerful of all the move- 
 ments, and more pronounced and regular during sleep than 
 in the waking state. They are concerned in carrying off the 
 waste products of the brain by establishing currents in the 
 lymphatic fluids.
 
 Insomnia and its Therapeutics. 13 
 
 Professor Mosso, of Turin, conducted upon three persons 
 (in each of whom a portion of the skull was wanting, permit- 
 ting 1 movements of the brain to be felt through the scalp) a 
 series of experiments connected with the cerebral circulation, 
 particularly during- sleep. By means of special instruments 
 he took tracings of the movements of the brain and thoracic 
 walls, and of the pulsations of the heart, and of the radial 
 artery at the wrist. He further devised the plethysmograph, 
 by mean of which he estimated and registered the quantity of 
 blood in the forearm and hand. And he showed (1) that in 
 the act of going to sleep a dilatation and relaxation of the 
 vessels of the forearm occur, with a corresponding contrac- 
 tion in the vessels of the brain, this change becoming most 
 pronounced during deep sleep. (2) That all external stimula- 
 tion, 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 accelera- 
 tion of the pulsation of the heart. (4) That during sleep the 
 quantity of blood in the brain is subject to fluctuation without 
 any apparent cause these fluctuations in the blood-supply 
 throwing some light on the observations of Kohlschiitter re- 
 garding the depth of sleep, alluded to at p. 508; and (5) that 
 all mental activity is attended by an increased quantity of 
 blood in the brain. 
 
 These facts abundantly prove that the functional activity 
 of the cerebral cells regulates the blood-supply of the brain in 
 health, and that it plays a most important part in the pro- 
 duction of sleeplessness. 
 
 Until recent years sleep was believed to depend on a de- 
 termination of blood to the brain, on account of its supposed 
 resemblance to coma, a condition in which the veins and 
 sinuses are engorged with blood, the nervous centres con- 
 gested, and the activity of the cerebral cells suspended. These 
 conditions have, however, nothing in common; sleep being a 
 healthy and physiological condition, coma an unhealthy and 
 pathological state, though, in some diseases, the one glides 
 imperceptibly into the other. Many facts have been adduced 
 in support of the hypersemic theory. It has been urged that 
 men of full habit of body and prone to stoutness are usually
 
 14 Insomnia and its Therapeutics. 
 
 good sleepers; but if anything 1 is certain in medicine, it is that 
 hyperasmia of the brain is incompatible with good and re- 
 freshing- sleep in health ; and also that all diseases that are 
 accompanied by that pathological condition are invariably 
 attended, at the onset, by sleeplessness and restlessness. Dr. 
 Fox, writing- on. insomnia, mentions that Chapin held nitrite 
 of amyl to the nostrils of sleeping- people, with the invariable 
 result of awaking- them in one or two minutes; while it has 
 been noticed that workers in the manufacture of nitre-glyce- 
 rin suffer from throbbing carotids and sleeplessness; and every 
 surgeon who has tried to put a patient under chloroform while 
 he was asleep can testify to the difficulty of doing so without 
 awaking him. 
 
 The belief, however, that the brain was congested during 
 sleep prevailed, in spite of numerous observations (chiefly 
 upon the movements of the brain), which, so far from tending 
 to support the hypothesis, went a long way to prove that, 
 during sleep, the brain contains less blood than when awake. 
 It had frequently been noticed that the fontanelles in young 
 children fall below the level of the skull during sleep, rising 
 again when waking occurs a fact not to be explained on the 
 hyperaemic theory. 
 
 About two hundred years ago, Philip Verheyen, the Regius 
 Professor of Surgery in the University of Louvain, propounded 
 the theory in his work on anatomy, that sleep was due to the 
 cessation from work of the majority of the external senses, 
 and that these contained certain essences (spiritus) which 
 passed into the blood, so that the "greater portion of the 
 medullary substance subsides or contracts," and that, after 
 sleep, these rush back into the brain " to swell it up, so as to 
 cause awaking" and further, that when these essences did 
 not leave the brain, dreams resulted. (Haller and Boerhaave 
 adopted the hypothesis of animal spirits, supposing that these 
 were gradually expended, and so used up during the waking 
 state, and that they were restored during sleep. The former 
 believed that the passage of the spirits through the brain was 
 impeded either by a deficiency or immobility of the spirits, or 
 by compression of the nerves. The latter thought sleep due, 
 either to the obstruction of the secretion, or to an altered cir- 
 culation of the nervous spirits. Cullen compared the natural 
 states of waking and sleeping to excitement and collapse, a
 
 Insomnia and its TJierapeutics, 15 
 
 theory which pervaded many of his writings, being- known as 
 the theory of excitement. He believed that the quantity of 
 nervous fluid was equable, but that during- waking- it moved 
 with greater, and during- sleep with less, vigor. He likewise 
 thought that during sleep the movements in the brain dimin- 
 ished, and that a degree of collapse took place ; while during 
 waking excitement was the normal and necessary condition.) 
 This statement seems to be wonderfully near the truth, though 
 expressed in an antiquated phraseology. 
 
 Blumenbach ascribed sleep to " a diminished or impeded 
 flow of oxygenated or arterial blood to the brain." In 1817 
 he recorded the case of a young man under his care whose 
 skull had been trepanned, and in whom the brain decreased 
 in size during sleep, and increased when he awoke. 
 
 Dr. Hammond noticed that the same thing happened in 
 the case of a man with a large opening in the skull, the result 
 of a railway accident; and he devised an instrument which 
 demonstrated and measured the extent of the cerebral pres- 
 sure. The late Dr. C. H. Moore wrote that the same "ob- 
 servation was made in Montpellier a century ago in a similar 
 case, and it was noted that the brain rose and fell in propor- 
 tion to the lightness or profoundness of sleep." Many distin- 
 guished -surgeons have since recorded cases, in which the skull 
 being defective, the convolutions of the brain have been seen 
 to become bloodless, and to subside below the level of the 
 skull during sleep. 
 
 These observations led to further inquiries, the chief of 
 which will now be referred to. Donders, in 1854, performed 
 some experiments on a dog, trepanning its skull and substitut- 
 ing for the bone a piece of glass, when he found that during 
 sleep the brain became anaemic. Similar experiments were 
 subsequently carried out by Ehrmann in an improved manner 
 with like results, and these have since been frequently con- 
 firmed by others. 
 
 In this country, Mr. Durham, in the " Guy's Hospital Re- 
 ports " for 1860, placed upon record a series of observations he 
 had made upon dogs, in all of which the greatest care was 
 taken to insure accuracy. Portions of the skull were removed 
 under chloroform, the dura mater clipped away, and pieces of 
 glass secured in the openings by means of Canada balsam. 
 He noted that during sleep the brain became pale and anaemic,
 
 1 6 Insomnia and its Therapeutics. 
 
 and sank below the level of the skull, the amount of blood in 
 the veins being reduced. The appearances presented by the 
 brain during its periods of activity differed remarkably from 
 those observed during sleep. He found further, that on in- 
 ducing an experimental hyperaemia of the brain by tying the 
 jugular veins, the vessels of the pia mater became congested, 
 while the animals fell into a state of torpor, but not of sleep. 
 He summarized his observations in the following deductions: 
 
 "Pressure of distended veins upon the brain is not the 
 cause of sleep, for during sleep the veins are not distended; 
 and when they are, symptoms and appearances arise which 
 differ from those which characterize sleep. 
 
 "During sleep the brain is in a comparatively bloodless 
 condition ; and the blood in the encephalic vessels is not only 
 diminished in quantity, but moves with diminished rapidity. 
 
 " The condition of the cerebral circulation during sleep is, 
 from physical causes, that which is the most favorable to the 
 nutrition of the brain tissue; and, on the other hand, the con- 
 dition which prevails during waking is associated with mental 
 activity, because it is that which is most favorable to oxida- 
 tion of the brain substance, and to various changes in its 
 chemical constitution. 
 
 " The blood which is derived from the brain during sleep is 
 distributed to the alimentary and excretory organs. 
 
 " Whatever increases the activity of the cerebral circula- 
 tion tends to preserve wakefulness; and whatever decreases 
 the activity of the cerebral circulation, and at the same time 
 is not inconsistent with the general health of the body, tends 
 to induce and favor sleep. Such circumstances may act pri- 
 marily through the nervous or through the vascular system. 
 Among those which act through the nervous system may be 
 instanced the presence or absence of impressions upon the 
 senses, and the presence or absence of exciting ideas. Among 
 those which act through the vascular system may be men- 
 tioned unnaturally or naturally increased or decreased force 
 or frequeiiC3 r of the heart's action. 
 
 "A probable explanation of the reason why quiescence of 
 the brain normally follows its activity is suggested by the 
 recognized analogical fact, that the products of chemical 
 action interfere with the continuance of the action by which 
 they are produced."
 
 Insomnia and its TJierapentics 17 
 
 In 18G6 Drs. Hammond and Weir-Mitchell conducted a 
 series of experiments upon dogs under the influence of chloro- 
 form and opium with practically the same results. 
 
 It seems, therefore, to be conclusively demonstrated that 
 sleep is not due to a plethora of blood in the brain. 
 
 The late Dr. C. H. Moore, in his essay on the " Plrvsiology 
 of Sleep," ascribed to the ganglionic nerves the important 
 function of constricting- the arterial vessels of the brain, and 
 so inducing an anaemic condition which temporarily suspends 
 cerebral activity. Support was gained for this view when Dr. 
 Flemming showed, by experiments upon himself and others, 
 that a state resembling sleep could be immediately produced 
 by compression of the carotid arteries. It was, however, 
 pointed out that the resulting condition was one of syncope, 
 and not of sleep. 
 
 Dr. Cappie, in his admirable essay on the " Causation of 
 Sleep " a work well worthy of perusal states that among 
 other causes there is an increased quantity of blood in the 
 veins of the pia mater which exerts a certain amount of press- 
 ure on the gray matter of the brain; adducing, in support of 
 this opinion, the evidence of Dr. Hughlings Jackson, who, in 
 ophthalmoscopic observations made upon sleeping children, 
 found the retinae paler, the arteries narrower, and the veins 
 more dilated than during the waking state. He also cites the 
 statement of Dr. Allan Jamieson, now of Edinburgh, who re- 
 ported that in a girl in a state of trance he found the retinas 
 pale, the arteries small and hair-like, and the veins full and 
 large. Such evidence, however, loses much of its value when 
 the appearances are found to be inconstant. Senator has re- 
 corded that the ophthalmoscopic appearances were normal 
 in a case of prolonged sleep which extended over some months. 
 Indeed, it is extremely doubtful whether ophthalmoscopic ob- 
 servations are of much utilit} T in such an investigation; for 
 Dr. Govvers, in his work on "Medical Ophthalmoscopy," in 
 discussing anaemia and hypersemia of the brain, writes: "It 
 has been supposed that the state of the circulation in the eye 
 and brain corresponds, and that the anaemia and hyperaemia 
 of the brain are revealed by similar conditions in the fundus 
 oculi. But, as has been already said, such a statement, if true 
 at all, is true only within certain narrow limits. The intra- 
 ocular tension so regulates the state of the vessels of the eye,
 
 1 8 Insomnia and its Therapeutics. 
 
 that very little alteration occurs in them, when changes occur 
 in the condition of the vessels of the brain." In referring 1 to 
 cases of anaemia Dr. Gowers says: "It is possible that the 
 initial stage of an epileptic fit, which is attended by pallor of 
 the face, may be accompanied by pallor of the disc, and per- 
 haps spasm of the retinal arteries; but very little evidence of 
 this fact has at present been obtained." 
 
 Moreover, it must be borne in mind that the very fact of 
 examining the eye is sufficient to modify the circulatoiy ar- 
 rangements of sleep. It has been already stated (p. 503) that 
 external stimuli of all kinds induce changes in the pupil in 
 healthy subjects; and it has also been shown (p. 511) that they 
 produce alterations in the circulation of the brain ; nay, more, 
 that the fact of throwing a light on the closed eye is sufficient 
 of itself to bring about these modifications. It is therefore 
 evident that ophthalmoscopic observations made during sleep 
 must of necessity be of doubtful value; certainly their impor- 
 tance falls far short of those conducted in the waking state. 
 
 Dr. Cappie takes exception to Mr. Durham's conclusions, 
 already quoted, alleging that atmospheric pressure would 
 empty the veins of the brain, and so vitiate the results. 
 
 Vulpian, the distinguished physiologist, adopted the same 
 view, believing that atmospheric pressure and the effects of 
 anesthetics and narcotics are important factors in the changes 
 observed in the experiments of Durham and Hammond. He 
 further expresses his dissent from Dr. Cappie's proposition, 
 on the ground that the mere displacement of blood from the 
 arteries to the veins cannot exert pressure on the nervous 
 tissues. 
 
 There is also difficulty in accepting Dr. Cappie's view on 
 the further ground that blood in the veins is useless for nutri- 
 tive purposes, and as sleep is highly restorative, it is difficult 
 to conceive how depuration and recuperation can be effected 
 under such conditions. Certainly, passive congestion of the 
 brain has never been deemed favorable for its nutrition, or for 
 sleep. 
 
 Vulpian holds the opinion that the state of the circulation 
 of the brain has little to do with the causation of sleep, the 
 vascular and cardiac modifications being only accessory to it. 
 He further points out that the carotid and vertebral arteries 
 in the lower animals have been tied so as to cause profound
 
 Insomnia and its Therapeutics. 19 
 
 anaemia of the brain, without the animals being made appre- 
 ciably drowsy. 
 
 Professor Mosso demonstrated that in the act of awaking 
 the brain undergoes a diminution in volume and contains less 
 blood than during sleep; this would appear to be coincident 
 with the sudden dilatation of the pupils (p. 503). Professor 
 Mosso thinks that this shrinking is " sufficient to render un- 
 tenable the hypothesis which attributes sleep to a state of 
 anaemia of the brain." This does not necessarily follow. Se- 
 vere and sudden anaemia is productive of convulsions; a less 
 intense form, of sleeplessness and restlessness. It is therefore 
 suggested as probable that this abrupt depletion may be 
 nature's method of securing awaking. The effects which 
 anaemia produces vary very greatly in different cases, and 
 appear to depend largely upon the degree of the anaemia and 
 the mode of its induction. 
 
 Slight and gradual anaemia of the brain is conducive to 
 sleep. There is abundant evidence to prove that mental iner- 
 tia and somnolence manifest themselves when the brain is 
 gradually deprived of its normal blood-supply. Dr. Buzzard 
 has recorded, in his work on " Diseases of the Nervous Sys- 
 tem," instances of somnolence in cerebral syphilis lasting sev- 
 eral weeks, which he states were probably due to arterial dis- 
 ease, and which recovered under specific treatment. In such 
 cases the circulation must have become lessened very slowly, 
 and must therefore have been causative of, and not dependent 
 on, sleep. 
 
 The thyroid gland plays an important part in the regula- 
 tion of the vascular supply of the brain, preventing too great 
 a flow to, but, particularly, from it. The extirpation of this 
 gland has led in many instances to mental lethargy and som- 
 nolence. 
 
 Cases of "sleeping sickness" have occurred chiefly in 
 Western Africa, characterized by swelling of the cervical 
 glands and a gradual and increasing inclination to sleep. The 
 pathology of this disease is not known, but Dr. Gore recorded 
 the post-mortem appearances in such a case (" British Medical 
 Journal," 1875), from which we can gather that the brain was 
 abnormally bloodless : " The substance of the brain was par- 
 ticularly firm, and not one drop of blood appeared on a section 
 of any part of it; the sinuses were unusually deficient in the
 
 2Q Insomnia and its Therapeutics. 
 
 quantity of blood." Less striking 1 but more familiar instances 
 of the fact that a moderate depletion of the brain favors sleep, 
 are to be seen in the drowsiness which follows the partaking- 
 of a full meal, and after a hot foot-bath. 
 
 Some have suggested that the quantity of blood in the 
 brain is not decreased at any one time during- sleep, although 
 the total amount circulating- throug-h it in the course of an 
 hour may be much less than during an equal period in the 
 waking- state, thus ascribing the causation of sleep to the 
 slowing of the pulsations of the heart. The writer is satisfied 
 this is not the explanation, as from observations he has made 
 upon persons going- to sleep, and upon those drowsy after 
 meals, he has ascertained that the pulse does not fall very 
 materially until sleep ensues. Indeed, after meals the pulse 
 is frequently accelerated, so that while the brain is deprived 
 of blood, throug-h contraction of its vessels, the volume sent 
 is transmitted more quickly. Of course it must be admitted 
 that the very fact of instituting these examinations may have 
 disturbed the vascular arrangements. 
 
 From these remarks it seems obvious that the cause of 
 sleep is not to be found solely in the cerebral vascular supply. 
 There is much truth in the statement of Sir J. Crichton Browne 
 that " The blood-vessels were clearly made for the brain, and 
 not the brain for the blood-vessels; and the amount of blood- 
 supply to the brain and its several parts is determined, not 
 by vascular domination, but by the functional activity of the 
 nervous tissues." Nevertheless, the vascularization of the 
 brain is of the highest importance, and in connection with 
 sleeplessness it must be studied most narrowly. 
 
 Waste Products. It is necessary, before going- further, to 
 say something regarding- waste products, seeing that they have 
 been credited with sleep-producing- properties. J. Ranke, 
 many years ago, pointed out that muscle is weakened by 
 work; and that by the exhaustion of its store of oxyg-en, and 
 the accumulation in it of the products of disintegration (chiefly 
 lactic acid and creatin), it loses its contractile power and be- 
 comes feeble and incapable of more work. During rest the 
 agents of fatigue are removed, the oxyg-en restored, and the 
 muscle once more becomes capable of doing- work. In proof 
 of this he showed that a muscle into which lactic acid is in- 
 jected becomes enfeebled, as if by exercise, and requires rest
 
 Insomnia and its TJierapeutics. 21 
 
 and the removal of the noxious agent for the recovery of its 
 normal condition. 
 
 Preyer, applying- the same reasoning- to the nervous sys- 
 tem, attributed sleep to the using- up of oxygen and the ac- 
 cumulation of waste products ponogenes, as he called them 
 in the brain and nervous S3 r stem. He says: "During- an 
 active condition of mind and body, certain substances are 
 broug-ht into existence which are not found (at all events very 
 sparingly) during a state cf rest: lactic acid, for example, 
 and creatin. These latter substances may accumulate in the 
 blood, and as they have a great affinity for oxygen, they ap- 
 propriate a principle required for active exertion. The first 
 stage of this accumulation characterizes fatigue, the second 
 stag-e gives rise to sleep, and the third, when oxidation has 
 been completed, is followed by awaking/' Preyer, however, 
 adds that the artificial introduction of lactic acid, or of the 
 lactates, into the system has not always been followed by 
 sleep. This failure of the lactates to produce sleep has been 
 noted by many others. According to Ehrlich the products of 
 cerebral cell activity are acid. 
 
 "While waste products may be a factor, sleep is not to be 
 explained on such grounds solely: they do not account for the 
 tendency to sleep while travelling by rail in hot weather, and 
 other similar facts, as sleep thus induced bears no relation to 
 the amount of mental work done. 
 
 Again, idiots, the feeble-minded, and even healthy persons 
 whose brains are inactive, sleep much longer than active- 
 minded men: this is due to the bloodless condition of their 
 brains, and not to their need for recuperation. Cases have 
 been recorded from time to time of persons sleeping during 
 several days, without it being suggested that they had .made 
 any severe calls upon their intellectual apparatus. 
 
 Vital Alkaloids. Last year Professor Leo Erraro, of 
 Brussels, in an elaborate essay founded chiefly upon the physio- 
 logical work of Professor Gautier and others, raised the theory 
 that sleep is due to the manufacture in the body of vital alka- 
 loids leucomaines basing his arguments mainly upon the 
 fact that G. Pouchhart and Bouchard had found alkaloids in 
 human urine (p. 507), and that Gautier had discovered in hu- 
 man saliva, alkaloids which were venomous or narcotic, at 
 least to birds. He states in further proof of his theory that
 
 22 Insomnia and its Therapeutics. 
 
 Gautier has Shown that creatin leucomames exert a power- 
 ful influence upon the nervous centres, producing" drowsiness 
 and fatig-ue, and at times purging- and vomiting-. Erraro 
 compares the action of leucomames to that of narcotics such 
 as morphine, and supports the comparison by stating that 
 "Beturk and: Van Dissel assure me that of forty-two vege- 
 table alkaloids known to them, only morphine partakes with 
 ptomaines the property of forming- Prussian blue, by the re- 
 duction of the perchloride of iron and of the ferricyanide, and 
 this in spite of the presence of an oxidant as energ-etic as an- 
 hydrous chrome." Leucomames for the most part, according- 
 to Gautier, resemble ptomaines in being- hig-hly oxidizable. 
 Morphine is also easily oxidized. He deduces from the above 
 data that muscular and cerebral work result in waste of the 
 muscular and cerebral tissues, and that these waste products 
 take the form of leucomames, which, by accumulating-, cause 
 a sensation of fatig-ue,, and intoxicate the superior nervous 
 centres to the point of inaction, which is equivalent to sleep. 
 During- sleep these products are slowly oxidized, and when 
 the oxidation is completed waking- ensues. 
 
 Dr. A. M. Brown, in his work on "Animal Alkaloids,'' in 
 discussing- the observations of Gautier and Bouchard on the 
 toxic qualities of the human saliva and urine respectively, 
 dwells upon the toxic narcotic quality of the saliva and urine 
 eliminated during- the day, and the convulsive quality of the 
 urine secreted by nig-ht. He refers to Houg-eney's sug-g-estion 
 that the nig-ht saliva of man may also be convulsive, and adds : 
 "It would certainly be remarkable, if true, to find the alkaloid, 
 in the interrupted succession of physiological effects, guaran- 
 teeing, as it were, the alternation of sleep and wakefulness." 
 
 The Oxygen Theory. A. von Humboldt, toward the end of 
 the last century, propounded the idea that sleep is due to the 
 want of oxyg-en; and Dr. (now Sir Lyon) Play fair, nearl}- half 
 a century ag-o, pointed out that everything- which robs the 
 brain of oxyg-en conduces to sleep. Since then, the subject 
 has never failed to receive attention; and the theory advanced 
 by Humboldt has also been upheld by Sommer, who refers in 
 support of his statements to the observations of Pettenkoffer 
 and Voit briefly alluded to on p. 507. 
 
 This is well exemplified in the drowsiness which affects a 
 congregation in a badly ventilated church. (In former years,
 
 Insomnia and its Therapeutics. 23 
 
 when less attention was paid to the renewal of the air in 
 places of worship than is customary at present, the pew- 
 openers were armed with long poles, having* a fox's tail at- 
 tached to the one end, to tickle the faces of the slumbering" 
 females, and a hard knob at the other end, to awake the 
 sleeping- males, by striking- them over the head !) 
 
 Pfliigger in 1875 showed that the brain is extremely sensi- 
 tive to the want of oxygen (thereby confirming- Dr. Playfair's 
 statement), and that when frogs are deprived of it for any 
 length of time they gradually fall into a condition resem- 
 bling- sleep. He believed that the activity of the psychical 
 cerebral cells depends upon the quantity of intra-molecular 
 oxygen they contain; and that, in the gray matter particu- 
 larly, all function is attended by oscillating or explosive 
 movements in the cells, these movements being caused by the 
 combination of the oxygen therein contained with certain car- 
 bonaceous particles in the tissues, oxygen disappearing and 
 carbonic acid being formed. If these movements continue to 
 use up oxygen at a greater rate of speed than the circulation 
 can replace, a time comes when the cerebral cells suffer from 
 the want of oxygen and the accumulation of carbonic acid; 
 the explosive movements, meanwhile, growing more and more 
 feeble, and psychical operations more and more debilitated, 
 until eventually sleep ensues. 
 
 In this connection it must be remembered that the nervous 
 tissues derive their oxygen from the blood, and that when the 
 blood is deficient in oxygen-carrying corpuscles, these textures 
 suffer to the same extent that they would from an atmo- 
 sphere defective in oxygen ; and being semi-starved they grow 
 irritable and hyper-sensitive. 
 
 The absence of external stimuli, such as exists in the dark- 
 ness and quietness of the night, has been advanced as a cause 
 of sleep, and not without reason. Strumpell, for instance, re- 
 corded a case of a girl of sixteen who became almost entirely 
 anaesthetic, so that she was unable to perceive the most vio- 
 lent stimulation of the skin and mucous membranes, while the 
 muscular sense and even the sense of muscular fatigue were 
 lost. Relations with the outer world were preserved by two 
 channels only the right eye and the left ear and if the eye 
 was bandaged and the ear plugged she fell asleep in a few 
 minutes. She could be awakened by stimuli acting on the
 
 24 Insomnia and its TJicrapeutics. 
 
 eye or ear, but if left alone she awoke naturally, in response, 
 apparently, to the action of some internal stimulus. 
 
 Periodicity. Sleep has also been attributed to the law of 
 periodicity which governs all natural things. In the vege- 
 table world these periodic changes are well seen, the growth 
 of plants being more rapid during the night than during the 
 day, while the leaves of many of them assume different pos- 
 tures during the alternating periods of growth and rest, as 
 Linnaeus first pointed out, and that although the plants are 
 shut up in a room from which all light is excluded. In the 
 animal kingdom the same periodicity is observed as regards 
 rest and work, and this holds good even in the case of those 
 centres in the medulla oblongata which apparently never 
 slumber those, namely, which preside over the circulatory, 
 respiratory, alimentarj^, and other systems. There is, for in- 
 stance, a period of rest between every expiration and inspira- 
 tion; the gastro-intestinal operations are carried on intermit- 
 tingly; while the heart has also ample time for rest. Dr. Yeo 
 writes: "If we assume the human heart to beat some seventy 
 times a minute, each cycle would occupy about eight-tenths 
 of a second, which would be made up as follows: auricular 
 systole = one-tenth of a second, ventricular systole = three- 
 tenths of a second, while the pause (or rest) would equal four- 
 tenths of a second/' This rhythmic repose is greater during 
 sleep, when the heart beats more slowly, so that the heart 
 enjoys nearly twelve hour's rest out of every twenty-four. In 
 like manner the nervous system, being constantly employed 
 during waking hours, requires periodic repose, which it can 
 only obtain during sleep. While this explains the need for 
 sleep, it throws no light upon its causation. 
 
 Sleep by Suggestion. Considerable attention has been 
 paid of late years to hypnotism, and many observers believe 
 that natural sleep is due to self-hypnotism that a man sug- 
 gests to his mind " sleep," goes to his bedroom for the express 
 purpose of sleeping, and sleeps by " suggestion." Many argu- 
 ments are advanced to support this view; one being that if a 
 man wishes to rise at a particular hour in the morning he 
 suggests to his mind before falling asleep that he must awake 
 at that hour, and frequently does so. 
 
 Dr. Brown-Sequard lately propounded a theory that sleep 
 is due to an inhibitory act in the nervous system.
 
 Insomnia and its Therapeutics. 25 
 
 These last two theories appear to be quite untenable. 
 
 Having- now stated at some length several of the theories 
 as to the causation of sleep, it only remains to reiterate the 
 remark made in the opening- sentence, that no one of them 
 can be accepted as settling- the subtle problem. Whatever 
 may be the immediate cause, the need for sleep is well ex- 
 plained by the fatigue of daily toil, in which waste products 
 are manufactured quickly and energy is expended, and that a 
 time of rest is required for the removal of the one and the re- 
 cuperation of the other. 
 
 DREAMS. 
 
 No account of sleep would be complete which did not em- 
 brace the subject of dreams; for it is only by reviewing- the 
 two subjects in connection with each other that any compre- 
 hensive acquaintance with either can be gained. 
 
 It is hig-hly probable that all animals possessing- brains 
 dream. Dog-s and other animals frequently give evidence of 
 this in their sleep by noises and movements which testify to 
 activity in the cerebral centres. Lucretius believed that dog-s 
 hunted in their sleep. That their dreams are not always 
 pleasant is indicated by their awaking suddenly in a state of 
 agitation. It is well known that animals suffer like the 
 g-enus homo from nightmare and somnambulism, while they 
 can be readily hypnotized. 
 
 Dreams are manifestations of partial or disturbed sleep, 
 and show that there are unequal degrees of activity in the 
 psychical centres, some having- abdicated their functions in 
 slumber, while others are in varying- degrees of activity. 
 Those which are asleep no longer guide and rectify the work- 
 ing of those which are awake or partially awake. It seems 
 likely that the active centres, besides being divorced from 
 those asleep, enter into unusual associations, which result in 
 distorted functions i.e., in disjointed and absurd aberrations 
 of thought. During waking moments thoughts and actions 
 are under the direction of the will, our highest faculties being 
 employed to guide them. Throughout sleep the will is de- 
 throned and sensibility suspended that being the essence of 
 sleep. It follows, necessarily, that the will can no longer 
 dominate thought and movement; and if we recollect that the 
 active psychical centres are uncontrolled by those which are
 
 26 Insomnia and its TJicrapcutics. 
 
 asleep, while their activity is disorderly and their operations 
 are badly correlated, we can well understand how our dreams 
 run on without rhyme or reason. 
 
 It has been suggested, with every probability of truth, that 
 when many centres are active, dreams are consistent and 
 coherent, while when few centres are working 1 they are unreal 
 and extravagant; stated briefly, the difference in the quality 
 of dreams appears to depend on the depth of sleep. 
 
 Dreams occur most frequently at the commencement and 
 .termination of sleep, the inequality in the state of the cerebral 
 centres being the condition necessary and suitable for their 
 development. They are of importance to the physician in in- 
 dicating some disturbance in the economy which might other- 
 wise pass unnoticed: e.g., they are frequently premonitory 
 symptoms of apoplexy and phthisis pulmonalis, and they may 
 be excited by sensations due to dyspepsia, which are trans- 
 mitted to the brain. In manj 7 instances dreams bear some 
 relation to their exciting causes: Maury's observations upon 
 himself in reference to this subject are well worthy of study. 
 Dreams occasionally exert such a powerful influence upon the 
 mind as to leave permanent impressions, and that in men and 
 w r omen of the strongest intellect and the greatest courage 
 people who would be ashamed to confess the fact, even to 
 themselves. 
 
 Dream-laden sleep is never refreshing; persons who dream 
 much rise in the morning as tired as when they \vent to bed. 
 The brain as a whole is not rested while intellectual operations 
 continue, and its hyperaemic condition is unfavorable for its 
 nutrition. 
 
 Somnambulism, or sleep-walking, occurs when the centres 
 of consciousness are asleep, the motor centres being awake or 
 active. Uninhibited by certain psychical centres, the sleep- 
 walker's muscular sense is apparently increased, enabling him 
 to walk about and perform feats which he would not, in his 
 waking moments, undertake. He does not see, hear, or smell; 
 he is wrapt up in the dream he is acting, and seldom recollects 
 that he has walked during his sleep. To this subject we shall 
 recur. 
 
 Hypnotism. Three conditions are described : the lethargic, 
 the cataleptic, and the somnambulistic, the latter being a 
 state of artificial somnambulism. The condition has been
 
 Insomnia and its Therapeutics. 27 
 
 recognized from the earliest ages. Mesmer, in the middle of 
 last century, gave an impetus to its study ; Mr. Braid, of Man- 
 chester, directed much attention to it about 1843; and of late 
 years it has been extensively studied by Charcot, Liebault, 
 Heidenheim, and others, being largely used on the Continent 
 as a means of cure by " suggestion." Mr. Braid showed that 
 a person fixing his attention steadfastly upon a luminous or 
 dark object held a little above and in front of his eyes, so as 
 to produce a convergent and superior squint, fell into a deep 
 sleep, during which he was powerless to change his condition, 
 except at the instigation of the operator. It is necessary, 
 however, that the mind should be concentrated upon the ob- 
 ject and the will wholly surrendered to the influence of the 
 operator. Hypnotism can be produced in many other ways, 
 but as no reference will be made to it as a means of treating 
 insomnia, it is not necessary to consider it in more detail.
 
 CHAPTEE II. 
 
 GENERAL REMARKS ON INSOMNIA. 
 
 THE word " insomnia/' which signifies the want of sleep, is 
 used, popularly, to indicate any interference with the depth 
 or duration of that condition; and it is in this wide sense that 
 the word will be used in these pages. 
 
 Insomnia is an evidence of vigilance in the cerebral cells, 
 initiated and maintained by some perturbing element in the 
 system, of which it may be the sole symptom. It is thus de- 
 signed to subserve a highly conservative purpose. In some 
 instances it attracts attention to ailments that might other- 
 wise elude detection ; while in many cases it is a necessity for 
 the preservation of life, as, for example, in some diseases of 
 the heart and lungs, in which consciousness is required for the 
 maintenance of respiration. 
 
 It is not a disease, but a symptom of many diseases, differ- 
 ing widely in their nature and complexity, as well as gravity. 
 It is associated equally with trivial ailments and with affec- 
 tions which jeopardize life. Its severity and persistence is no 
 guide to the diagnosis of the disturbance upon which it de- 
 pends, for in such important lesions as organic diseases of the 
 brain it may be absent, while it is a frequent and obstinate 
 symptom in such prevalent affections as the functional de- 
 rangements of digestion. Again, diseases which are wont to 
 give rise to insomnia cannot be said to do so uniformly or 
 constantly. A disease may produce it in a pronounced form 
 in one patient, in a modified degree in a second, and not at all 
 in a third; and it may originate it in a patient at one time 
 and not at another. The wakefulness appears in every case 
 to be influenced and biassed by the condition of the nervous 
 system, the temperament of the patient, and by the state of 
 the general health at the time. 
 
 In many severe diseases, e.g., typhus fever, sleeplessness 
 per se endangers life, by increasing the enfeeblement and ex-
 
 Insomnia and its TJicrapcutics. 29 
 
 haustion at a critical juncture, when a refreshing- and quiet 
 sleep would conserve the limited store of strength the patient 
 possesses. In cases such as these we are justified in ranking- 
 sleep as a powerful curative agent, and sufficient, of itself, to 
 determine recovery. 
 
 In less important disorders in which insomnia is an un- 
 yielding S3*mptom, it is not only the source of much misery 
 and discomfort, but it entails upon the sufferer a grievous 
 hardship, in that he has to fight the battle of life in a maimed 
 condition. Deprived of the nightly restoration of his potential 
 energ3 r , his brain grows weary, and his whole mental and 
 physical vigor becomes impaired; and if, in these circum- 
 stances, he persists in striving to work, he encroaches upon 
 his fund of reserve force to such an extent as to lead eventu- 
 ally to the bankruptcy of his nervous system. A man's power 
 of work is intimately related to his ability to sleep, and there 
 is no more reliable indication of sound health than the capacity 
 to sleep naturally. 
 
 Sleep has been called " Jbhe chiefest thing- in physic." As a 
 restorative, it has neither substitute nor rival; it is co-equal 
 in importance with food and clothing for the preservation of 
 life. 
 
 It will materially assist us in the clinical study of insomnia 
 if we consider, further, certain physiological and pathological 
 facts appertaining to sleep. 
 
 First of all we may predicate that sound nervous structures, 
 'properly nourished, adequately rested, and rightly exercised, 
 are fundamental desiderata for good sleep; and on the other 
 hand, that all circumstances interfering with the health, nu- 
 trition, repose, and working of the nervous textures are detri- 
 mental to sleep. Let us glance very shortly at these points. 
 
 found Nervous Structures. These comprise typical cells 
 of stable character, normal nerve fibres, neuroglia, blood- 
 vessels, pericellular and perivascular spaces, etc. We pro- 
 pose to refer to the first two essentials only, the cells and 
 their connecting nerves, as the remarks regarding them will 
 suffice to illustrate the fact that any defect in one or more of 
 these structures must of necessity disturb the harmonious 
 working of the others, and initiate disordered function; while 
 they will exemplify the truth of the old saying that " a chain 
 is no stronger than its weakest link."
 
 30 Insomnia and its Therapeutics. 
 
 Cerebral cells vary very considerably in their construction, 
 size, and shape according to the special functions they sub- 
 serve. For example, some possess the power of perceiving 
 and registering impressions transmitted to them, and others 
 of emitting special and individual impulses which they have 
 originated. These functions, whether psychical, sensorj-, or 
 motor, necessitate a faculty for storing up nervous or poten- 
 tial energy and discharging it in response to normal stimuli 
 a capacity distinctly characteristic of their health. 
 
 Cerebral cells differ greatly in the degree of stamina they 
 possess. They are so inherently strong, in some persons, as 
 to be able to resist in a great measure the effects of work and 
 strain; while, primarily or congenitally feeble, or secondarily 
 debilitated by unhealthy conditions in others, they are vul- 
 nerable and soon break down under the wear and tear of 
 everj'-day life. They display their enfeeblement in an incom- 
 petency to accumulate nervous force, and in discharging it in 
 response to trivial excitations. Such cells, in short, are irri- 
 table and impressionable, and thus liable to disturb sleep. 
 
 Some cells have their functions so perverted by imperfect 
 nourishment and other causes that they originate erroneous 
 sensations spontaneously; for example, in hypochondriasis. 
 
 - Unrest in the cerebral cells is perpetuated by faulty condi- 
 tions inherent in themselves; by sensations combed to them,) 
 whether from the interior or exterior of the economy ; f and 
 an altered state of nutrition, (an exciting cause whicH will b 
 considered in detail under the section on normal metabolism. 
 
 All diseases interfering with the integrity of the cells are 
 apt to lead to modifications of sleep. When organic, they 
 usually cause insomnia in the early stages; in the later there 
 is often the reverse condition of coma. When functional, as 
 from continued psychical operations, they are invariably at- 
 tended by insomnolenc3 T . 
 
 When activity is excited in the cells by perturbing sensa- 
 tions originating in distant parts, the sensations are trans- 
 mitted by cells at the distal extremities of the nerves or nerve 
 endings, cells which exist in every portion of the mucous and 
 cutaneous surfaces, as well as in the deeper structures, and 
 which vary in size and shape according to the special function 
 that they subserve. These terminal cells transmit different 
 sensations too numerous to specify, but those of light, sound,
 
 Insomnia and its TJierapeutics. 31 
 
 and pain, and of hunger and fatigue, may be mentioned to 
 indicate the diversity of their functions. 
 
 Each description of cell, however, practically acts in a 
 similar manner, receiving- and transmitting its own particular 
 kind of sensation to its own special centre in the brain. For 
 example, the terminal endings of the auditory nerve can only 
 receive and transmit impressions of sound, and these must 
 reach the centre for hearing before they can be recognized. 
 All conditions (such as diseases affecting the periphery, organs, 
 viscera, etc.) implicating and interfering with the integrity of 
 these terminal cells, render them irritable and liable to project 
 impressions arising from insignificant causes. 
 
 Nerve fibres of varying structure connect the cerebral and 
 peripheral cells. For their efficient function they are depen- 
 dent upon the integrity of the cells they represent. When 
 the cells are faulty, the nerves participate in the irritability, 
 and convey trifling impressions in an amplified manner. This 
 is well exemplified in the exaggerated reflexes in some neuras- 
 thenic conditions, and still more palpably when degeneration 
 has followed destruction of the cerebral cells, as in hemiplegia. 
 
 In health, sensations thus conveyed to the cerebral cells 
 arouse activity which is incompatible with sleep, for their per- 
 ception in the various centres in the brain induces in them a 
 concurren/hyperaemia, an occurrence to which we must revert 
 at some length immediately?} 
 
 f For instance, an excess of light in a bedroom, such as pro- 
 ceeds from a fire, or in /summer from the early morning light, 
 often prevents sleep.^/To many, complete absence of light is 
 an essential condition for sleep. It is recorded that Napoleon 
 I. (to whose sleeping powers reference will hereafter be made) 
 could only fall asleep in total darkness. 
 
 Noises, too, not necessarily loud, but out of place, act in 
 like manner on a limited number of persons. One constantly 
 reads in the newspapers of actions being brought against the 
 owners of dogs and poultry, by people whose early slumbers 
 are disturbed by barking and cock-crowing. Certainly, many 
 persons have their rest disturbed for some time after coming 
 to town from the country, and others cannot sleep with a 
 clock ticking in their bedroom. 
 
 Smells occasionally hinder sleep, although they are seldom 
 capable of interrupting it. Of the power of smells to hinder
 
 32 Insomnia and its Therapeutics. 
 
 sleep, the writer recently had practical experience while trav- 
 elling in a sleeping carriage, the musty, dusty odor of the 
 mattress rendering it impossible. 
 
 Pillows of hops, wormwood, mandrake, henbane, and poppy 
 capsules were used in olden times as aids to sleep; more re- 
 cently, those composed of the flowers of the lime tree and of 
 the leaves of the blue gum tree have been recommended. 
 Neither of these has been found reliable, the writer believes, 
 because their odor not infrequently prevents sleep. 
 
 Many enfeebled persons are extremely sensitive to odors, 
 and are apt to be kept awake by trifling effluvia. They are 
 equally susceptible to insignificant noises and other sensory 
 impressions which in health they would not heed. Their com- 
 plaint that they cannot sleep for reasons which appear to be 
 paltry seems to be well-grounded, as they sometimes get to 
 sleep quickly when the source of disturbance is removed. 
 
 Taste may also thwart sleep. For example, since cascara 
 sagrada has come into general use as a purgative, many pa- 
 tients have complained that its taste kept them from sleeping. 
 
 Painful sensations are able both to prevent and to inter- 
 rupt sleep. It is practically the same wherever the pain 
 arises, whether central, peripheral, or in the course of the 
 nerves, the pain being referred to the terminal branches of the 
 nerves. Sensations far short of pain, such as those arising 
 from cold feet, and from the irritation of eczema, pruritus, 
 etc., or perverted sensations, as formication, are all able to 
 prevent or, if already induced, to terminate sleep. In skin 
 affections, sleep, good or bad, is intimately associated \vith 
 improvement or the reverse in the progress of the disease. 
 
 Sleep is the chosen time for the onset of many painful af- 
 fections, such as the passage of biliary and renal calculi, and 
 many diseases having " algia " as the terminal sj'llable of their 
 names. It is also the time when neuralgic, syphilitic, and 
 other pains become aggravated. 
 
 Normal Metabolism. Insomnia, from whatever source, 
 is so constantly associated with perverted cerebral vasculari- 
 zation, that for all practical purposes we may conclude that, 
 primsfrily or secondarily, it is excited and maintained by an 
 alteration either as regards the quality or the quantity, the 
 access or the egress, of the nutritive fluid. 
 
 Healthy cerebral cells require for their recuperation and
 
 Insomnia and its Therapeutics, 33 
 
 depuration a normal blood-suppty. They are extremely sensi- 
 tive to all interference with their nourishment. For example, 
 they speedily evince the effects of imperfectly oxygenated 
 blood in headache and drowsiness, and still more permanently 
 the consequences of an impaired metabolism in irritability by 
 day and sleeplessness by night. In the course of this work 
 we shall require to consider this subject fully in connection 
 with the sleeplessness which occurs in the various fevers and 
 cachexise, and in gout, syphilis, etc. 
 
 Cells inherently weak manifest still more markedly such 
 defective nutrition. 
 
 It will be advantageous to review here some of the de- 
 rangements which are apt to occur in the circulation of the 
 brain. 
 
 Congestion or hyperaemia of the brain occurs in two forms, 
 active and passive. The first is accompanied by an increased 
 arterial supply; the second by venous stasis. These may exist 
 in all possible degrees and in very varying extent, and the 
 congestion may be slight and partial, or severe and general. 
 
 Active hyperaemia may occur in the form of a slight and 
 transient congestion of a very limited portion of the cerebral 
 tissue, or as a more pronounced general congestion, which is 
 the first stage of inflammation. It is only to the slighter 
 cases that reference will be made. It is influenced by sex and 
 age. Men are more liable to cerebral congestion than women 
 and children, their mental and bodily activity rendering them 
 so; though women with finely-developed and sensitive nervous 
 systems are frequently the victims of irritable cerebral cells, 
 which give rise to hyperaemia. Children suffer from it occa- 
 sionally in consequence of digestive disorders, and also during 
 the process of teething. 
 
 It is most frequently seen in persons of sanguine tempera- 
 ment, who have a tendency to vascular derangements; in the 
 plethoric, with their florid countenances, short necks, and ten- 
 dency to obesity; and in those who have a well-marked gouty 
 diathesis. 
 
 Mosso found, in his experiments, that all mental exertion 
 and emotional excitement were accompanied, in health, by 
 functional hyperaemia of the brain. This is quite in accordance 
 with the law that the blood-supply of an organ varies with 
 the work it has to do.
 
 34 Insomnia and its Tlierapeutics. 
 
 It occurs as the result of all diseases which increase the 
 force and frequency of the heart's action, and which raise the 
 vascular tension unduly; it is present also in some diseases of 
 the blood-vessels; chronic alcoholism; the morphine habit; 
 organic diseases of the brain; and in some functional derange- 
 ments of the lungs, liver, and gastro-intestinal canal, etc., etc. 
 
 Passive hyperaemia exists, like the active form, in all de- 
 grees of severity. It is due to accumulation of blood in the 
 veins and sinuses of the brain, a condition which frequently 
 gives rise to coma. The blood, impeded in its return to the 
 heart, not only becomes a disturbing element, by hindering 
 the capillary circulation, but, venous blood being unsuitable 
 for the purposes of nutrition, the nervous textures are starved, 
 and so rendered feeble and irritable. The causes of passive 
 congestion of the brain are chiefly those which act by ob- 
 structing the free return of blood from the head, such as 
 valvular lesions of the heart, especially if the right ventricle 
 is dilated and the lungs and other organs are engorged; 
 aneurisms or tumors pressing upon the veins of the neck; 
 severe coughing, particularly whooping cough; bronchitis and 
 emphysema of the lungs; croup and laryngeal diphtheria. 
 
 Anaemia of the brain depends upon a cerebral blood-supply 
 deficient in quantity or quality, or both combined. If the 
 quantity is greatly reduced, the symptoms to which the im- 
 poverished blood gives rise are aggravated by the interference 
 with the normal pressure within the skull. Anaemia may be 
 trivial and partial, or severe and general. Among the causes 
 are: Hemorrhage, as in accidents or operations; uterine hem- 
 orrhages, post-partum or otherwise; epistaxis; haemoptj'sis, 
 haematemesis; hemorrhoidal losses. Exhausting diseases, es- 
 pecially those accompanied by profuse discharges, as in deep- 
 seated suppuration, excessive diarrhoea, and leucorrhoea; con- 
 tinued fevers; septicaemia; malarious and cachectic conditions, 
 and wasting complaints; severe inflammatory diseases. Af- 
 fections interfering with the calibre of the cerebral arteries, 
 such as Bright's disease; syphilis, aneurism, or tumor obstruct- 
 ing the lumen of the vessels, and complicated sometimes by 
 passive congestion; embolic and thrombotic obstructions. 
 "Shock," caused, for example, by fright; the too sudden emp- 
 tying of the pregnant uterus when there has been an excessive 
 accumulation of liquor amnii; the sudden evacuation of a large
 
 Insomnia and its Therapeutics, 35 
 
 ovarian cyst or of a collection of ascitic fluid; the too rapid 
 emptying 1 of an over-distended bladder in certain enfeebled 
 states of the system. Heart disease, when the quantity of 
 blood sent to the brain is inadequate in amount, as in some 
 kinds of aortic and mitral disease and in fatty degeneration. 
 Poisonous agents in the system. 
 
 We must now inquire into several subservient agencies 
 which exert a very decided influence upon the circulation of 
 the brain and, consequently, upon sleep. 
 
 Vascular Tension. This was alluded to in enumerating 
 the causes of cerebral hypersemia. Its modifications, either 
 in the way of increased or diminished blood-pressure, are so 
 invariably associated with insomnia, that a few words must 
 be said regarding- the conditions under which these occur. 
 
 The blood-pressure is increased when the calibre of the 
 arterioles is narrowed, and that whether it is due to spasm or 
 to organic changes in the walls of the vessels themselves. In 
 the former case, it may depend upon stimulation of the vaso- 
 motor centre, as in great emotional excitement, hysteria, an- 
 gina pectoris, or in the chills which mark the onset of acute 
 diseases and the cold stag-e of the intermit tents. It may like- 
 wise result from the presence of some noxious agent in the 
 blood, such as lead, ergot of rye, etc., or the materies morbi of 
 g-out. It occurs also, in all cases, where the heart beats with 
 unusual force and rapidity, as in hypertrophy, particularly if 
 it is associated with mental excitement; in pregnancy, in ob- 
 structive diseases of the lungs, such as bronchitis, and in con- 
 stipation of the bowels. 
 
 Increased arterial tension is indicated by such signs as 
 hard and incompressible arteries; accentuation of the second 
 sound of the heart best heard in the aortic area, and prolonga- 
 tion of the first sound most marked in the mitral area; and 
 by symptoms, such as sleeplessness, increased micturition, etc. 
 
 Decreased arterial tension depends upon the reverse condi- 
 tions. It occurs when the arterioles are dilated, as in all 
 paralyzing influences acting on the vaso-motor centres, such 
 as distressing emotions; in weak and enfeebled states of the 
 system, as in anaemia or phthisis pulmonalis and cachexiae; in 
 the course of most of the continued fevers; and very markedly 
 in those diseases in which the strength is drained by exhaust- 
 ing discharges, e.g., menorrhagia, etc. A weak heart beating
 
 36 Insomnia and its TJicrapcutics. 
 
 slowly and feebly is constantly associated with .low tension. 
 It may be remembered, however, that a certain amount of re- 
 laxation of the blood-pressure is one of the essential factors 
 in producing good sleep. The signs -of decreased vascular 
 tension are soft and compressible arteries; enfeebled cardiac 
 sounds, the first being occasionally inaudible, etc. 
 
 CARDIAC AND VASO-MOTOR CENTRES IN THE MEDULLA OB- 
 
 LONGATA. 
 
 ^Cardiac Centres. This very important region contains 
 certain nerve centres governing the heart, by means of which 
 its action is inhibited or accelerated, these being in the most 
 intimate relation with the whole nervous system. Pleasur- 
 able emotions, for example, by acting upon them, cause the 
 heart to beat more vigorously; while sudden fright may, 
 through their agency, arrest its action. Impressions of which 
 \ve are unconscious, transmitted through the vagus from the 
 gastro-intestinal canal, may be sufficiently strong to cause 
 inhibition of the cardiac action and intermission of the pulse. 
 Similar sensations may be conveyed by nerves from every 
 part of the body, so that the closest and most sensitive con- 
 nections are established between the whole organism and the 
 heart. Everything which tends to enfeeble the body neces- 
 sarily leads to disorderly movements of the heart, which are 
 shown by its halting, irregular, and excited pulsations. 
 
 'aso-motor Centres. These are probably in close proxim- 
 ity to the cardiac centres in the medulla (they are so located 
 in the rabbit). By means of the nerves with which they are 
 in connection, they so act upon the muscular walls of the 
 arteries, throughout the entire body, as to cause dilatation 
 and contraction, with a corresponding increase and decrease 
 in the amount of blood that they contain. These vaso-motor 
 centres in the medulla, which are the dominating centres, and 
 probably made up of constricting and dilating mechanisms, 
 are supplemented by many minor centres situated in as many 
 different parts of the gray matter of the spinal cord. Lanclois 
 and Stirling state that " From the vaso-motor centre fibres 
 proceed directly through some of the cranial nerves to their 
 area of distribution; through the trigeminus partly to the 
 interior of the eye, through the lingual and hypoglossal to the
 
 Insomnia and its Therapeutics. 37 
 
 ongue, through the vagus to a limited extent to the lungs, 
 and to the intestines." . . . "All the other vaso-motor nerves 
 descend in the lateral columns of the spinal cord." ..." In 
 their course through the cord, these fibres form connections 
 with the subordinate vaso-motor centres in the gray matter 
 of the cord, and then leave the cord either directly through 
 the anterior roots of the spinal nerves to their areas of dis- 
 tribution, or pass through the rami communicantes into the 
 sympathetic, and from them reach the blood-vessels to which 
 they are distributed." It follows that the vaso-motor centres 
 are in the most delicate and intimate relation with the sensori- 
 motor nerves, as well as with the sympathetic ganglionic SA-S- 
 tem, and are so sensitive that they are readily affected by 
 alterations in the quantity and quality of their blood-supply. 
 The vaso-motor nerves are probably of two kinds. One variety 
 has the function, when stimulated, of causing contraction of 
 the vessels and increased blood-pressure the vaso-constric- 
 tors; the other has the power, when stimulated, of producing 
 dilatation of the vessels and diminished blood-pressure the 
 so-dilators. 
 
 The centres which control these dilators probably act 
 through reflex impressions. When the vaso-constrictors are 
 inhibited, the arterial vessels dilate and the blood-pressure is 
 lowered. In health, the vaso-motor centres, higher and lower, 
 with their nerves, co-ordinate, in order to preserve in all the 
 arteries of the body a certain amount of contraction, known 
 as " arterial tone." Interference with this tonicity may be 
 confined to limited areas or it may become general, according 
 to the nature of the disturbing influence; but whether local 
 general, the medullary centres dominate the whole. 
 
 These cardiac and vaso-motor centres are intimately asso- 
 ciated in the medulla oblongata with many other centres of 
 the greatest importance, such as those of respiration, mastica- 
 tion, deglutition, secretion of saliva, vomiting, sneezing, and 
 those for the sweat glands, as well as others of less impor- 
 tance. If to this be added the fact that all the cranial nerves 
 except the first four have their origin in the medulla, and that 
 all sensory and motor impulses to and from the brain pass 
 through it, it will be apparent that the cardiac and vaso-motor 
 centres are in the very closest proximity to centres and chan- 
 nels which control and communicate with every part of th
 
 38 Insomnia and its Therapeutics. 
 
 body, and that they must be influenced by impressions con- 
 veyed to them by contiguity as well as by continuity. Vomit- 
 ing, for instance, is of frequent occurrence after prolonged fits 
 of coughing, and it can only be satisfactorily explained upon 
 the theory that the excitement in the centre for cough spreads 
 to that for vomiting. Sweating, likewise, is caused by stimu- 
 lation of other centres in the vicinity of its particular centre ; 
 e.g., many persons whose sleep is disturbed are prone to wake 
 bathed in cold perspiration. In further illustration of the fact 
 that excitement spreads from one centre to another, it may be 
 mentioned that the writer has twice lately witnessed most 
 profuse sweating, in a case where the exciting cause was a 
 dyspeptic attack of nervous origin, in which vomiting and op- 
 pression of breathing were marked symptoms. 
 
 Cough, depending upon distant excitations, such as spinal 
 irritation, arises in a similar-manner. If investigators are 
 able in the future toUemonstrate the existence of centres for 
 gout and other constitutional diseases, which are at present 
 supposed to exist in the medulla oblongata, in close proximity 
 to the vaso-motor centres, it will be easy to understand why 
 sleeplessness is so apt to supervene in these affections. 
 
 'hat mental impressions affect the vaso-motor and cardiac 
 centres, we have ample evidence in the pallor induced by fear; 
 while we know that stimulation of any of the sensory nerves 
 leads at once to modification of blood-pressure,. particularl3 r 
 in that of the brain. It has been suggested that this is the 
 mechanism by which the safety of sleepers is secured. Altera- 
 tions in the quality of the blood lead to changes in the cardiac 
 and vaso-motor centres, their irritability being increased, with 
 
 \ consequent contraction of the arteries, when the blood is cle- 
 
 \ ficient in oxygen. 
 
 xThe sympathetic or ganglionic nervous system exercises 
 An important influence upon sleeplessness. Dominating as it 
 
 / does the nutritive processes, and acting as a direct channel of 
 communication between the viscera and the brain, it conveys 
 
 \ impressions arising out of deranged functions, which often 
 lead to insomnia. 
 
 It does not seem advisable to pursue this interesting ques- 
 tion a greater length, sufficient data having been advanced to 
 indicate its bearing upon the subject under consideration. 
 The diseases enumerated as causes of active and passive
 
 Insomnia and its Therapeutics. 39 
 
 congestion and anaemia of the brain, as well as the conditions 
 giving rise to alterations in the vascular tension, etc., will, if 
 carefully scanned, be seen to correspond, with wonderful ex- 
 actness, to a list of the diseases which give rise to insomnia. 
 It is not for a moment alleged that the list is by any means 
 complete, or that insomnia depends solely upon these vascular 
 derangements, brought about, in some cases, by the influence 
 of the brain and nervous system; 'but these preliminary con- 
 siderations go some way in the direction of a rational ex- 
 planation of the causation of insomnia, upon which we may 
 reasonably hope to found a broad and enlarged conception of 
 the subject, as we go on to consider in detail some of the nu- 
 merous diseases of which it is a symptom. 
 
 Adequate Repose. In the preceding chapter we saw 
 that repose was necessary for restoration of the equilibrium 
 in the nervous system for the removal of the products of 
 waste, and the renewal of nervous energy. 
 
 The loss of a single night's sleep shows its effects on the 
 nervous system in the exhaustion, drowsiness, irritability, 
 febrile disturbance, and digestive derangements which ensue. 
 The tone of the whole body is lowered to such a degree, as 
 every medical man knows by experience, that it invariably 
 requires more than one good night's sleep, to restore the in- 
 dividual to his accustomed mental and physical state, justify- 
 ing the old saying that " one good night's sleep requires an- 
 other." 
 
 When sleep is voluntarily limited for any length of time, 
 the consequences are perceived in a still more marked degree, 
 and may be well studied by examiners in medicine in the per- 
 sons of young and healthy candidates, who, in the course of 
 preparation for examination, have made continued inroads 
 upon their usual allowance of sleep. In cases such as these, 
 the system becomes exhausted, and they look worn and wan, 
 feel jaded, depressed, irritable, and disinclined for exertion. 
 All the organs suffer from enervation, the heart becomes irri- 
 table, palpitates, and beats intermittingly; digestion is lan- 
 guidly and imperfectly performed ; and if the pernicious prac- 
 tice has been carried beyond certain limits, disturbances of 
 nutrition may be initiated which are the starting-point of 
 serious organic changes. 
 
 These effects may likewise be noticed in the poor, who are
 
 40 Insomnia and its Therapeutics. 
 
 obliged to continue their work into the night to eke out their 
 means of subsistence, as well as in searchers after pleasure 
 who convert night into day. The results in the former case 
 !/ L^x^eing complicated by symptoms of further privations, and in 
 both by the breathing of heated and contaminated air. These 
 consequences appear more easily and quickly in those whose 
 nervous systems are sensitive, and they tend to develop into 
 diseases, to which such persons may have an hereditary pre- 
 disposition. A time at last arrives when sleep can no longer 
 be obtained, and sleeplessness becomes the bane of existence. 
 This S3 7 mptom being superadded to the already enfeebled 
 condition, leads to neurasthenia, or to diseases more grave, 
 even in some cases to insanity and suicide. 
 
 In animals, the untoward effects of want of sleep are so 
 generally recognized by those who keep them for gain or 
 work, that the utmost care is taken to secure for them a suffi- 
 ciency of undisturbed sleep. 
 
 Rightly-adjusted Work. As in a subsequent chapter we 
 must discuss this subject very fully, we need simply premise 
 here that a function can only be satisfactorily discharged, 
 when the work imposed upon the structures is regulated in 
 accordance with their strength. It is equally necessary that 
 the tissues should be exercised. A brain which is properly 
 used is adequately nourished and, consequently, vigorous. Its 
 functions (such as sleep) are healthily performed. An excess 
 of work leads to hypersemia, and a deficiency to anaemia, of 
 the brain. Both of these conditions are unfavorable for good 
 sleep. 
 
 CONDITIONS WHICH INFLUENCE SLEEP AND SLEEPLESSNESS. 
 
 It will be convenient to study the questions of sex, age, 
 temperament, habit of sleep, occupation, method of living, his- 
 tory, season, and climate, in their relation to sleep and sleep- 
 lessness, the amount of sleep that the individual requires 
 being, to a great extent, influenced by these factors. 
 
 Sex. Men require less sleep than women, and in this con- 
 nection it should be remembered that a man's pulse beats on 
 an average five times less per minute than a woman's. As 
 a rule, the female possesses more nervous excitability, and 
 being more impressionable than the male, she requires more 
 sleep for the restoration of her energies; and this is equally
 
 Insomnia and its Therapeutics. 41 
 
 true of the weakly and of convalescents, in whom nutrition is 
 slowly performed. Women, however, bear the loss of sleep 
 better, for a time, than men. The length of time they can 
 devote themselves to night-nursing in response to the calls of 
 affection or duty has scarcely any limit. On account of the 
 impressionable and unstable character of the nervous system, 
 women bear the strain of life less buoyantly than men, and so 
 are more liable to insomnia. Girls more frequently than boys 
 suffer from overwork at school. Woman's work in every-day 
 life is usually more monotonous than that of man ; she is less 
 in the open air, and frequently takes less exercise; and these 
 causes combined are not conducive to good sleep. Men, on 
 the other hand, have to bear the brunt of the battle of life; 
 this in many instances necessitates great mental activity and 
 anxiety, which are prone to cause sleeplessness. 
 
 Age. A large portion of an infant's life is spent in sleep. 
 The enormous expenditure of energy connected with the evo- 
 lution of the brain and body generally, demands a relatively 
 greater amount of sleep than is necessary when comparative 
 maturity has been reached. Sleep is often disturbed at this 
 tender age by improper sleeping arrangements, as when the 
 child's feet are cold, or the temperature of the apartment is 
 too high. 
 
 The need for sleep decreases as the growth of the body ap- 
 proaches completion. During the years from ten to twenty, 
 from nine to ten hours' sleep are required, especially on the 
 approach of puberty. 
 
 In middle age, when the waste and repair of the tissues 
 alone require adjustment, eight hours' sleep is abundant. 
 
 In advanced years, the bodily temperature is modified, the 
 heart beats more slowly, the cerebral arteries undergo degen- 
 erative changes, brain and body deteriorate, and nutrition is 
 slowly and imperfectly accomplished. Under these circum- 
 stances a longer period of sleep is indispensable. 
 
 The late Mr. Hilton, in his lectures on " Rest and Pain," 
 wrote : " The interruption of rest by local disease, occurring 
 to persons in the middle period of life, does not cause the 
 same degree of exhaustion and wasting as in the young. They 
 bear the loss of sleep better, because their constitution has to 
 sustain the stress of repair only, not of both development and 
 repair, as in the child. Their recovery is slower; their subse-
 
 42 Insomnia and its Therapeutics. 
 
 quent sleep is not so profound nor so prolonged, nor their rest 
 so complete. The defective sleep and slow repair which mani- 
 fest themselves in the old after injury of any kind are familiar 
 to us all." 
 
 Notwithstanding- the general indications given above, it 
 must be admitted that no hard-and-fast rule can be laid down 
 as to how many hours an individual ought to sleep. For all 
 practical purposes the rule holds good, that a child or adult 
 should sleep until he is recruited, awaking in the morning full 
 of vigor and with a marked sense of well-being. Restoration 
 should be the crucial test. It is a far more reliable guide 
 than any empirical statement as to the time to be spent in 
 sleep; for it follows, if it is wanting, that the energies have 
 not been sufficiently renovated. Sleep requires to be of cer- 
 tain duration and quality to complete the repair of the ex- 
 hausted tissues by the removal of the excrementitious products 
 and by the assimilation of the pabulum necessary for the ac- 
 cumulation of the store of potential energy. 
 
 No two persons are similarly constituted, and if they were, 
 the demands they make upon their strength are utterly un- 
 like. One class of men expend their energies with some degree 
 of regularity; while another class make extraordinary calls 
 upon their vigor on occasions of special urgency. This latter 
 class is illustrated by the merchant in deciding gigantic trans- 
 actions; by the barrister in important trials; and by the 
 surgeon in deciding upon and performing 'difficult and dan- 
 gerous operations, etc. In the intervals, no such expenditure 
 of energy is needed, work being of an ordinary and less event- 
 ful kind. Again, the demands made upon the digestive sys- 
 tem (not to refer to the muscular system) vary in a similar 
 manner, and these, implying unequal degrees of waste, re- 
 quire diverse quantities and qualities of recuperation. 
 
 The benefits arising from sleep cannot possibly be esti- 
 mated by its duration alone; its quality is an equally impor- 
 tant factor. There are many kinds of sleep. Without referring 
 to restless and dream -laden sleep, it is a matter of common 
 knowledge that a short sound sleep often recuperates a man 
 better than a long sleep, and this is specially the case in par- 
 ticular climates. Many bad sleepers find themselves much 
 more jaded and exhausted after an unusually long and very 
 deep sleep than after one shorter and less sound. Such per-
 
 Insomnia and its Therapeutics. 43 
 
 sons not infrequently awake after their lethargic slumbers 
 bathed in perspiration and in much mental distress. 
 
 The fickleness (if the expression may be permitted) of sleep 
 is well exemplified by an occurrence which almost every one 
 must have experienced that the invigoration they felt on 
 awaking in the morning after six hours' sleep was completely 
 dispelled by a second sleep of one or two hours' duration. It 
 is equally well known that a siesta of a few minutes' duration 
 is often followed by a sense of invigoration, while one lasting 
 an hour or two is followed by weariness and depression. In 
 this latter case digestive derangements may of course account 
 for some of the depression. 
 
 Temperament. In people of sanguine temperament the 
 heart is, as a rule, large and powerful, the circulation active, 
 and the bodily functions easily and quickly performed; so 
 that in health such persons usually sleep well and soundly, 
 and rise in the morning refreshed and vigorous. About mid- 
 dle life they become subject to circulatory derangements, 
 which not infrequently lead to disturbed sleep. Many in this 
 class are gouty, and consequently have a predisposition to 
 insomnia, depending on an altered state of the blood from im- 
 perfect metabolism. Such persons bear any abridgment of 
 sleep badly, and they very speedily evince signs of this in 
 general enfeeblement. They suffer more quickly and severely 
 from loss of sleep than almost any other class. 
 
 The neurotic temperament includes a class whose brain 
 and nervous systems dominate tyrannically over the other 
 systems of the body. In health, sleep is of comparatively 
 short duration. Neurotics are indefatigable workers, prone 
 to fatigue their nervous systems, and this, combined with an 
 hereditary tendency to nervous diseases, conduces to bring 
 about conditions which cause insomnia. In youth, a neurotic 
 often breaks down and becomes sleepless from mental and 
 physical over-fatigue. In middle age, when defective innerva- 
 tion originates faulty digestion, which results in impaired nu- 
 trition of the brain and nervous system, sleeplessness is seldom 
 absent. 
 
 The lymphatic temperament embraces a group who sleep 
 well if not soundly, their functions being languidly performed. 
 They have no tendency to those circulatory or neurotic ail- 
 ments which are pregnant sources of insomnia.
 
 44 Insomnia and its Therapeutics. 
 
 There are many combinations of these temperaments, and 
 it is of some importance to trace out the predominating one, 
 as in many cases it affords a clue to the origin as well as to 
 the treatment of persistent wakefulness. 
 
 Habit of Sleep. Some people have the faculty of sleeping 
 at will, and certainly the power may be cultivated, as it is 
 said to have been by the great Napoleon, M. Thiers, and by 
 the first Duke of Wellington. 
 
 Others, again, have accustomed themselves to a very lim- 
 ited amount of sleep, and are able to work actively and 
 steadily for lengthened periods of time without suffering any 
 apparent inconvenience, while sleeping only for four or five 
 hours out of twenty-four. As a rule, however, this practice is 
 inadvisable, for though all duties may be capable of easy per- 
 formance, there is a liability, in such persons, to the onset of 
 certain disorders, and probably, in the long run, to the abridg- 
 ment of life. John Wesley, who appears to have acquired an 
 excellent habit of sleep, believed that a man could determine 
 how much sleep he actually needed simply by rising half an 
 hour earlier every morning until he fell asleep the moment he 
 got into bed at night, and did not wake until it was time to 
 rise. Such an opinion must be accepted conditionally; the 
 question cannot be so concisely disposed of. It is recorded 
 that the late Duke 1 of Wellington (who had a famous sleep 
 habit) said to some one who remarked that his bed was so 
 narrow that there was no room in it to turn, that " when a 
 man began to turn it was time to get up." This was the 
 speech of a man in full health and with a remarkable faculty 
 for sleep. Although it has often served as the text of a lec- 
 ture on the subject of earty-rising, it has no general applica- 
 tion. Such lectures delivered, as they commonly are, to the 
 indolent and slothful, may do no harm; to poor sleepers they 
 are nothing less than travesties, for if these rose every time 
 they turned, they might as well never go to bed. 
 
 Charles Lamb, in his famous " Essays of Elia," discusses 
 several popular fallacies, among others, " That we should rise 
 with the lark/' and in doing so states the other side of this 
 question. "Not but there are pretty sun-risings, as we are 
 told, and such like gawds, abroad in the world, in summer- 
 time especially, some hours before what we have assigned; 
 which a gentleman may see, as they say, only for getting up.
 
 Insomnia and its Therapeutics. 45 
 
 But having been tempted once or twice, in earlier life, to assist 
 at those ceremonies, we confess our curiosity abated. We 
 are no longer ambitious of being- the sun's courtiers, to attend 
 at his morning levees. We hold the good hours of the dawn 
 too sacred to waste them upon such observances, which have 
 in them, besides, something Pagan and Persic. To say truth, 
 we never anticipated our usual hour, or got up with the sun 
 (as 'tis called) to go a journey, or upon a foolish whole day's 
 pleasuring, but we suffered for it all the long hours after in 
 listlessness and headaches; Nature herself sufficiently declar- 
 ing her sense of our presumption in aspiring to regulate our 
 frail waking courses by the measure of that celestial and 
 sleepless traveller." 
 
 The benefits accruing from a capacity to fall asleep quickly 
 and to slumber soundly until the hour for rising cannot be 
 overstated. Such a capacity constitutes a good habit of sleep. 
 On the contrary, the practice of curtailing sleep by sitting up 
 late into the night, or by rising at too early an hour in the 
 morning, is anything but a desirable one. 
 
 Occupation. The more highly-cultured races sleep for a 
 shorter time than those in the lower grades of civilization. 
 Active brain-workers require, and probably get, a smaller 
 amount of sleep than those who are engaged in manual labor, 
 and still less than those who spend their days in frivolity and 
 ' idleness. They live their lives more fully. Some of the most 
 acute and brilliant thinkers and writers of the present day 
 sleep comparatively little, from the power, probably, that they 
 possess of concentrating their sleep (illustrating the quality 
 of sleep). Brain -workers are peculiarly liable to sleeplessness. 
 The cerebral cells, being in constant use, are apt to remain 
 active after w r ork has been abandoned, and while this is the 
 case, sleep is prevented. Those who work with their bodies 
 sleep more than brain-workers, for two reasons: first, on ac- 
 count of the resulting physical fatigue; and second, because 
 their brains being seldom called into activity, hyperaemic con- 
 ditions which, in the other case, act as causes of insomnia, are 
 absent. Their sleep is heavy and more lethargic than in the 
 case of brain-workers. If, however, the work is carried on in 
 close workshops and in constrained positions, the dyspeptic 
 troubles which are liable to follow may induce wakefulness. 
 Dr. Lauder Brunton, in his Croonian Lectures this year, re-
 
 46 Insomnia and its Therapeutics. 
 
 ferring 1 to 'the fabrication of lactic acid during plv^sical exer- 
 tion, as observed by Preyer (page 519), writes: "If much of it 
 be formed in consequence of violent or prolonged exertion, it 
 will pass into the circulation and tend to lessen the alkalinity 
 of the brain as well as other tissues, and sleep might therefore 
 be induced by a long walk, where acid is formed in the limbs, 
 as well as by prolonged mental work, where the acid is a 
 product of the brain itself." This statement makes reference 
 to mental and physical exercises within physiological limits, 
 for no fact is more generally recognized than that mental and 
 bodily over-fatigue are not conducive to good sleep. A certain 
 amount of muscular activity is almost an absolute necessity 
 for sound sleep. (Exercise is the antithesis of repose, and the 
 study of every function indicates the need for work alternating 
 with rest for its healthy performance.) 
 
 It may be that a limited amount of lactic acid, such as is 
 manufactured by an adequate measure of intellectual and 
 corporeal work, promotes sleep; while an excessive formation 
 of acid, the result of exhaustive labor, hinders sleep. Such 
 an explanation would account for the disturbed sleep in acute 
 rheumatism, a disease in which an acid, probably lactic, is 
 supposed to exist in excess in thje blood. Moreover, it would 
 explain why gouty persons (whose blood contains an excep- 
 tionally large quantity of uric acid) are so much troubled with 
 insomnia. 
 
 Much was written at one time concerning the effects of 
 railway travelling in preventing sleep, but the writer, after 
 careful inquiries, which, as medical adviser to two railwaj" 
 companies, he had extensive opportunities for making, was 
 unable to find any evidence in support of this opinion. 
 
 Method of Living. Large and generous feeders sleep more 
 than small and careful eaters, the continued congestion of the 
 digestive organs depleting the brain and favoring sleep, pro- 
 vided no dyspeptic troubles arise. This tendency to sleep after 
 meals is worthy of consideration in connection with the hy- 
 pothesis just stated, that a certain increase of acid in the blood 
 tends to promote sleep. It is well known that the ingestion 
 of food increases the alkalinity of the blood. Sir William 
 Eoberts believes that a meal " is pro tanto a dose of alkali, 
 and must necessarily, for a time, add to the alkalescence of the 
 blood." If acid was an essential requisite for sleep, it would
 
 Insomnia and its Therapeutics. 47 
 
 almost necessarily follow that food would cause wakefulness. 
 Such is not the case. The belief that has long- prevailed, which 
 ascribes drowsiness after meals to congestion of the stomach 
 and a concurrent modified anaemia of the brain appears to be 
 well grounded. 
 
 Those persons whose extremities grow cold after eating, 
 the kind of people that are usually subject to chilblains, are 
 frequently poor sleepers. Those who consume alcohol in any 
 quantity sleep longer and more heavily than those who ab- 
 stain altogether. Any excess requires to be slept off. Both 
 large eaters and large drinkers are prone to sleep disturbance. 
 Privation leads to debilitated conditions which are inimical to 
 sleep. Residence in unhealthy places, in close offices, and 
 badly-ventilated rooms; deficient exercise; excesses of all 
 kinds; the inordinate use of tea, tobacco, etc., are all sources 
 of sleeplessness. 
 
 History. This embraces hereditary tendencies to nervous 
 diseases, such as insanity, hysteria, etc. ; to gout, rheumatism, 
 etc.; to heart disease, etc., which are all predisposing causes 
 of insomnia. Evidence of 'these must be searched for in the 
 collateral branches, as well as in the direct line of descent. It 
 is occasionally useful, when consulted by a sleepless married 
 person of middle age, to inquire carefully into the health of 
 their progenj", for a history of somnambulism or incontinence 
 of urine occurring in a child may throw a good deal of light 
 on the case; past history, as previous residence in unhealthy 
 or malarious districts; illnesses, such as hemorrhages, inflam- 
 mations, fevers, sunstroke, syphilis, dyspepsia, etc.; former 
 habits for example, excesses, mental or physical strain, etc. ; 
 present condition the existence of obstructed nostrils, en- 
 larged tonsils, elongated uvula, and like abnormalities. These 
 and similar influences are provocative of sleep disturbance. 
 Persons who have dry and harsh skins (skins that do not per- 
 spire easily) are often bad sleepers. 
 
 Season. Less sleep is demanded in summer than in win- 
 ter. This has been attributed to the fact that the maintenance 
 of animal heat calls forth a larger consumption of energy 
 during cold weather, requiring, in consequence, an increased 
 amount of sleep to adjust the equilibrium between waste and 
 repair. 
 
 Climate. For a like reason, those who reside in cold re-
 
 48 Insomnia and its Therapeutics. 
 
 gions require more sleep than the inhabitants of warmer cli- 
 mates, the temperate zone being more conducive to good sleep 
 than those localities exposed either to the extremes of heat or 
 of cold. Cold, by contracting- the peripheral vessels of the 
 body, causes cerebral congestion, which is incompatible with 
 sleep. If the cold is very intense, sleep may supervene, but it 
 is probable in this case that the sleep is associated with slight 
 coma, as it soo'n deepens into that condition, and is followed 
 by death. If the body is exposed to cold during sleep, when 
 the bodily functions are being languidly performed, it is cooled 
 with greater rapidity than if it were exposed to the same 
 degree of cold during the waking state, and consequently a 
 fatal termination is more to be apprehended. 
 
 Sleep is rendered difficult or impossible, also, when the 
 temperature of the atmosphere is high, as in tropical cli- 
 mates; and in India this difficulty is so generally recognized, 
 that provisions are made in every-day life to insure sleep be- 
 moans of artificial devices, those who can afford the luxury 
 securing a supply of cool air to their bedrooms by means of a 
 punkah-wallah, which is worked by a servant outside the 
 house. Sir Joseph Fayrer writes: "Near almost every vil- 
 lage there are one or more small channels, by which water 
 from the neighboring spring is conducted to the cultivated 
 lots of ground for the purpose of irrigation, and these chan- 
 nels are, in parts, formed of troughs hollowed out of trees. A 
 piece of bark or matting is laid on the lower of these troughs, 
 and on this the infant, swathed in a large mass of clothes, is 
 so placed that the water from the upper trough falls on the 
 vertex of the cranium, and glancing off runs away under the 
 bark or matting, without further wetting the child or its 
 clothes ; or if the stream is full and copious, the child is placed 
 on the side of the channel, and a portion of the stream directed 
 on its head by a large leaf or piece of bark, another leaf or 
 piece of bark being arranged on the other side of the head, so 
 as to catch the water and carry it away. Children so placed 
 will lie asleep for hours, and the mothers leave them while 
 they go about their daily occupations. 
 
 Excessive heat has a marked effect in producing weak 
 action of the heart, which is apt to be followed by insolation. 
 For centuries it has been noted that unusual dryness of the 
 atmosphere, such as is found on the shores of the Mediterra-
 
 Insomnia and its Therapeutics. 49 
 
 nean, is a frequent cause of sleeplessness, especially in excitable 
 persons, whose sleep, at the best of times, is not satisfactory. 
 It is important to bear this in mind when recommending 
 change of air for such individuals. Various devices have been 
 proposed to obviate this, such as hang-ing 1 up wet sheets, water- 
 ing the carpets, or exposing vessels of water in the room to 
 supply the deficiency by evaporation. 
 
 One constantly hears complaints of inability to sleep dur- 
 ing temporary residence at seaside resorts, and the cause of 
 this is not difficult to explain. The invigorating air acts as a 
 powerful tonic to the heart and blood-vessels, raising the 
 blood-pressure considerably, as is evidenced by the large in- 
 crease in the amount of urine secreted; and thus, for a time 
 at all events, disturbing the balance of the circulation so as to 
 interfere with sleep. 
 
 Moderate altitudes are more conducive to good sleep than 
 the sea level or high altitudes. 
 
 Many persons in health have their sleep improved by a 
 visit to the seaside, and they usually, though not invariably, 
 sleep well there when they are ill; others, again, are rendered 
 wakeful, and this is generally aggravated during illness. 
 
 In the belief that it may serve some good purpose to indi- 
 cate the causes of insomnia as they present themselves to the 
 physician in private practice, the writer subjoins a list of one 
 hundred and sixty-seven consecutive cases. His previous 
 notes are of selected cases alone. From the category are ex- 
 cluded all cases depending upon pain, inflammatory and fe- 
 brile affections, cough, as well as the more trivial cases, caused 
 by drinking tea or coffee after dinner, in which the insomnia 
 disappeared when these beverages were discarded. 
 
 AGES. 
 Cases. Males. Females. 
 
 Neurasthenia, . . 19 48, 47, 44, 40, 40, 30, 45, 40, 34. 32, 30, 30. 
 
 24, 19. 29, 28, 25, 25, 23. 
 
 Chronic gout, . . 19 74. 70, 61, 60, 56, 50, 84, 70, 65, 63, 60, 60, 
 
 50, 44. 60, 59, 50, 45, 40. 
 
 Overwork, . . . 17 46, 45, 43. 42, 40, 40, 18, 13, 13, 11, 11, 10, 
 
 30, 28, 18. 10, 10. 
 
 Worry, .... 17 45, 45, 45, 44, 40. 66, 53, 46, 45, 45, 44, 
 
 44,37,36,36,30, 22. 
 
 Alcoholism, . . 10 55, 50, 50, 45, 36, 30. 60, 50, 49, 44. 
 
 Dyspepsia (not gouty), 10 64. 40, 37, 34. 50, 46, 45, 34, 29, 26, 
 
 Menopause, ... 8 50, 49, 48, 46, 46, 46. 
 
 45, 44. 
 
 Senility, ... 8 81, 77. 84, 81, 80, 76, 72, 63. 
 
 Chronic heart-disease, 6 61, 58. 76, 68,65,30.
 
 Insomnia and its Therapeutics. 
 
 Cases 
 
 Males. 
 
 AGES. 
 Females. 
 
 Incipient Insanity, 
 
 5 
 
 70, 18. 
 
 65, 63, 40. 
 
 Night terrors, . . 
 
 5 
 
 7, 4, 3. 
 
 5, 3. 
 
 Eczema, 
 
 5 
 
 68, 60, 54. 
 
 45, 18. 
 
 Rickets. 
 
 4 
 
 5, 3. 
 
 4,2. 
 
 Shock, .... 
 
 3 
 
 80, 50. 
 
 64. 
 
 Exophthalmic goitre, 
 
 3 
 
 
 42, 40, 24. 
 
 Somnambulism, . 
 
 3 
 
 30, 15. 
 
 28. 
 
 H y pochond r iasis," 
 
 8 
 
 45, 30. 
 
 44. 
 
 Paralysis agitahs, 
 
 2 
 
 60, 54 
 
 
 Migraine, 
 
 2 
 
 
 42, 31. 
 
 Hysteria, 
 
 2 
 
 
 35, 20. 
 
 Constipation, 
 
 2 
 
 34, 26. 
 
 
 Syphilis (acquired), . 
 
 2 
 
 45. 
 
 35. 
 
 Syphilis (inherited), . 
 
 1 
 
 
 3 months. 
 
 Epilepsy, 
 
 1 
 
 18. 
 
 
 Locomotor ataxy, 
 
 1 
 
 50. 
 
 
 Enlarged prostate, 
 
 1 
 
 85. 
 
 
 After parturition, 
 
 1 
 
 
 23. 
 
 Noises, .... 
 
 1 
 
 
 70. 
 
 Post-choreal, 
 
 1 
 
 14. 
 
 
 Anaemia, 
 
 1 
 
 
 30. 
 
 Morphine habit, 
 
 1 
 
 46. 
 
 
 Chloral and cocaine habit, 
 
 1 
 
 
 37. 
 
 Tapeworm, . 
 
 1 
 
 
 34. 
 
 Threadworms, 
 
 1 
 
 50. 
 
 
 Total, . 
 
 167 
 
 71 
 
 Dr. Guthrie Rankin, who practises in the county town of 
 Warwick, has kindly given the writer his notes of the last 
 sixty-three consecutive cases of insomnia similar to the above 
 that he has had under his care. They are as follows: 
 
 Neurasthenia, 
 Menopause, 
 Chronic gout, 
 Worry, . 
 Overwork, . 
 Dyspepsia (not gouty), 
 Post-dysenteric, . 
 Shock, . 
 Alcoholism, . 
 Anaemia, 
 Senility, 
 
 Chronic heart disease, 
 Threatened insanity, . 
 Hyperosmia, 
 Melancholia, 
 Post-choreal, 
 Since childbirth, 
 Somnambulism, . 
 Since sunstroke, . 
 Chronic bone disease, 
 
 Total, . 
 
 AGES. 
 Cases. Males. Females. 
 
 9 46. 54, 39, 39, 38, 32, 32, 32, 28. 
 
 8 50, 50, 49, 49, 47, 46, 46, 40. 
 
 7 53,38,32,32,32,26. 54. 
 
 69,63, 56, 34. 
 
 24, 22. 
 
 40, 30. 
 
 32. 
 
 47, 38, 37. 
 
 74. 
 
 39. 
 
 37. 
 
 56. 
 18. 
 30. 
 
 18. 
 
 () 
 
 54, 39. 
 
 5 
 
 33, 27, 17. 
 
 4 
 
 54, 47. 
 
 3 
 
 41, 28, 28. 
 
 8 
 
 76, 63. 
 
 a 
 
 45, 34, 31. 
 
 3 
 
 
 2 
 
 84. 
 
 2 
 
 58. 
 
 1 
 
 
 1 
 
 43. 
 
 1 
 
 
 1 
 
 
 1 
 
 
 1 
 
 
 1 
 
 28. 
 
 1 
 
 
 52. 
 
 26 
 
 37.
 
 Insomnia and its Therapeutics. 51 
 
 Dr. Malcolm Mackintosh, who practises in the populous 
 district of Clapham, has also been good enough to furnish the 
 writer with notes of the last forty-three consecutive cases 
 which he has had under treatment. 
 
 AGES. 
 
 
 Males. 
 
 
 Females. 
 
 Worry, 
 
 13 50, 44, 23. 
 
 50, 50, 47, 
 
 46, 45, 44. 39, 38,34, 
 
 
 
 33. 
 
 
 Neurasthenia, 
 
 9 
 
 53, 51, 48, 
 
 48, 46, 42, 39, 37, 81. 
 
 Chronic bronchitis, 
 
 4 72, 71, 43. 
 
 56. 
 
 
 Alcoholism, 
 
 3 
 
 60, 50 32. 
 
 
 Dyspepsia. 
 
 3 
 
 56, 48, 36. 
 
 
 Chronic phthisis, 
 
 2 
 
 48, 42. 
 
 
 Menopause, 
 
 2 
 
 49, 46. 
 
 
 Senility, . 
 
 2 
 
 82, 72. 
 
 
 Chronic rheumatism, 
 
 2 53, 48. 
 
 
 
 Disease of stomach, 
 
 1 
 
 41. 
 
 
 Epilepsy, 
 
 1 
 
 42. 
 
 
 Chronic uterine disease 
 
 1 
 
 32. 
 
 
 Total, ... 43 8 35 
 
 Although no definite or reliable conclusions can be deduced 
 from such scanty premises, these statistics are nevertheless 
 valuable, as indicating, in some measure, the causes of func- 
 tional (?) insomnia, and the ages at which these most frequently 
 operate. Being consecutive cases, and occurring in different 
 parts of the country and in varying classes of society, they 
 show the influence of like agencies, and that these act with 
 tolerable uniformity. 
 
 They justify the opinion which the writer has long held, 
 that quite a half of all of the cases that are popularly known 
 as functional insomnia are due to an inherent instability in 
 the cerebral textures which renders them vulnerable, and lia- 
 ble to be impressed unfavorably by circumstances incident to 
 various stages of life; in short, prone to break down under 
 the strain of the wear and tear of every-day life. 
 
 In the writer's own cases such defective structures may 
 be said to have caused the following. Neurasthenia 19, over- 
 work 17, worry 17, menopause 8, night terrors 5, shock 3, hy- 
 pochondriasis 3, somnambulism 3, hysteria 2, epilepsy 1, in- 
 cipient insanity 5, post-choreal 1, after parturition 1, migraine 
 2; in all, 87 cases, or 52.095 per cent. 
 
 The other cases are as follows : 
 
 Gout, or defective metabolism, . 19 cases, or 11.372 per cent. 
 Toxic, alcohol, etc., '. . .15 8.982 " 
 
 Alimentary system, . . .14 " 8.383 "
 
 52 Insomnia and its Therapeutics. 
 
 Circulatory system, . . .10 cases, or 5.987 per cent. 
 
 Senility, . . , . . 8 " 4.790 
 
 Cutaneous, . . v J ^ .5 " 2.994 
 
 Rickets, . . . -v . 4 " 2.335 
 Paralysis agitans and locomo- 
 
 tor ataxy, , . . 3 " 1.796 " 
 
 Enlarged prostate, . . .1 " .598 " 
 
 Noises, . . . . ... 1 " .598 " 
 
 Total, . . 167 99.930 " 
 
 The combined statistics of two hundred and seventy-three 
 cases of insomnia were caused mainly by 
 
 (1) Neurasthenia, . 37 cases, or 13.55 per cent. 
 
 (2) Worry, . ^ . 35 " 13.18 
 
 (3) Gout, . . *. 26 " 9.52 
 
 (4) Overwork, . ..23 " 8.04 " 
 
 (5) Menopause, . .18 " 6.59 " 
 
 (6) Dyspepsia, . .17 " 6.22 " 
 
 (7) Alcoholism, . 16 " 5.86 
 
 (8) Senility, . .12 " 4.39 
 
 In short, these eight causes account for 184 cases, or 67.36 per 
 cent of the whole number. They will, consequently, form the 
 chief subjects for discussion in the following pages. 
 
 These statistics, moreover, when considered in connection 
 with previous experience, go some \vay in the direction of con- 
 stituting a basis upon which the sources of insomnia may be 
 generally, if roughly, summarized as follows: 
 
 In the tender age of infancy, digestive derangements (which 
 often arise from injudicious feeding); dentition; hereditary 
 taint, as syphilis, and rickets, act prejudicially; and infantile 
 convulsions, night terrors, laryngismus stridulus, spasmodic 
 croup, etc., are the result. 
 
 In childhood, while yet the emotional centres predominate 
 in activity, impressions such as fright, fear, etc., cause chorea ; 
 and these, as well as digestive derangements and the strain 
 of educational competition, lead to impaired sleep. At this 
 period, sleep is apt to be unequal in distribution and depth, a 
 condition which initiates somnambulism, incontinence of urine, 
 and similar disorders. 
 
 At puberty, when the evolution disturbs the equilibrium
 
 Insomnia and its Therapeutics. 
 
 53 
 
 of the nervous .system in girls, hysteria, epilepsy, and like ail- 
 ments may be induced, and result in insomnia. At this age, 
 boys and girls may suffer from the effects of overwork. 
 
 TABLE INDICATING THE AGES AT WHICH INSOMNIA OCCURS. 
 
 
 Dr. Macfarlane's 
 
 Dr. Rankin's. 
 
 Dr. Mackintosh's 
 
 Totals. 
 
 1 
 
 Females. 
 
 a 
 g 
 
 tf 
 
 1 
 
 1 
 
 1 
 
 1 
 
 Females. 
 
 3 
 
 i 
 
 1 
 
 i 
 
 I 
 
 10 
 18 
 
 1 10 years 
 1020 " 
 
 5 
 6 
 
 5 
 9 
 
 10 
 15 
 
 
 
 
 
 
 
 5 
 
 7 
 
 5 
 
 11. 
 
 1 
 
 2 
 
 3 
 
 
 
 
 2030 " 
 
 3 
 
 12 
 
 15 
 
 3 
 
 5 
 
 8 
 
 1 
 
 
 i 
 
 7 
 
 17 
 
 24 
 
 3040 tl 
 
 9 
 
 17 
 
 26 
 
 9 
 
 13 
 
 22 
 
 
 10 
 
 10 
 
 18 
 
 40 
 
 58 
 
 4050 " 
 
 22 
 
 26 
 
 48 
 
 6 
 
 10 
 
 16 
 
 3 
 
 15 
 
 18 
 
 31 
 
 51 
 
 82 
 
 5060 " 
 
 12 
 
 5 
 
 17 
 
 4 
 
 4 
 
 8 
 
 2 
 
 7 
 
 9 
 
 18 
 
 16 
 
 34 
 
 6070 " 
 
 7 
 
 13 
 
 20 
 
 1 
 
 2 
 
 3 
 
 
 1 
 
 1 
 
 8 
 
 16 
 
 24 
 
 7080 " 
 
 4 
 
 5 
 
 9 
 
 1 
 
 1 
 
 2 
 
 2 
 
 1 
 
 3 
 
 7 
 
 7 
 
 14 
 
 8090 " 
 
 3 
 
 4 
 
 7 
 
 1 
 
 
 1 
 
 
 1 
 
 1 
 
 4 
 
 5 
 
 9 
 
 273 
 
 Total 
 
 71 
 
 96 
 
 167 
 
 26 
 
 37 
 
 63 
 
 8 
 
 35 
 
 43 
 
 105 
 
 168 
 
 In adult life, sleeplessness is apt to appear at an earlier 
 age in women than in men. This arises, in the married, from 
 disturbance of the uterine functions, pregnancies, hemor- 
 rhages, and over-lactation. In the childless, from causes con- 
 nected with their sterility. In the unmarried, from disap- 
 pointments, etc. In all these cases, the indiscreet use of tea 
 and, in rarer instances, of alcohol, may act deleteriously; while 
 many such persons tend to become neurasthenic. 
 
 In middle ag-e there are three great sources of sleeplessness 
 in men: neurasthenia; metabolic and digestive derangements; 
 poisons, as tea, tobacco, and alcohol. In women the sources 
 are chiefly threefold : neurasthenia, the menopause, lithiasis. 
 
 In later life, when the trials of existence begin to press 
 heavily and to be borne less buoyantly, worry becomes a 
 pregnant source of insomnia. 
 
 In advanced years, an altered state of the nutrition of the
 
 54 Insomnia and its Therapeutics, 
 
 brain, and digestive and circulatory troubles, are the chief 
 causes of disturbed sleep. 
 
 Diagnosis. As insomnia depends on causes so numerous, 
 so diverse, and so inconstant, it is impossible to generalize or 
 to formulate a table to convey any clear idea of its source. 
 
 Every case requires to be studied carefully upon its own 
 merits, but the main lines upon which the inquiry should be 
 conducted may be briefly indicated. The age, sex, and occu- 
 pation of the patient should be noted, and the habits, past his- 
 tory, temperament, and hereditary tendencies investigated, 
 especial attention being directed to the habit of sleep. In ob- 
 scure cases, the condition of the nervous system should be 
 studied in order to determine whether the excitability of the 
 cerebral cells is dependent on inherent exhaustion or on irrita- 
 bility, or is due to impressions transmitted from distant parts 
 of the body. The state of the various reflexes, and the con- 
 ductivity of the nerves, especially the cranial nerves, should 
 be ascertained. The condition of the digestive organs and 
 liver must be narrowly scrutinized. Careful examination of 
 the vascular system should be made, and the amount of vas- 
 cular tension determined; and any modification in the quan- 
 tity or quality of the blood noted, such as anaemia, or plethora, 
 or the presence of the gouty, rheumatic, or S3 7 philitic poisons. 
 The condition of the lungs, kidneys, and other organs must 
 not be overlooked. [If the inquiry could be limited to cases 
 dependent on functional (?) origin, some assistance would be 
 obtained from considering the time at which the sleep disturb- 
 ance occurs; for the reason that sufferers from insomnia from 
 these causes maybe roughly divided into two classes: (1) 
 those who are unable to fall asleep; and (2) those who fall 
 asleep easily, but soon awaken. 
 
 (1) Those who are unable to fall asleep when they go to 
 bed. This is usually due to activity in the brain, maintained 
 (a) by the effects of overwork, worry, fear, hysteria, or of tea 
 or coffee, etc.; (b) in consequence of an increased blood-supply 
 (preventing its quiescence) arising from disturbing agencies 
 in the economy, as cold feet, pruriginous irritations, acute 
 dyspepsia, or feverish states, implying, as these do, the quick- 
 ening of the circulation to the extent of from eight to ten 
 beats for every degree of increased temperature. 
 
 (2) Those who fall asleep easily, but whose slumbers soon
 
 Insomnia and its Therapeutics. 55 
 
 terminate in a vigil. They embrace two sections, (a) Those 
 who possess impressionable cerebral cells, as in neurasthenia, 
 hypochondriasis, night terrors, etc. Such cells, being- pecu- 
 liarly sensitive, perceive speedily and acutely trifling disturb- 
 ances in the system. (6) Those whose cerebral cells are ren- 
 dered irritable by an impure blood-supply, such as accrues 
 from a disordered metabolism, as in hepatic and intestinal 
 dyspepsia; or pertains to gout, rheumatism, and syphilis. It 
 must, however, be remembered that there remain many ex- 
 ceptions to such a classification.] 
 
 The various instruments used in diagnosis must be called 
 into requisition, although less assistance is derived from the 
 ophthalmoscope and sphygmograph than one would a priori 
 have expected. 
 
 It may here be added that dreams are not yet sufficiently 
 understood to be valuable as a means of diagnosis. Thej T pre- 
 lude insanity, apoplectic and epileptic seizures; the menstrual 
 periods; phthisis pulmonalis, and the continued fevers. They 
 are seldom absent in congestive conditions of the brain and its 
 membranes; in valvular heart disease; aneurism; chronic dis- 
 eases of the lungs, and in dyspepsias. A dream occurring at 
 rare intervals is usually attributable to indiscretion in eating 
 or drinking. It is worthy of note that many gouty persons, 
 who dream a great deal, affirm that it does not seem to inter- 
 fere with the restoration of their nervous energy. 
 
 Prognosis. The value of sleep in prognosis. Hippocrates, 
 in discussing prognostics, wrote with regard to sleep : "As is 
 usual with us in health, the patient should wake during the 
 day and sleep during the night. If this rule be anywise altered 
 it is so far worse, but there will be little harm, provided he 
 sleep in the morning for the third part of the day ; such sleep 
 as takes place after this time is more unfavorable; but the 
 worst of all is to get no sleep night or day, for it follows from 
 this symptom that the insomnolency is connected with sorrow 
 and pains, or that he is about to become delirious/' He like- 
 wise gave three aphorisms connected with sleep: "In what- 
 ever disease sleep is laborious it is a deadly symptom; but if 
 sleep does good it is not deadly " (he evidently refers to coma). 
 "When sleep puts an end to delirium it is a good symptom; 
 when it increases delirium it is deadly. Both sleep and in- 
 somnolency, when immoderate, are bad."
 
 56 Insomnia and its Therapeutics. 
 
 The capacity for sleep is always an important factor in 
 prognosticating 1 the question of recovery from a serious ill- 
 ness, or the advisability of operative interference; it being- a 
 rule, to which there are few exceptions, that the better a pa- 
 tient sleeps the greater are his chances of recovery. Sir James 
 Paget wrote in 1867 concerning the various risks of operations: 
 "A better sign is the capacity for sleep. If a patient can 
 always sleep long at a spin, that is a good patient/' 
 
 Natural sleep, returning and becoming sounder in intensity 
 and longer in duration, in the course of a severe disease, is 
 always an excellent omen, and one to be relied upon, even 
 when the other symptoms appear not to justify it. It is of 
 equally good import in less pronounced affections. 
 
 Wakeful and restless nights supervening in the course of 
 a prolonged illness are often, if not always, indicative of an 
 unfavorable change, or of a relapse. Occasionally they derive 
 additional importance from the fact that they precede all 
 other unpropitious symptoms, the cerebral cells apparently 
 perceiving and evincing the effects of alterations in the system 
 before any of the other structures. 
 
 In regard to young children, the following remarks of 
 Henoch are worth quoting: "In judging of the condition of 
 new-born infants and children at the breast, I should further 
 recommend you to observe how the hands are held during 
 sleep. Healthy children at this age sleep, as is well known, 
 with their arms flexed to such an extent that the hands are 
 directed right upward and are on a level with the neck or 
 lower jaw. This attitude which is perhaps a reminiscence of 
 intra-uterine life is changed in the case of serious illness, and 
 its presence may consequently be regarded as a reassuring 
 sign." 
 
 It is found that people who usually sleep well in health 
 often do so also during illness; while those whose sleep is 
 never very sound have their rest more seriously interfered 
 with when they are ill^ this being, as already said, a factor 
 which adds considerably to their peril. 
 
 Treatment. It goes without saying that the cure of sleep- 
 lessness is sleep. If the definition of insomnia given in the 
 opening sentence of this chapter is accurate, sleep can only be 
 obtained by allaying the vigilance of the cerebral cells. To 
 accomplish this, we must unravel the abnormal condition in
 
 Insomnia and its Therapeutics. 57 
 
 the economy which originates it, so that the exciting- cause 
 may be removed and any predisposing- cause alleviated, as far 
 as it is possible. In this manner the health and stability of 
 the cerebral cells are re-established and their healthy func- 
 tion, sleep, restored. The method in which this may be best 
 achieved will be treated fully in the following pages. We 
 may here offer a few preliminary remarks on treatment. 
 
 First, as regards habit of sleep, to which we have already 
 referred (p. 542), there can be no doubt that sleeplessness is 
 frequently the result of the acquirement of a bad habit, either 
 as regards the regularity and duration of sleep, or the prac- 
 tice of taking with us, into the hours which ought to be de- 
 voted to repose, the worries and anxieties of our daily life. 
 These evils stamp themselves upon the nervous system in the 
 same way that over-indulgence in alcoholic stimulants does, 
 and, like the latter, are very difficult to root out. This influ- 
 ence of habit is well exemplified in many aged persons, who 
 . in their youth were accustomed to rise at an early hour in the 
 morning, and who in consequence have continued to do so 
 throughout their lives; and also by the loss of sleep which 
 some experience when sleeping in a strange bedroom, although 
 the bed and surroundings are even more comfortable than 
 those to which they are habituated. 
 
 The writer has intimate knowledge of a man who now 
 sleeps soundly for eight hours every night, having succeeded, 
 bj r dint of a determined effort of the will, in overcoming a 
 sleepless habit that for years afflicted him. Every one ought 
 to cultivate the habit of retiring punctually at a certain hour, 
 divesting the mind, as far as it is possible, of care, so as to 
 fall asleep at once, and of rising at the instant of awaking in 
 the morning. Early rising is not for its own sake to be ad- 
 vised, unless the hour of retiring to rest is correspondingly 
 early. 
 
 The conditions of sleep as regards warmth, light, ventila- 
 tion, etc., are of some importance ; and to them frequent refer- 
 ence must be hereafter made. The bed-clothes should be 
 warm, but light, and the temperature of the apartment about 
 58 Fahr. A heated atmosphere is prejudicial to sleep, it being 
 a matter of common experience that during a hot, airless, 
 summers night sleep is restless and disturbed, especially in 
 children; this being due to the heat causing acceleration of
 
 58 Insomnia and its TJicrapeutics. 
 
 the action of the heart, with consequent hyperaemia of the 
 brain. A low temperature is equally hurtful, and acts by 
 causing contraction of the cutaneous blood-vessels, which is 
 followed by cerebral congestion and insomnolency. This con- 
 dition of things should be carefully guarded against by the 
 aged, whose powers of resistance and reaction are feeble. The 
 same effect is often produced by cold feet. In short, the most 
 favorable conditions, as regards temperature, for securing 
 quiet, refreshing sleep, are those in which the surface of the 
 body is kept moderately warm and the brain in a state of 
 partial depletion. 
 
 Next to a comfortable temperature, thorough ventilation 
 is of the greatest importance. When circumstances permit, 
 it is desirable to have the window open a little way at the top, 
 taking care, by means of curtains and other devices, to pro- 
 tect the body from draughts. It is often possible to do this 
 by opening a window in an adjoining room. In this way, con- 
 tamination of the air with the products of respiration is 
 avoided, for although carbonic acid may induce drowsiness, it 
 does not cause sound sleep, its toxic effects being noticeable in 
 the headache, languor, and disinclination to exertion present 
 after sleeping all night in an ill-ventilated bedroom. 
 
 It is not desirable to sleep in a room containing plants of 
 any kind. 
 
 Last j'ear it was proposed (" Lancet," 1888) to induce sleep 
 by interfering temporarily with the perfect aeration of the 
 blood, by holding the breath after a deep inspiration until dis- 
 comfort ensued, and repeating the process a few times. 
 
 If disturbing noises cannot be put a stop to, the ears may 
 be plugged with cotton wool, or Dr. Ward Cousins' sound- 
 deadeners employed. 
 
 It is hardly necessary to suggest the avoidance of all 
 smells. 
 
 Light should be excluded by means of dark blinds, and 
 light in the room dispensed with, except in the case of children, 
 timid persons, or some sufferers from hysteria and hypochon- 
 driasis, to whom a well-shaded light is frequently a great 
 comfort. 
 
 The bed ought to be yielding, without being too soft, the 
 pillows moderate^ 7 firm, and either high or low according to 
 the taste of the sleeper. The conditions, in short, should be
 
 Insomnia and its Therapeutics. 59 
 
 such as to insure the minimum of external stimulations, 
 which, as \ve have already seen, tend to prevent and disturb 
 sleep. The writer is informed that the grievance of which 
 some criminals complain most is the plank bed on which they 
 are required to recline. 
 
 The best position of the body during sleep is that instinct- 
 ively selected by the sleeper. The great majority of people 
 sleep upon either side, the larger portion preferring the right 
 side, while probably one out of every five assumes the dorsal 
 position, which is generally considered to be the least desir- 
 able. The custom of assuming peculiar postures during sleep 
 appears, in some cases, to be hereditary. 
 
 It has long been a popular opinion that lying with the 
 body in a particular direction, north or south, improves sleep 
 by allowing "the magnetic currents pervading the globe to 
 exert a certain influence on the iron contained in the body." 
 Much stress has been laid upon the advisability of placing the 
 bed so that the head should point to the north. 
 
 Many years ago the writer's attention being directed to 
 this subject, he made extensive observations and inquiries re- 
 garding it, but was unable to satisfy himself that it exercised 
 any influence upon sleep at all, the apparent successes of the 
 method being, in his opinion, accidental rather than conse- 
 quent, or resulting from the imagination. 
 
 In sleeping in a train the head should be directed toward 
 the engine. 
 
 It is important in the case of those whose work is chiefly 
 mental, that a certain amount of bodily fatigue should be in- 
 duced daily by exercise in the open air; if this is disregarded 
 sleep is liable to be interfered with. Brain-work should be de- 
 sisted from at least an hour before retiring, and conversation, 
 light reading, or recreation indulged in. Ptolemy, king of 
 Egypt, was wisely told that the best way to sleep " A\ as to 
 have divine and celestial meditations, and to use honest actions 
 in the daytime." 
 
 He who would sleep well must go to bed " animo securo, 
 quieto, et libero." 
 
 The food must be proportioned to the work of the body 
 and to the strength of digestion. 
 
 The last meal is an important one in connection with sleep. 
 If a heavy meal, it ought to be partaken of from three to four
 
 60 Insomnia and its Therapeutics, 
 
 hours before r going to bed. If food be taken at a later hour, 
 it should consist of clear soup, which can be readily absorbed 
 loy the stomach, and farinaceous food, that the salivary fer- 
 ment can change. In this way gastric, hepatic, and intestinal 
 digestion so apt to disturb sleep is rendered unnecessary. 
 The stomach should not be struggling with a burden, nor feel- 
 ing the effects of want. 
 
 Insomnia is frequently benefited by climatic change. This 
 is brought about by the altered physiological conditions influ- 
 encing favorably the disturbance upon which it depen'ds. In 
 considering the therapeutics of a climate in this connection, it 
 is wise to be guided, to some extent, by the previous personal 
 experience of the patient, and to recollect that if sleep is faulty 
 or imperfect it will more than counterbalance any benefit 
 which might be derived from atmospheric change. It is a 
 fact worthy of note that localities in which people sleep soundly 
 when they are well, generally suit them, in this regard, when 
 they are ill. 
 
 The duration of sleep must not be trusted as the sole guide 
 in this matter, for the sense of recuperation, as has been al- 
 ready pointed out, is a more reliable one. There is a quality 
 in sleep as well as a quantity; therefore it cannot be judged 
 altogether by its duration. Such measures, by alleviating 
 perturbing elements in the economy, toning the vascular sys- 
 tem, and strengthening and calming the nervous centres, fre- 
 quently suffice alone to palliate wakefulness and to restoj 
 natural sleep. 
 
 If in spite of these curative means insomnia persists, atten- 
 tion must be directed to the attainment of three points. The 
 quiescence of excitability and activity in the psychical centres. 
 This can be accomplished by means of remedies which act di- 
 rectly upon the nervous textures and calm the activity of the 
 cells, thus allowing the blood-supply to slack off. The diminu- 
 tion and tranquillization of the cerebral blood-supply. (It 
 has already been stated that cellular activity necessitates an 
 augmented vascular supply, just as increased vascularization 
 implies activity.) This can be achieved by medicines, chiefly 
 tonics, whose properties act specially upon the great centres 
 in the medulla, and through their agency quiet the heart and 
 give tone to the blood-vessels, so as to diminish the force and 
 volume of "the blood current. The modification of the quality
 
 Insomnia and its TJierapeutics. 61 
 
 of the blood. This can be brought about by medicines which 
 increase the number of the corpuscles, or act favorably upon 
 poisonous constituents. Sleep so induced frequently terminates 
 in natural sleep. 
 
 Hypnotics act in various ways, some affecting one portion 
 of the nervous system more than the others. 
 
 Dr. Lauder Brunton, in the Croonian Lectures already re- 
 ferred to, states that " hypnotics may probably lessen the 
 functional activity of the cerebral cells, by causing their pro- 
 toplasm to contract, and thus interposing a barrier of para- 
 plasm between it and the oxygen brought by the blood, and 
 by lessening the affinity of the cells for oxygen by diminish- 
 ing their alkalinity, or by entering into actual combination 
 with them for a time, and thus altering their chemical rela- 
 tionships." 
 
 Alcohol taken in the form of whiskey or brandy of goof 
 I ^ualityaiid~in judicious quantity is probably one of the jnost, 
 I reliable and least hurtful hypnotics we possses. Its efll 
 """"has stood the test oftlme^ Many memTJErs ot tne"alcohol groui 
 act ashypnotics! They simply induce sleep as one of the first 
 effects of their action. In larger doses, however, they may 
 cause complete unconsciousness and anaesthesia and abolish 
 the reflexes. For the production of prolonged sleep it is nec- 
 essary to administer a remedy whose action is at once mild 
 and of some duration, that the untoward results referred to 
 may be avoided. For such a substance we look among the 
 compounds which contain a heavy molecule, whether these are 
 solid or liquid in form. It is usually best to prescribe them by 
 the mouth, that they may be gradually absorbed into the 
 blood and continue to act for a protracted time. Recently 
 several new remedies have been introduced, which seem likely 
 to take a high and permanent place in the materia medica. 
 Among these must be specially mentioned sulphonal, chloral- 
 amide, and paraldehyde; and in a less prominent way urethane, 
 hypnone, and the tertiary nitrite amylene hydrate. So far, no 
 one of these has been found free from all objection, although 
 they are very superior in many respects to the bulk of the 
 older remedies. 
 
 Such a rapid advance is being made at present in aug- 
 menting this class of remedies, owing to the many new com- 
 pounds which synthetical chemistry has brought into existence,
 
 62 Insomnia and its Therapeutics. 
 
 possessing strong 1 hypnotic properties, that \ve may confi- 
 dently look forward to the fabrication of one which will safely 
 and benignly induce sleep. 
 
 The benefits to be derived from hypnotics are most con- 
 spicuously seen in acute diseases, such as inflammations, 
 fevers, etc., where it is necessary to prolong life by conserv- 
 ing strength, until the natural crisis of the affection arrives; 
 the greatest of all conservative agents being sleep. Every 
 eight hours' sleep out of twenty-four represents an enormous 
 saving of energy; the heart beating five thousand times less, 
 the respirations being one thousand five hundred fewer, while 
 the temperature remains at a lower point. If to this it be 
 added that the products of waste are more perfectly removed 
 from the sj'stem, it becomes apparent how very desirable sleep 
 is in acute diseases, and particularly in those of the nervous 
 system and of the lungs and heart. 
 
 In chronic affections, hypnotics fill a more limited sphere 
 of usefulness; still, the benefits gained from a few nights' sleep 
 secure at least three distinct advantages: time is acquired for 
 the remedying of the ailment; the cerebral cells are rested 
 and, with the whole body, are strengthened, thus permitting 
 their excitability to subside; it often allows a sleep habit to 
 be established. To this extent their use is helpful, and it must 
 not be withheld. 
 
 It is, however, in such cases that one is apt to forget that 
 hypnotics are not per se curative; to continue their adminis- 
 tration indefinitely is to misuse them. Coincident with the 
 widely-spread abuse of these drugs there has sprung up a 
 fashion to inveigh against their employment at all, but it 
 must be urged that drug-induced sleep is better than no sleep. 
 There is a vast amount of evidence to prove that the use of 
 hypnotics in strictly medicinal doses is not so detrimental to 
 health as is commonly supposed. There are many men of 
 advanced years, occupying high positions in this country, who 
 for years, ay, for half a century in some instances, have never 
 gone to bed at night without a soporific, and so far from suffer- 
 ing in health, have benefited by the practice. Although it is 
 far from our purpose to advocate or countenance the use, and 
 particularly the misuse, of drugs of any description, yet we 
 must conclude that the experience of the efficacy of hypnotics, 
 accumulated during centuries, is based upon a sound founda-
 
 Insomnia and its Therapeutics. 63 
 
 tion and must endure. Remedies which, skilfully selected and 
 rightly administered, are able to conserve life, preserve reason, 
 and, in less urgent cases, to influence an affection favorably, 
 cannot be lightly discarded. 
 
 At the same time it must be remembered that many ob- 
 stinate cases of insomnia can be managed and cured without 
 the employment of hypnotics; and when that is accomplished 
 it illustrates the truth of the old saying that " the best medi- 
 cine is none/' 
 
 If a patient awake during the night and is unable to fall 
 asleep again, he should on no account lie tossing about worry- 
 ing at his fate. Such a course invariably prevents the return 
 of sleep. It is better to rise and walk two or three times 
 round the room, brush the hair, take a drink of water, and 
 then go back to bed. If that does not prove efficacious, he 
 should light a candle, and take to a novel or other light read- 
 ing, that he may occupy his mind. It is at once a comfort 
 and an aid to sleep.
 
 CHAPTEE III. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 NERVOUS SYSTEM. 
 
 OVERWORK. 
 
 THIS term in the following lines is applied to conditions 
 arising- out of excessive mental effort ; it refers to an undue 
 strain on the intellectual apparatus. 
 
 In different persons the capacity for mental work varies 
 very remarkably, one man being- able to overtake easily an 
 amount of labor, without apparent detriment to health, which 
 another finds quite beyond his scope, both in quantity and 
 quality. Every one has his own individual range, the limits 
 of which he cannot exceed with impunity. 
 
 The term " overwork," then, is necessarily used in a relative 
 sense. Its effects are chiefly seen in the literary, scientific, 
 professional, and commercial classes, and in children; being 
 largely caused by the fierce competitive struggle of the pres- 
 ent day. It is one of the great sources of insomnia. 
 
 Reference has already been made to the fact that an in- 
 active brain during waking moments (as in the condition 
 known as " thought drifting ") is comparatively bloodless, and 
 of smaller size than when in active function. During mental 
 operations some of the psychical areas are called into activity; 
 the blood-vessels supplying these dilate, more blood is conveyed 
 to the parts, and the brain increases in size. If the particular 
 intellectual occupation is changed for another, a fresh group 
 of centres is brought into requisition, which in their turn 
 grow hyperaemic, while those first in use, becoming quiescent, 
 resume their normal or comparatively anaemic state. (It has 
 been clearly demonstrated by Mosso that hyperaemia of the 
 brain is coincident with mental work. It seems legitimate to 
 argue from analogy that this increased blood-supply is limited 
 to the active portions of the brain, and not uniformly dis- 
 tributed to every portion. Therefore, while the writer is well
 
 Insomnia and its Therapeutics. 65 
 
 aware that no such localized anatomical apportionment has 
 been shown to take place, he thinks it a very reasonable 
 proposition, and it is certainly a very attractive and conve- 
 nient working- theory. The theory, moreover, appears to be 
 justified on the further ground that the cerebral blood-vessels 
 are terminal, and do not anastomose freety one with another. 
 They are thus capable of vascularizing certain limited areas 
 without increasing the blood supply of the brain generally.) 
 These are healthy and physiological processes, just as needful 
 for the proper nutrition, growth, and development of the brain 
 and its powers, as are muscular contractions for the nutrition 
 and development of a muscle; and as disuse in the latter case 
 is surely followed by atrophy, so, in the former, does it lead to 
 mental lethargy and decay of function. 
 
 When mental work of an arduous and engrossing kind is 
 pursued, particular psychical sites are extremely active, and 
 toiling at their highest possible pressure. At first, when the 
 reserve fund of nerve force is considerable, the deleterious con- 
 sequences of straining are not apparent, for during the hours 
 of rest these sites recover their normal condition, and recu- 
 perative changes are effected, so that work can be resumed 
 as usual on awaking. This is accomplished by means of the 
 vaso-motor nerve, whose function it is to regulate the blood- 
 supply to the amount of work being carried on. 
 
 When, however, this high pressure is obstinately main- 
 tained, there conies a time, sooner or later, depending mainly 
 upon the stability of the nervous tissues, when these physio- 
 logical arrangements begin to fail, and the active centres be- 
 come weary, jaded, and irritable. The vaso-motor nerves, 
 being inhibited during lengthened periods, grow exhausted 
 and paretic, and become unable, on temporary cessation of 
 mental work, to cause contraction of the blood-vessels as they 
 ought to do, so that a condition of local chronic hypereemia is 
 excited in the particular centres in use, and these sites becom- 
 ing exhausted, the case assumes a pathological aspect. It 
 constitutes an example of derangement accruing from work 
 imposed upon the cerebral textures being badly arranged and 
 in excess of their powers. When this stage has been reached, 
 work may still be carried on by a powerful effort of the will, 
 but sleeplessness becomes pronounced, the general health 
 gives way, and the breakdown is complete.
 
 66 Insomnia and its Therapeutics. 
 
 The symptoms which such persons present are tolerably 
 uniform. Sleeplessness is one of the most urgent, being usu- 
 ally associated with throbbing blood-vessels and restless cere- 
 bration. When sleep does occur it is disturbed, unrefreshing, 
 and accompanied by dreams, and as these are dependent upon 
 activity in the centres called into function by the work en- 
 thralling the. -mind, the dreams are usually connected with 
 one's daily toil. 
 
 Exhaustion and misery are felt in the morning; depression, 
 despondency, and irritability during the day. All mental and 
 plrysical work is accomplished with an effort, concentration 
 of thought is difficult, and headache is seldom absent. The 
 overworked man looks worn and anaemic, and has a soft, com- 
 pressible pulse; although in some cases he is plethoric, with 
 bright eyes and a hard, tense pulse. In both types, the brain 
 and nervous system, being neither recuperated nor relieved 
 of their waste products, innervate the various organs of the 
 body defectively; and so dyspepsia, constipation, and palpita- 
 tion of the heart are generally complained of; and the urine 
 may contain oxalate of lime, or an excess of phosphates. 
 
 It will be gathered, from consideration of the foregoing 
 sentences, that it is an exclusive or almost exclusive use, or 
 rather misuse, of a particular and limited portion of the brain 
 which leads to the portrayed disaster. An analogous instance 
 of the same thing occurring in another system is to be found 
 in writer's cramp, where the constant use of a particular set 
 of muscles is followed by serious disorder. Another proof, if 
 proof were needed, of the evil effects of prolonged and unvaried 
 mental toil, is to be found in the fact that \vhen insanity super- 
 venes upon mental overwork, it occurs chiefly, if not entirely, 
 among those whose work is of a protracted, monotonous, and 
 undiversified description. 
 
 The import of sleeplessness is apt occasionally to be mis- 
 apprehended. Some years ago the writer was intimately ac- 
 quainted with a man who was engaged in literary work of a 
 hopeful kind, and who, though obviously suffering from 
 mental strain, was wont to congratulate himself upon his 
 special power of dispensing with sleep, making calculations as 
 to how many years of his life he had lost in sleep during the 
 course of his career. For a long time he worked well on an 
 allowance of six hours' sleep a night, for a shorter time upon
 
 Insomnia and its TJierapeutics. 67 
 
 four, then upon two, and latterly he slept not at all. He 
 turned a deaf ear to all warnings of the dangers which he was 
 only too surely incurring-, until the crash came in an extremely 
 severe attack of meningeal inflammation, from which he 
 eventually recovered, but only to be the wreck of his former 
 self. 
 
 The evils of mental overwork are frequently manifested in 
 children, owing to the pernicious system of cram which pre- 
 vails so extensively at the present day. Their brains require 
 an unusually large amount of sleep for the purpose of supply- 
 ing the necessary pabulum for growth, as well as for the re- 
 moval of the products caused by tissue-metamorphosis. This 
 fact presents itself in a striking light when it is remembered 
 that the male brain reaches five-sixths and the female ten- 
 elevenths of its full size at the age of seven years. When 
 children are encouraged to make great strains upon the high- 
 est cerebral centres, it frequently leads to brain irritation, or 
 congestion, which shows itself in irritability and peevishness, 
 headache, sleeplessness, or sleep accompanied by disturbing 
 dreams, loss of appetite, and failure of nutrition and strength. 
 If these symptoms are neglected or misconstrued, they may 
 culminate in organic lesions, such as meningitis. Unfortu- 
 nately, brains that are not allowed to grow naturally, but 
 are forced, are apt to become permanently weak and un- 
 stable, and to be the cause of much trouble and misery in 
 after-life. 
 
 Chorea, of which sleeplessness is so common a symptom, 
 was found by the Collective Investigation Committee of the 
 British Medical Association to be caused in seventy-one cases 
 out of four hundred and thirty-nine by overwork, fifteen being 
 males and fifty-six females. Sixty-three of these cases oc- 
 curred in children between the ages of six and fifteen years, 
 and eight between fifteen and twenty years. 
 
 Formerly the symptoms of overwork in children were com- 
 monly ascribed to worms or low fever, the victims being kept 
 at home from school and dosed with drastic purgatives. 
 These are excellent remedies for cerebral congestion, and can 
 hardly be improved upon even now, though, with our extended 
 knowledge and experience, they are seldom required. 
 
 Sleep is the best criterion as to the amount of work a child 
 can do without injury to health. So long as sleep is sound
 
 68 Insomnia and its Tlurapcutics. 
 
 and dreamless the question of overwork need not be con-, 
 sidered. 
 
 It has often been urged that work never kills, and probably 
 healthy and well-arranged work never does. That badly- 
 balanced, unvarying, and excessive work initiates pathological 
 changes which, in children, lead to fatal terminations, and in 
 adults to disastrous consequences, must be within the experi- 
 ence of every physician. There certainly can be no prolonged 
 interference with sleep without the health becoming seriously 
 compromised. 
 
 Treatment. This will be most advantageous^ considered 
 under the following heads : removal of the cause, diminution 
 of the hyperaemia of the nervous centres, restoration of tone 
 to the vaso-motor nerves, calming and strengthening the 
 nervous centres. 
 
 (1) Removal of the Cause. In most cases it is best to 
 advise temporary cessation from all work until health im- 
 proves and sleep returns. The resumption of work should be 
 gradual, and the method subjected to careful re-arrange- 
 ment upon strictly physiological lines. The amount of work 
 performed need not necessarily be more limited than before, 
 but it should be of a more varied character, its range being 
 curtailed in some directions while it is extended in others. 
 
 (2) Diminution of the Hypercemia of the Nervous Cen- 
 tres. This may be accomplished in several ways. Among 
 the most important is change in the character of the work. 
 The benefit to be derived from this diversity is well illustrated 
 in the lives of some of our greatest men. Leading statesmen, 
 busy judges, those at the head of gigantic business concerns, 
 all find it necessary to have hobbies, and find in them sources 
 of relaxation and distraction from cares which would otherwise 
 overwhelm them, and without which sleeplessness and its at- 
 tendant evils would speedily supervene. It is of the highest 
 importance that patients be advised to avail themselves of 
 this physiological cure by devoting their attention to light 
 reading, cards, billards, or some other amusement for an hour 
 before going to bed. 
 
 The writer has long been of opinion that the benefit derived 
 from billiards, wood-carving, playing musical instruments, 
 such as the piano or violin, etc., is largely due to the number 
 of cerebral centres called into requisition. The complexity
 
 Insomnia and its Tlierapeutics. 69 
 
 and precision of the fine movements imply high activity in 
 some motor centres; the sensory centres are stimulated by 
 way of the eye and ear; while at the same time the centres 
 of intellectual operations are brought into activity in order to 
 correlate the whole a combination of circumstances the re- 
 sult of which will most probably be depletion of the hyperse- 
 mic centres. 
 
 Many devices based upon the same physiological grounds 
 have been suggested as means of procuring sleep. The thoughts 
 are to be concentrated, by an effort of will, on one subject, 
 preferably a monotonous one, such as in imagination singing 
 some melody, or counting sheep marching in single fill through 
 a gate, counting numbers, or one's own respirations. A medi- 
 cal friend of great determination of purpose says that he is 
 never conscious of counting more than seventeen sheep walk- 
 ing through a gate before he falls asleep. Smiles, in his work 
 on "Life and Labor," relates that "a missionary troubled 
 with sleeplessness repeated the Lord's Prayer till Satan sent 
 him to sleep to get rid of it, and he says he never found the 
 receipt to fail." 
 
 The difficulty is in directing the thoughts exclusively to 
 the new subject, as it requires the greatest effort to inhibit 
 the activity of the hyperaemic centres, and to prevent the ideas 
 from returning to their accustomed channels; indeed, the 
 artifice often fails for this reason. 
 
 Other expedients, the physiological effects of which are, to 
 a large extent, of a similar character to the foregoing, are 
 found in change of scene from the country to the city, or vice 
 versa or in travel; while a well-planned walking tour, or a 
 month's fishing, hunting, or shooting, for the more robust, are 
 excellent hypnotics. 
 
 Wordsworth, who was manifestly acquainted with the use- 
 fulness of such aids to sleep, as well as with their occasional 
 inadequacy, recounts them in the following lines : 
 
 " A flock of sheep that leisurely pass by 
 One after one ; the sound of rain, and bees 
 Murmuring ; the fall of rivers, winds, and seas, 
 Smooth fields, white sheets of water, and pure sky ; 
 I've thought of all by turns, and still 1 lie 
 Sleepless ; and soon the small birds' melodies 
 Must hear, first utter'd from my orchard trees, 
 And the first cuckoo's melancholy cry.
 
 7O Insomnia and its Therapeutics. 
 
 Even thus last night and two nights more I lay, 
 And could not win thee, Sleep! by any stealth; 
 So do not let me wear to-night away. 
 Without thee what is all the morning's wealth? 
 Come, blessed barrier between day and day, 
 Dear mother of fresh thoughts and joyous health ! " 
 
 In these cases the writer relies much upon the use of the 
 Turkish bath under medical advice, as a curative agent; for 
 as a derivative, depurative, and tonic it has no equal, relieving 
 the cerebral congestion and toning the nervous and circula- 
 tory systems, thereby aiding digestion and assimilation (Chap. 
 XVII.). The lamp bath and the sitz bath, although inferior to. 
 the Turkish, are sometimes serviceable. Several other applica- 
 tions of hydrotherapy, which are all more or less useful in the 
 cases under consideration, may be mentioned. One of these 
 consists in douching the head with cold water at bedtime; 
 and this may be combined with the use of moist applications 
 to the feet and legs. Good effects are said to be got from a 
 pair of wet cotton socks worn all night covered with a pair 
 of thick woollen ones. The writer has frequently seen good 
 results follow the use of wet towels rolled round the legs and 
 worn during the night. Such appliances, however, occasion- 
 ally prevent sleep by acting as disturbants. Of much more 
 service than these partial remedies is the employment of the 
 wet pack immediately before bedtime. Reference to this 
 measure is made at some length elsewhere. 
 
 Bodily exercise is a valuable curative in these cases of in- 
 somnia, attracting a large supply of blood to the muscles and 
 skin, and acting as a powerful derivative to the brain, while 
 it increases cardiac action and vascular tension. On discon- 
 tinuing the exertion these states are reversed; the heart beats 
 more quietly, the blood-pressure is lowered, and sleep becomes 
 possible. Exercise should be taken in the open air, and be 
 proportioned to the strength of the patient, all fatigue being 
 avoided. The form most desirable for a particular case re- 
 quires some consideration. Walking, riding, gymnastics, etc., 
 have each its special advantage; and in many instances, walk- 
 ing or riding to and from business is all that is necessary to 
 promote sleep. 
 
 In those instances in which the general vascular tension is 
 much increased, alkalies, combined with tincture of aconite,
 
 Insomnia and its Therapeutics. 71 
 
 may be advantageously prescribed, and their action is aug- 
 mented by saline purgatives. In some few cases it may be 
 necessary to resort to depletion, but dry cupping to the neck 
 and upper part of the shoulders will generally suffice. 
 
 Restoration of Tone to the Vaso-motor Nerves. Some 
 of the foregoing measures will materially assist in accomplish- 
 ing this object, but it is occasionally desirable to administer 
 some tonic medicine, more particularly in those cases in which 
 the vascular tone is relaxed. For many years the writer has 
 prescribed, with most excellent results, a combination of nux 
 vomica and hyd rob romic acid. 
 
 5 Acid, hydrobrom., 3 vi. 
 
 Tinct. nucis vom., . . . 3 ij. vel 3 iij. 
 
 Tinct. cichon. rub., . . . . . 3 vi. 
 
 Aquam, ad 3 vi. 
 
 Sig. A tablespoonful in a wineglassful of water an hour 
 before luncheon and dinner. 
 
 When the urine contains an excess of phosphates or oxalate 
 of lime the following may be substituted : 
 
 IJ Acid, nitro-hydrochlor. dil., . . . . 3 iij. 
 
 Liquoris strychnin., 3 i. 
 
 Tinct. gent, co., 3 vi. 
 
 Aquam, ad vi. 
 
 Sig. A tablespoonful immediately after meals, in water, 
 thrice daily. 
 
 Calming and Strengthening the Nervous Centres. To 
 accomplish this it is necessary to direct attention to the gen- 
 eral health. The patient should cultivate the habit of going 
 to bed at a regular hour, and of rising with punctuality. The 
 bedroom should be well ventilated, and the head raised upon 
 a high pillow. The hours for eating and drinking must be 
 laid down with precision,. the diet being adapted to the tem- 
 perament and digestive powers, the last meal being taken 
 some three hours before going to bed. If dinner is an early 
 meal, a cupful of some farinaceous food, such as milk arrow- 
 root, is necessary before retiring. Tea, coffee, and tobacco are 
 to be used in great moderation, if not discontinued entirely, 
 and the excretory organs kept active.
 
 72 Insomnia and its Therapeutics. 
 
 No hard-and-fast rule can be laid down as to the employ- 
 ment of alcoholic stimulants, each case requiring separate and 
 careful consideration. The plethoric, whose A^ascular tension 
 is already high, do best without alcohol in any form; while 
 the anasmic are often benefited by a moderate quantity taken 
 with food to promote digestion, and a " night-cap " of whiskey 
 or brand}', with warm water and sugar. For centuries the 
 hypnotic effect of alcohol in combination with sugar and nut- 
 meg has been recognized, strong ale and nutmeg being a fa- 
 vorite form for its administration. In this connection it is 
 interesting to note that Horace, in his " Satires/' gives an ex- 
 cellent prescription of Trebatius' for this form of insomnia; it 
 is as follow r s : "Anointed let them swim the Tiber thrice who 
 require a deep sleep; let them also have their bodies saturated 
 with wine at night" a combination of stimulant with exer- 
 cise. On account of its stimulant and derivative action, tur- 
 pentine in TT L xxx. doses at bedtime is a powerful aid to sleep. 
 It suits best in plethoric cases. Knowing how efficacious the 
 late Dr. Warburton Begbie found it in the " headache of a 
 fatigued brain," the writer was induced to prescribe it in this 
 class of cases, and his anticipations were abundantly realized. 
 It yields equally good results in worry. It is easily taken in 
 capsules, which usually contain TH xv. each 
 
 If the remedies detailed fail to accomplish the end in view, 
 we must resort to the use of hypnotics, which, by their sooth- 
 ing effect on the irritable nervous textures, are calculated to 
 induce sleep, and, in so doing, to restore tone to the exhausted 
 and enervated tissues. There are many agents from which 
 to choose. The bromides are especially applicable in cases of 
 insomnia arising from overwork, the only centra-indication to 
 their use being anemia, on account of the tendency which 
 these drugs have to lead to an impoverished state of the blood, 
 and this itself is a cause of sleeplessness. 
 
 The bromide of lithium of the United States Pharmacopoeia 
 is the best hypnotic of the bromide salts, as it contains a half 
 more bromine than the potassium bromide. Its dose is from 
 ten to twenty grains. The bromides of sodium and potassium, 
 which are in most frequent use in this country, are given in 
 doses of 3 ss. to 3 i. They are best prescribed in syrup and 
 water, a full dose being taken two hours before bedtime, and 
 another at bedtime. If these doses do not succeed in procur-
 
 Insomnia and its Therapeutics. 73 
 
 ing sleep they may be associated with ergot of rye and digi- 
 talis, both of which are stimulants of the vaso-motor centres. 
 
 Ijl Bromidi lithii, ...... gr. xl. 
 
 Extracti ergotse liq., . , . . . 3i. 
 Tinct. digitalis, . . \ . . .in, xx. 
 Aquae chloroform!, 3 xv. 
 
 M. Sig. Take one-half two hours before going to bed, and 
 the other half at bedtime. 
 
 If the bromides fail to induce sleep after eight days' trial, 
 their use should be discontinued. 
 
 In anaemic cases where it is advisable not to give the bro- 
 mides, sulphonal, paraldehyde, or urethane may be tried, as 
 they are each suitable drugs. 
 
 In children, treatment should be conducted on like princi- 
 ples, badly arranged work being interdicted and the child re- 
 moved from school and placed for two or three days in bed in 
 a quiet, cool, and darkened room, with cold applications to 
 the head, a tepid bath being given night and morning. The 
 food should be light and bland. A purgative may be required, 
 as well as potassium bromide in doses of one grain for every 
 year of age, thrice daily, in some sweetened water. 
 
 If the symptoms of irritation do not .speedily subside, six 
 or eight leeches must be applied to the temples, all subsequent 
 bleeding being checked. 
 
 After all headache and restlessness have disappeared, a 
 change of air and scene will complete the cure. It is better 
 to avoid the seaside. 
 
 When the child returns to school it must be stipulated 
 that its lessons be more varied, and that it should play for at 
 least half an hour after each meal. 
 
 The following table is one modified by the writer from that 
 of 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. 
 
 AGE. 
 1 
 
 Exercise. 
 7 
 
 Work. 
 3 
 
 Leisure. 
 4 
 
 Sleep. 
 10 
 
 8 
 
 6 
 
 4 
 
 4 
 
 10 
 
 9 
 
 5 
 
 5 
 
 4 
 
 10 
 
 10.. 
 
 5 
 
 6 
 
 4 
 
 9
 
 74 Insomnia and its Therapeutics. 
 
 AGE. 
 11 
 
 Exercise. 
 5 
 
 Work. 
 6 
 
 Leisure. 
 4 
 
 Sleep. 
 9 
 
 12 
 
 5 
 
 6 
 
 4 
 
 9 
 
 13 . . 
 
 4 
 
 7 
 
 4 
 
 9 
 
 14 
 
 4 
 
 8 
 
 3 
 
 9 
 
 15.. 
 
 4 
 
 8 
 
 3 
 
 9 
 
 Dr. Dukes," of Rugby, is of opinion that boys under ten 
 years of age require eleven hours' sleep, and that those under 
 thirteen need ten hours and a half set aside for this purpose. 
 In his work on " Health at School " he writes : " The tendency 
 in schools is rather toward too little than too much sleep; in 
 fact, in public schools I think boys scarcely get enough, espe- 
 cially the younger ones; and were it not for the holidays 
 coming every twelve or thirteen weeks, I do not believe they 
 could do their full share of work and yet continue in health." 
 
 SHOCK. 
 
 Sleeplessness from shock is not so frequently met with in 
 practice as to entitle it to a very prominent place in a work 
 on insomnia ; but as the facts connected with it will serve to 
 illustrate much that is to follow, a brief reference will be made 
 to its effects upon the nervous system. 
 
 Shock may be caused by any severe injury or excessive 
 pain, or by overwhelming mental emotion. It varies in sever- 
 ity with the nature and extent of its cause, and affects some 
 individuals much more profoundly than others. The difference 
 depends upon the age, sex, habits, temperament, and more es- 
 pecially on the stability of the nervous system. In illustration 
 of this, the writer some years ago made a post-mortem exam- 
 ination of the body of a man who had died from extensive 
 fracture of the base of the skull with hemorrhage. The his- 
 tory showed that he had sustained an injury about 12 noon, 
 after which he walked home, a distance of two miles. In the 
 evening he visited a neighboring tavern, where he drank 
 freely, and only made casual reference to his accident. On 
 going home he went to bed, and died during the night. In 
 contrast is a case seen more recently, in which a man lay 
 pulseless for many hours, with the heart beating inaudibly, 
 after a trifling injury from a knife which merely punctured 
 the skin and did not involve the loss of a drachm of blood.
 
 Insomnia and its Therapeutics. 75 
 
 This difference in constitution well explains the varying- de- 
 grees of sleep disturbance following- shock. 
 
 Shock causes a rapid depletion of the brain and cutaneous 
 surface, and interference with the normal irritability of the 
 psychical, motor, and sensory centres; respiration and circu- 
 lation are deranged, and the temperature of the body is low- 
 ered. These conditions combine to bring about a partial par- 
 alysis of the heart, and a sudden dilatation of the abdominal 
 blood-vessels, which are found after death from shock to be 
 enormously distended, while the vessels in the rest of the body 
 are comparatively empty. The result of this sudden flushing- 
 of the vessels of the abdominal viscera is that less blood than 
 usual reaches the feebly-acting heart, and the brain and sur- 
 face of the bod3^ are rendered anaemic. 
 
 Sleeplessness, often of a pronounced character, follows; 
 and it may continue during months or years. 
 
 In many cases the cardiac and vaso-motor centres never 
 seem to recover their tone, as in the following case. A healthy 
 lady, aged sixty-four, had the misfortune to fall upon the 
 pavement, and although she sustained no injury to the bony 
 structures, she suffered severely from shock and died six weeks 
 afterward, notwithstanding every care. Throughout her ill- 
 ness she had no natural sleep, vomited everything she swal- 
 lowed, and sweated profusely ; in short, the symptoms were 
 all referable to grave disturbance in the medulla oblongata. 
 
 Shock is not seldom the originating- cause of organic heart 
 disease, even when no lesion can be diagnosed at the time, and 
 in many cases the cardiac disorder still further disturbs sleep. 
 Shock depending upon sudden mental perturbation is ac- 
 countable for a certain percentage of all cases of insanity; 
 and it is capable of arresting the menstrual flow and the 
 secretion of milk and of the digestive fluids. To severe cases 
 of shock, or to the slighter cases which quickly recover, we 
 shall not allude further. It is with those of medium severity 
 that we are chiefly concerned cases which recover speedily 
 up to a certain point, then progress less satisfactorily, and 
 end in an extremely protracted convalescence. During their 
 progress the nervous system is excitable and impressionable, 
 the chief, constant, and persistent symptom being insomnia, 
 or imperfect sleep disturbed by distressing dreams from which 
 the patient commonly awakes in a state of terror.
 
 76 Insomnia and its Therapeutics. 
 
 Treatment. The most urgent indication at the time is to 
 establish reaction, and to restore the equilibrium of the circu- 
 lation without unduly exciting it. The shorter the duration 
 of the shock, and the more complete the restoration of tone, 
 the less likelihood will there be of sleeplessness resulting. 
 Hence the necessity for adopting- adequate measures at the 
 onset. This is so widely recognized that surgeons invariably 
 resort to the use of morphine or opiates after severe opera- 
 tions. 
 
 If sleeplessness appears after reaction is established, and 
 persists when the stage of convalescence is reached, there is 
 need to administer remedies which will act powerfully upon 
 the enfeebled centres in the medulla, so that the cardiac and 
 vascular tone may be recuperated. Probably the most pow- 
 erful remedy we possess is strychnine. Its stimulant action 
 upon these centres is slower in manifesting itself than when 
 sulphuric ether is used, but its effects, once secured, are much 
 more lasting, its elimination requiring almost as many hours 
 as ether does minutes. It is best administered hypodermically, 
 and the salts most suitable for the purpose are the nitrate 
 and the acid sulphate. From -fa to -^ of a grain, repeated 
 three or four times in twenty-four hours, is usually sufficient, 
 although these doses may be cautiously increased up to y 1 ^ or 
 j^ of a grain. Tincture of nux vomica may be injected in 
 ten-minim doses instead of strychnine, but the pain it causes 
 lasts for two or three hours. Either remedy can be given by 
 the mouth, when it is highly advantageous to combine it with 
 quinine, for that medicine exerts an exceedingly tonic influence 
 over the nervous and vascular systems, and is especially use- 
 ful in anaemia of the brain and medulla oblongata. The fol- 
 lowing is the formula the writer has used for many years : 
 
 B Liq. strychnin., . 3 i. 
 
 Sulph. quinin., gr. xx. 
 
 Acid, hj'drobrom., 3 vi. 
 
 Infus. serpentar., . . . ad f vi. 
 
 M. Sig. Take a tablespoonful in water, three times a day, 
 between meals. 
 
 Phosphorus, by increasing the circulation of the brain and 
 acting as a tonic and nutrient to the nervous system, is also 
 found useful in these cases, and is best given in doses of -^ of
 
 Insomnia and its Therapeutics. jj 
 
 a grain three times a day, the elixir of phosphorus (Martin- 
 dale's) and the perles of phosphorated oil being good forms 
 for its administration. 
 
 Calabar bean has been suggested, but of its use in this con- 
 dition the writer has no experience. 
 
 It is usually necessary to resort to the use of hypnotics for 
 a few nights for the purpose of securing sleep, which is, par 
 excellence, the most potent recuperative agent of all; and for 
 this purpose opium, or its alkaloid morphine, is especially in- 
 dicated, as it is in all anaemic states in which insomnia is a 
 prominent symptom. 
 
 The following is a useful pill : 
 
 5 Ext. opii, . . . . . . gr. ss. 
 
 Ext. belladon., gr. . 
 
 Pulv. digital., '. gr. i. 
 
 Pulv. camphor., gr. ij. 
 
 Ft. pil. i. Sig. Take at bedtime. 
 
 Morphine administered hypodermically in doses of -fa to \ 
 of a grain, in most cases, insures a good night's rest. Of the 
 many preparations of morphine, the writer thinks the tar- 
 trate the best for general use, on account of its solubility. It 
 is often advantageous to combine it with -j-J-g- of a grain of 
 atropine sulphate, which checks the tendency to vomiting 
 which morphine so frequently causes immediately after it is 
 injected, while it appears to augment the hypnotic properties 
 of morphine. Atropine alone is a valuable therapeutic remedy 
 in all cases of reflex cardiac inhibition, such as obtains in shock. 
 
 The food should be nourishing and easily digested, and the 
 bowels, if constipated, regulated by some mild laxative, such 
 as aloes combined with belladonna or henbane. Alcohol in 
 the most suitable form must be allowed, so long as it aids 
 digestion; and everything that is likely to inspire the patient 
 with confidence and hope must be sedulously considered and 
 adopted. 
 
 DEPRESSING EMOTIONS. 
 
 Prolonged depressing emotions, such as anxiety, grief, 
 worry, etc., are frequent sources of insomnia, and though usu- 
 ally classed with overwork, the symptoms of which they 
 closely resemble, they differ in certain important respects, one
 
 78 Insomnia and its Therapeutics. 
 
 being that overwork may cause sleeplessness to arise in the 
 hopeful and vigorous, while worry is always more or less as- 
 sociated with hopelessness. From the earliest times mental 
 perturbations have been recognized as inimical to sleep. Hip- 
 pocrates notes as a fact that "the insomnolency is connected 
 with sorrow." 
 
 Burton gi-ves the following- quotations from Crato which 
 point in the same direction : " Grief, cares, expectations, anx- 
 ieties, great businesses, and all violent perturbations of the 
 mind must be in some source gratified before one can hope for 
 any good repose. . . . He that is in suspense, fear, or in any 
 way troubled in mind can never rest at night." 
 
 The effects of such emotions are truly credited with being 
 more baneful than those of overwork, with which they are 
 often, though not necessarily, associated; and they appear 
 to depend on a combination of circumstances. Emotion, of 
 whatever form, implies activity in the emotional regions of 
 the brain. In worry these parts, from being in constant 
 function, get into the same pathological condition of exhaus- 
 tion and congestion which we described as resulting in the 
 psychical sites from overwork. Upon this fact is based the 
 physiologically true saying that "fifty worries are better 
 than one worry," for in the former case the sites of activity 
 are altered from time to time, and the strain, being distributed 
 over a wider area, is better borne than when the mental dis- 
 turbance is due to one never-changing cause. This, however, 
 is not the whole case, for the effects of mental emotions upon 
 the sympathetic nervous system require to be taken into ac- 
 count. If they are pleasurable, these centres are stimulated 
 to greater activity, and this, being reflected along the whole 
 circulatory apparatus, gives rise to feelings of comfort and 
 exhilaration. If, on the contrary, these emotions are of an 
 opposite kind, the effect on the nervous centres is such as to 
 cause circulatory modifications of an atonic character, which 
 are followed by general depression and mental suffering. 
 These vascular changes are due to inhibition of the cardiac 
 and vaso-motor centres similar to that occurring in shock, 
 but more gradual and insidious in their onset, as was well 
 expressed by Dr. Hughlings Jackson in the following words: 
 "Fright and anxiety which latter is only fright spread out 
 thin." This inhibition leads to defective innervation of the
 
 Insomnia and its 77ierapeutics. 79 
 
 heart and gastro-intestinal canal, which brings in its train 
 cardiac derangements and digestive troubles, with consequent 
 disordered nutrition. In most cases vascular tension is re- 
 laxed, and in all sleep is seriously interfered with, being either 
 absent altogether, or imperfect, and disturbed by nightmare 
 and dreams. The conditions, in short, brought about by de- 
 pressing emotions are similar to those which result from over- 
 work, with a modified amount of shock superadded. 
 
 The effects of worry, etc., expend themselves upon the 
 feeblest portion of the nervous textures, and consequently are 
 most frequently seen in sj^mpathetic persons whose emotional 
 centres are weak and impressionable. They are often devel- 
 oped in severe forms in females, and are always modified by 
 age, temperament, general health, and the source of the 
 worry. A patient so afflicted presents a downcast and de- 
 jected aspect, the face is drawn and haggard, the eyes are dull 
 and expressionless, while vision is dim, and the pupils react to 
 light sluggishly. 
 
 Mental depression and misery are complained of, with 
 headache, confusion of thought, loss of memory, lassitude, and 
 disinclination for exertion. The heart is weak and palpitates, 
 and not infrequently the functional derangement ends in or- 
 ganic change, the explanation of which is sufficiently obvious. 
 Worry, as has already been hinted, consists of a series of 
 small shocks, following upon each other more or less rapidly, 
 and at each shock, small though it be, the heart is temporary 
 inhibited and fails to expel its contents thoroughly, so that at 
 the next systole it has to deal with a larger amount of blood 
 than usual. The consequence is that the weakened muscular 
 walls yield under the strain, and dilatation occurs. 
 
 The appetite is poor, and the patient suffers from flatu- 
 lence, acidity, heartburn, and constipation or relaxation of the 
 bowels. 
 
 The urine may contain phosphates in excess, or oxalate of 
 lime, or traces of sugar or albumin. It is often copious and 
 of low specific gravity, and, in fact, presents all the character- 
 istics of the urine of chronic Bright's disease, of which worry 
 is sometimes the only recognizable cause. The patient usu- 
 ally loses flesh quickly, in consequence of defective metabolism, 
 and if his condition is not ameliorated he gradually merges 
 into the more pronounced condition of neurasthenia.
 
 8o Insomnia and its Therapeutics. 
 
 We may here remark in passing- that the effects of grief 
 have frequently been studied in animals, notably in dogs; and 
 cases have been recorded in which they proved fatal. 
 
 Treatment. It is important in the first place to ascertain 
 the source and nature of the worry, so that if it has its origin 
 in some bodily ailment, such as varicocele, the cause may be 
 removed. In many cases, however, the patient seeks advice 
 for insomnia, or dyspepsia with disturbed sleep, and so far 
 from hinting- that it is due to grief, he seeks to conceal his 
 sorrow, and it requires delicacy and tact to overcome reti- 
 cence and to obtain a frank confession of the trouble. 
 
 If it is a monetary anxiety, the physician might prove him- 
 self a magician if, instead of writing- a prescription, he could 
 give an order upon his banker for the needed amount. Un- 
 fortunately few physicians have it in their power to do so, and 
 those who have do not appear to think of it! If it is due to 
 the strain of over-speculation or gambling 1 , which keeps the 
 cerebral cells ever on the qui vive, watching- constantly for 
 telegrams, until every ring at the bell acts like a shock, hop- 
 ing and fearing- by turns, little good can be done until the ill- 
 used cells are released from their bondage of uncertainty and 
 suspense. The physician's powers are likewise limited in cases 
 of anxiety about personal health, or that of friends, or when 
 grief depends upon bereavement, or, still worse, upon living- 
 sources of sorrow. There is one thing, however, that the 
 physician has in his power he can bring a clear and unbiassed 
 mind to bear upon the case, and by judicious advice and coun- 
 sel he may go a long way toward putting- the sufferer into a 
 condition for bearing his trials manfully. He may also help 
 him greatly with his burden by securing repose for his wearied 
 brain and by bracing his heart and arterial system. 
 
 In cases in which the general health is not greatly impli- 
 cated, the best of all remedies is work of a good and hopeful 
 kind, perseveringly maintained. It calls the psychical centres 
 into operation, and by withdrawing the excess of blood from 
 the emotional centres, the latter gradually obtain the repose 
 they so much require, and their hypersensitive condition, 
 which responded to the most trifling impressions, soon be- 
 comes less marked. Many a man has reason to be thankful 
 for the blessing of work which enables him to bury his worry, 
 for the time being, in oblivion. If work does not form a part
 
 Insomnia and its Therapeutics. 81 
 
 of his every-day life, it is essential that he should find some 
 "healthful and wise enterprise in which he can engross himself. 
 The alternation from idleness to healthy employment is the 
 best and the only physiological change that he can obtain. 
 All that was written on the subject of a second occupation, 
 regimen, diet, stimulant, exercise, change of scene, when dis- 
 cussing the treatment of overwork, and much of what has still 
 to be added regarding the treatment of neurasthenia, might 
 be repeated here, but to these remarks the reader is referred. 
 
 In pronounced cases, the stimulating effects of the morn- 
 ing bath must be proportioned to the strength of the patient. 
 The more robust may employ cold, but the weakly should use 
 tepid or warm water, exposing the body during the process as 
 little as possible, and employing the flesh-brush freely. The 
 Turkish bath and sitz bath are both useful in these conditions, 
 and if the Turkish bath is advised, the patient should be 
 recommended to " finish " with the spinal douche. 
 
 At night besides douching the head with tepid water, and 
 using" the other means already referred to, several applications 
 may be tried to promote sleep, among them sponging the 
 nape of the neck and spine with very hot water, or merely 
 rubbing the spine firmly with a warm hand until redness of 
 the skin is produced. Kneading and rubbing the abdomen 
 appears to produce hj^persemia of its contents with a corre- 
 sponding ansemia of the brain. This may perhaps simulate 
 in a very moderate degree the results obtained by Goltz, 
 who, by smartly tapping on the belly- of a frog, drew into its 
 abdominal vessels the most of the blood in the body, by para- 
 lyzing the splanchnic nerves. 
 
 A mustard plaster applied over the abdomen has a most 
 soothing influence, causing contraction of the blood-vessels of 
 the pia mater, which is favorable for sleep. It should not be 
 kept on longer than ten or twelve minutes, else it may cause 
 so much local irritation as to defeat the end in view ; nor must 
 it be applied over the region of the heart, as the stimulation 
 of that organ is inimical to sleep. Dr. George Keith, who 
 formerly practised in Edinburgh, mentioned to the writer that 
 in some cases it did not act so beneficially if placed over the 
 lower part of the abdomen ; a clinical observation which he 
 could not explain. This fact militates against the simple 
 theory of a transposition of blood from the cerebral to the
 
 82 Insomnia and its Therapeutics. 
 
 abdominal blood-vessels. When the plaster is taken off, the 
 part should be sponged with warm water to remove any ad- 
 herent particles of mustard. 
 
 The hot foot-bath at night acts in some as a hypnotic. In 
 fairly nourished cases quinine and strychnine_are, as in shock, 
 useful and powerful agents. 
 
 3 Sulph. .quinin., gr. i. 
 
 Sulph. strychnin., . . . . . gr. ^. 
 
 Ext. gentian., q. s. 
 
 Ft. pil. i. Sig. Take one before meals thrice daily. 
 
 Arsenic may in some cases be combined with these reme- 
 dies, for as an alterative and tonic it has few rivals, strength- 
 ening and calming the nervous system. 
 
 IJ Tinct. quinin., f i. 
 
 Liq. strychnin., 3 i. 
 
 Liq. arsen. sodii, . . . 3 ss. vel 3 i. 
 
 Infus. serpentar., ad 3 vi. 
 
 M. Sig. Take a tablespoonful in water, after meals, thrice 
 daily. 
 
 If the heart is irritable, and there is great relaxation of 
 vascular tension, digitalis must be added. 
 
 5 Tinct. digital., 3 ij. 
 
 Liq. strychnin., 3 i. 
 
 Liq. arsen. sodii, . . . 3 ss. vel 3 i. 
 
 Infus. calumb., ad vi. 
 
 M. Sig. Take a tablespoonful, in water, three times a 
 day after meals. 
 
 In the anaemic and badly nourished, when the digestive 
 powers will bear the use of iron, few remedies surpass the 
 syrup of the phosphates of quinine, strychnine, and iron 
 (Easton's syrup), in doses of one teaspoonful in water after 
 meals three times a day. Iron may also be prescribed in a 
 pill. 
 
 $ Ferri. redact., . . . . . . gr. iij. 
 
 Sulph. quinin., . ' gr. i. 
 
 Ext. nucis vomic., gr. ss. 
 
 Glycer. tragacanth., q. s. 
 
 Ft. pil. i. Sig. Take one after meals three times a day. 
 Notwithstanding all that has been written against phos-
 
 Insomnia and its Therapeutics. 83 
 
 phorus and its efficacy, the writer has reason to be satisfied 
 with the results he has obtained from it; besides the elixir 
 and perles, it may be given in the form of the phosphide of 
 zinc in a pill containing 1 from gr. -fa to gr. |. It may also be 
 prescribed in combination with quinine and strychnine, which 
 emphasize its effects. 
 
 Iji Phosphid. zinc., .... gr. -^ vel gr. ss. 
 
 Sulph. quinin., gr. i. 
 
 Ext. nucis vomic., gr. ss. 
 
 Ext. gentian., q. s. 
 
 Ft. pil. i. Sig. Take one after meals thrice daily. 
 
 When these remedies and regimen fail to induce sleep, it 
 becomes absolutely necessary to resort to the use of hypnotics, 
 for no appreciable improvement can accrue until sleep recu- 
 perates the nervous system. It is only when the distressed 
 mind is oblivious to its sorrows that the cerebral cells can re- 
 cruit their tone. For this purpose chloral hydrate may be 
 prescribed, as it is probably one of the most powerful pure 
 hypnotics we possess, though its employment is so fraught 
 with risk that its use, except under medical advice, is much 
 to be deprecated. The number of deaths that have followed 
 its indiscriminate use warrants this warning. Its administra- 
 tion should not, under any circumstances, be long persevered 
 in, on account of its depressing effects. Its use in the cases 
 of neurotic patients should be carefully considered, they being 
 very liable to acquire the chloral habit, to which we shall 
 refer hereafter. It is best given in doses of 20 to 25 grains 
 with syrup of tolu at bedtime, and it can be repeated in an 
 hour if it is required. Its efficacy is augmented by potassium 
 bromide. 
 
 5 Hydrat. chloral., . . . . 3ij. vel 3iiss. 
 
 Bromid. potass., . , . . . . 3 i. 
 
 Syr. tolu., . . . . . .3 iss. 
 
 Mist, camph., 3 xivss. 
 
 M. Sig. Take one half at bedtime, and the other half in 
 an hour if required. 
 
 In the weakly, when chloral hydrate is deemed to be too 
 depressing, paraldehyde often answers well. The usual dose 
 is said to be from 15 to 50 grains; to insure sleep 45 to 50 
 grains re required. Some think that from 3 i. to 3 ij. is the
 
 84 Insomnia and its Therapeutics. 
 
 proper dose. The following 1 formula has afforded the writer 
 excellent results : 
 
 B Paraldehyd., . TH, xlv. vel in, lx. 
 
 Syr. torn., ....... 3 i. 
 
 Inf us. caryophyll., 3 xi. 
 
 M. Sig-. Take at bedtime. 
 
 Like all other hypnotics, the system becomes tolerant to 
 its use; it should not therefore be administered for more than 
 six or eight nights consecutively. 
 
 Bromidia, though a proprietary medicine, has in several 
 instances been found reliable, in drachm doses given in syrup 
 and water at intervals of an hour until sleep is induced. 
 
 Sulphonal upon several occasions has yielded the writer 
 most excellent results, so much so that he believes this remedy 
 to be a real addition to the list of hypnotics. He gives it in 
 doses varj'ing from 20 to 30 grains made into an electuary 
 with honey, two hours before bedtime, and directs that warm 
 water or very weak toddy should be taken shortly afterward 
 to promote its solution in the stomach. 
 
 Urethane and hypnone have both been prescribed with 
 good effect, but they seem to be less reliable than the hypno- 
 tics already mentioned. 
 
 Dlosely allied to the conditions caused by depressing- emo- 
 tions is that state of mind produced so frequently in children 
 by fear. Fear is merely a modification of fright and, like it, 
 gives rise to nervous shock with its usual accompaniments. 
 Some children are naturally timid and afraid to remain by 
 themselves, or to go to bed in the dark. When a strain of 
 this description is put upon them, the emotional centres tend 
 to become active and hypersemic, while the volitional centres 
 are dominated, and loss of voluntary control is the result. 
 Such patients require careful consideration and management ; 
 bullying- and jeering only make matters worse, while a light 
 in the bedroom or the presence of some one within call in- 
 spires confidence, and allows the emotional centres to calm 
 down, and natural sleep to ensue. With kindly treatment 
 and encouragement the dread of the unknown disappears with 
 advancing years and increasing strength. As regards thera- 
 peutic measures, the bromides will be found the most suita- 
 ble as well as the most efficacious. Sulphonal has been found 
 worthy of trial in these cases.
 
 CHAPTER IV. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 NERVOUS SYSTEM Continued. 
 
 NEURASTHENIA. 
 
 CEREBRAL and spinal neurasthenia are names applied to 
 certain obscure conditions which are the most common of all 
 causes of insomnia. They are characterized by irritability 
 and exhaustion of the brain or spinal cord, as the symptoms 
 are able to be referred to either of those centres respectively. 
 In many cases they indicate that both are implicated. The 
 symptoms differ very considerably in severity in various cases, 
 amounting in some to mere " nervousness " and in others to 
 profoundly marked neurasthenia. 
 
 The causes are of the most variable kind, and the sufferers 
 have their symptoms biassed in a remarkable way by their 
 temperament and mental and physical development, as modi- 
 fied by education, self-training 1 , habits, and social position. It 
 occurs mostly in those who have an hereditary tendency to 
 nervous diseases, and who possess a neurotic temperament. 
 It affects males more frequently than females, especially males 
 in early middle life belonging* to the wealthier classes who 
 may previously have been robust and muscular men. 
 
 The symptoms follow in the train of many circumstances 
 which tend to produce nervous prostration. It is a disease of 
 fatigue, in which the expenditure of nervous energy has ex- 
 ceeded the recuperative powers of the economy. The mental 
 causes include prolonged mental toil, protracted excitement, 
 depressing emotions, such as worry, grief, anxiety, ungratified 
 ambition or desires, etc. The physical causes embrace great 
 and prolonged bodily fatigue, all excesses, or discharges, the 
 immoderate use of alcohol and tobacco, living under unhealthy 
 conditions, and food deficient in quality and quantity. The 
 symptoms may appear in the convalescence from severe dis- 
 eases, fevers, anaemias, cachexias, and in the disorders of nutri- 

 
 86 Insomnia and its Therapeutics, 
 
 tion. In females, from drains upon the system, too frequent 
 pregnancies, and over-suckling 1 . In the young adult from 
 defective nutrition, badly-balanced mental work, and physical 
 over-training. 
 
 In the great majority of cases, these causes have been as- 
 sociated with insomnia for lengthened periods of time, an ag- 
 gravation which has accelerated the breakdown. The first 
 indications of the exhaustion or prostration are referred to 
 the brain and nervous system, which in their turn display 
 their enfeeblement by signs of irritability and instability in 
 the whole nervous apparatus, including the vaso-motor centres. 
 The whole body is made to feel the lack of efficient inner va- 
 tion (the heart, digestive organs, etc.), and this, in the course 
 of time, leads to deficient and imperfect nutrition, which 
 vastly adds to the exhaustion. The symptoms belong to the 
 different organs and viscera. There is a profound sense of 
 the loss of energy and power, with failure of mental vigor and 
 memory, accompanied by a feeling of depression (mental 
 pain) and despondency. The power of will is enfeebled, lead- 
 ing to uncertainty of temper and unreasoning obstinacy. At 
 all times irritable, vacillating, and self-conscious, these individ- 
 uals dwell watchfully upon various sensations, and with ever- 
 increasing introspection become timid, and live in the constant 
 dread of the unknown happening. Every little trouble ap- 
 pears to overwhelm them. Some are afraid to be left alone in 
 a room, or to travel by rail; others have a dread of fire, or 
 that they will lose their reason, or become the victims of some 
 deadly disease. They complain of swimming in the head, 
 headache occipital in character and often accompanied by 
 tenderness of the scalp, giddiness, uncertainty in movements, 
 noises in the ears, and neuralgic pains in various parts of the 
 body, dimness of vision, intolerance to strong light, and often 
 of specks floating before the eyes, while sighing and yawning 
 are frequently present. The pupils may be dilated, and the 
 dimness of vision may depend upon errors of refraction, which 
 in health could be overcome by muscular effort, but which the 
 exhaustion renders impossible. In other cases no ascertain- 
 able ocular lesion exists, and the weakness of sight is ex- 
 tremely variable, being made worse by fatigue, and improved 
 by food and stimulant; it is worst in the morning and best in 
 the evening. .
 
 Insomnia and its Therapeutics. 87 
 
 In the cases where the symptoms are chiefly referable to 
 the spinal cord, besides suffering 1 from some of the foregoing 1 
 symptoms, these patients complain of utter prostration greatly 
 exaggerated by even slight exertion, accompanied by stiff ness, 
 cramps and pains in the muscles (which are probably due to 
 the coagulation of the myosin), most marked after resting 
 for a short time and subsequent to some exercise; and also of 
 muscular twitchings and fibrillar tremblings the physiologi- 
 cal signs of fatigued muscular fibre. 
 
 Pain is referred to the lower part of the spine or to the 
 nape of the neck, and is due in many cases to spinal anaemia, 
 or hyperaemia, both of which conditions, causing disordered 
 nutrition of the nerve cells, give rise to similar symptoms. 
 These symptoms vary in different cases according to the por- 
 tion of the cord affected. 
 
 Sensations of numbness, formication, or pins and needles, 
 are invariably more or less decidedly present. The upper ex- 
 tremities may participate in the weakness, and in some cases 
 there are pseudo-spasms of the hand and fingers, associated 
 with more or less persistent numbness. Usually the weak- 
 ness is mainly referred to the legs, the patient observing, " If 
 I had to fight, I should have to sit down to do so." The patel- 
 lar tendon reflex is sometimes exaggerated, and occasionally 
 the ankle clonus may be elicited in a faint degree, though this 
 varies from day to day, and as recovery takes place excita- 
 bility disappears. 
 
 Neurasthenics are dyspeptic, the digestive derangements 
 depending upon the defective innervation of the various pro- 
 cesses. The appetite may be impaired, but in the majority of 
 cases it is increased, and there is a craving for food and stimu- 
 lant which for a time dispels the symptoms. Flatulence, con- 
 stipation, or looseness of the bowels, uneasy, even painful 
 sensations, and pulsations in the abdomen, are frequently 
 prominent and troublesome symptoms. One patient compared 
 his abdominal discomfort to the contents being grasped by a 
 strong claw or vice. These dyspeptic troubles aggravate the 
 mental gloom, and, combined, they lead to functional disorders 
 of the liver. 
 
 There is cardiac weakness, the heart's sounds and impulse 
 are feeble, pulse weak and compressible; although often slow, 
 it is readily quickened by exertion. There are abnormal
 
 88 Insomnia and its Therapeiitics. 
 
 sensations in the region of the heart, with uneasy pain causing 
 faintness; the patient often, besides sighing, complains that 
 he cannot draw a long breath, or " get to the bottom of it." 
 In some cases there is weakness or irritability of the bladder, 
 and the urine may contain oxalate of lime crystals, phos- 
 phates in excess, urates, uric acid, and occasionally traces of 
 sugar, and sometimes albumin with a deficient excretion of 
 urea. 
 
 These patients are extremely susceptible to draughts and 
 to changes of temperature; cool, bright, and bracing weather 
 suits them best, their lassitude and disinclination for exertion 
 being much increased in warm, close weather. 
 
 The personal appearance is variable; in some it is remark- 
 ably little altered; others look haggard and worn out; most 
 look older than their years. The hair is dry and lacks lustre, 
 tends to fall off and to become gray; the teeth begin to decay; 
 the skin is either clammy and moist or dry and scaly, and 
 quickly loses the suppleness of health. In young adults the 
 symptoms are accompanied by a listlessness and apathy 
 which is very characteristic. If it arises from over-training, 
 it is ushered in by a loss of m uscular and nervous energy, loss 
 of pluck, headache, and feverishness. 
 
 The two symptoms, however, which demand and receive 
 most attention are, first, a loss of flesh which is quite remark- 
 able, being as great as that which occurs in connection with 
 organic disease, and, second, sleeplessness, which is a distress- 
 ing and pronounced feature in probably three-fourths of all 
 cases. It is probably due mainly to exhaustion and irritabil- 
 ity of the nervous centres depending upon malnutrition, and 
 in a less degree to circulatory derangements arising from the 
 impressionability of the vaso-motor centres. Patients usually 
 fall asleep soon after going to bed, to awake in one, two, or 
 three hours, and to remain awake for the rest of the night; or 
 if they get to sleep again, it is only for an hour or so before 
 the time of arising, and their doze is disturbed and uneasy. 
 During their wakefulness, apparently from irritability and 
 congestion of the motor centres, they are restless, fidgety, 
 and occasionally require to get up and wander about. In 
 almost all cases they rise in the morning more weary than 
 when they went to bed. Many patients are accustomed to 
 estimate the amount of sleep they get by their feelings of re-
 
 Insomnia and its Therapeutics. 89 
 
 cuperation the following- day; sometimes they say, "I must 
 have got more sleep than I thought." 
 
 Besides being urgent symptoms, the emaciation and in- 
 somnia have a special prognostic value. All improvement 
 being preceded by a gain in weight, a relapse may equally be 
 predicted from a loss of flesh. Dr. Beard writes : " So one of 
 the first signs of improvement, the earliest evidence that the 
 treatment is doing the work designed, is sleep sounder and 
 more of it, less troubled dreaming, less nightmare, less rest- 
 lessness/' There cannot certainly be any amelioration of the 
 symptoms without increased nutrition and sleep. 
 
 The onset of the symptoms is usually gradual, amounting 1 
 at first only to a depression or lowness of spirits, from which 
 the patient recovers to relapse again into a condition in which 
 they are more pronounced. When the symptoms are marked 
 they may resist treatment for lengthened periods, even 3 r ears, 
 but under proper conditions the prognosis is favorable. 
 
 Relapses are frequent; patients impatient for speedy re- 
 sults cannot obtain them; the recuperative process is always 
 slow and gradual. 
 
 Treatment. Dr. Clifford Allbutt, in his third Gulstonian 
 lecture on visceral neuroses, in 1884, spoke some truths which 
 are particularly applicable here: "The beginning- of all suc- 
 cessful treatment must be to convince the patient of the true 
 nature of his malady. Now, your neurotic is one who has no 
 reserve. This want is probably due to a congenital instability 
 of nerve, showing itself as waste, so ceaseless, that the reserve 
 once dissipated is never reaccumulated. This reserve may 
 have been spent in beneficent activities, or it may have been 
 dissipated in fidgets, fretfulness, or shrewishness; in sleepless- 
 ness, in anxiousness, or in pain, according to the quality of 
 the person. We are disposed to forget that the silent work 
 of nutrition uses more force perhaps than many people expend 
 in their neuro-muscular life; hence the early failure of the di- 
 gestive resources in neurotics, hence the fall of the balance of 
 nutrition below the needs even of a controlled expenditure. 
 We know that g-ood nutrition is a chief condition of steady 
 work, good temper, and self-control; we know, too, that to 
 trade daily only upon the supplies of the day is to court col- 
 lapse ; we must have more brain, more spinal marrow, more 
 liver, more kidney than we want for the day." This powerful
 
 90 Insomnia and its Therapeutics. 
 
 and explicit statement indicates the end to which the treat- 
 ment must be designed and directed. 
 
 The causation of the neurasthenic state must be diligently 
 investigated, with the view of discovering the faulty physio- 
 logical arrangements in the patient's life that have brought 
 it about, that they may be amended; and this is the more 
 urgently called for when it is realized that the diagnosis of 
 the affection can only be arrived at per viam exclusionis. 
 When the condition has been induced by excessive mental 
 work, shock, depressing mental emotions, or prolonged excite- 
 ment, the reader is referred to the preceding chapter, which 
 treats of these subjects, and which must be taken in connec- 
 tion with what is to follow. 
 
 When it has been caused by prolonged bodily fatigue, 
 physical over-training, sexual excesses or masturbation, these 
 indiscretions must be most strenuously interdicted. 
 
 If it has resulted from excessive drains on the system, as 
 in spermatorrhoea, leucorrhoea, menorrhagia, or over-lactation, 
 these exhausting influences require special treatment that 
 they may be remedied. Uterine derangements must be recti- 
 fied; unhealthy surroundings abandoned; disorders of nutri- 
 tion and digestion critically inquired into and relieved; and 
 in each and every case sleep must be secured. 
 
 The patient must be carefully imbued with the fact that 
 his symptoms do not depend upon organic mischief; that to a 
 large extent his convalescence depends upon his doing exactly 
 what he is advised to do ; and that if he does this, and avoids 
 all things likely to weaken and depress him further, he will 
 probably recover his health in time. 
 
 The building up of nervous force is at all times a difficult 
 task, as the centres discharge their energy under the most 
 trifling provocations, which leads to relapses, and of this the 
 patient should be warned, so that he may not be too downcast 
 when they do occur. He must be inspired with hope and con- 
 fidence, and have his life arranged upon strictly physiological 
 grounds, in which food, stimulant, and mental and physical 
 work should be well balanced, and bear an intimate relation 
 the one to the other. If the symptoms are very urgent, he 
 must be advised to give up regular employment, and to rest 
 the jaded brain by calling into use new psychical centres, 
 through new channels of thought. What direction or form
 
 Insomnia and its Therapeutics. 91 
 
 this new work should take must be determined by the patient 
 himself, sua cuique voluptas; the physician can only indicate 
 its necessity. Carlyle wrote these words : " The modern ma- 
 jesty consists in work. What a man can do is his greatest 
 ornament, and he always consults his dignity by doing it." 
 To ask a patient to give up his usual occupation without ex- 
 plaining the need for a new one, is to intensify his sufferings; 
 for mental work of a new and pleasurable kind not only tends 
 to deplete the over-wrought centres, but by its distraction to 
 dispel gloom and depression, and to render him less conscious 
 of his woes, which to him is of no small import. Happier 
 mentally, the control of temper will become easier, he will be 
 able to dominate himself, and will lose much of the mental in- 
 decision which is so distressing to those to whom it was un- 
 known in former years. Vacillation will be replaced \)y de- 
 termination of purpose, which will increase month by month, 
 if not day by day, and exemplify the scriptural truth, " Unto 
 him that hath shall be given." 
 
 The question of exercise is important. It must at all 
 times be kept strictly within the limits of fatigue; for fatigue 
 invariably intensifies the symptoms, whatever that limit may 
 be. The amount to be taken must be determined in each 
 separate case, and it must not be forgotten that it has a high 
 therapeutic value, as a derivative in local congestions, such 
 as occur in mental overwork ; and in hyper-excitability of the 
 sexual organs it can scarcely be esteemed too highly. Within 
 due limits it tends, in all cases, to increase the bodily vigor 
 by exciting the appetite and by quickening and perfecting the 
 digestive processes. Walking, riding, rowing, and gymnastic 
 exercises are all useful, and each has its special indication. 
 In genital and pelvic derangements, rowing and the use of 
 light dumb-bells or clubs are to be preferred to walking, which 
 attracts blood to the lower extremities. On the other hand, 
 the exercise of the muscles of the arms, back, and chest di- 
 verts the blood from the pelvis. Riding is specially useful to 
 those who have led sedentary lives, and whose biliary and di- 
 gestive organs are impaired ; the invigoration in many cases 
 being rapid and appreciable. For those who have sufficient 
 strength, a walking tour, or shooting, or fishing often proves 
 beneficial. Exercise properly regulated is, for the reasons 
 already mentioned, an exceedingly valuable means of promot- 
 ing sleep, and particularly if it is taken in the open air.
 
 92 Insomnia and its Therapeutics. 
 
 The food will demand careful attention, for the aim must 
 be to increase as speedily as possible the quantity and the 
 quality of the blood, as well as the store of fat, so essential 
 for the nourishment of the nervous system. It is consequently 
 necessary to feed up to the extreme limit of the digestive 
 powers. Unfortunately, these are in most cases impaired, 
 and in almost all they are easily overtaxed and deranged. 
 This latter must be carefully avoided, for much time may be 
 consumed in restoring 1 the impaired function. 
 
 When the digestive powers will bear it, two substantial 
 meals should be taken daily; the first about one o'clock, the 
 second about seven P.M., each consisting of clear soup, meat 
 (such as beef, mutton, poultry, venison, or game), and milk 
 puddings or stewed fruit with cream; varied every alternate 
 day by fish being substituted for soup. The fish should be, 
 preferably, raw oysters, whiting, sole, haddock, turbot, or 
 brill. Green vegetables boiled in a plentiful supply of water 
 should be eaten freely, also salads and tomatoes; potatoes 
 more sparingly. Besides these, there should be at least two 
 other meals; a substantial breakfast of Scotch porridge and. 
 cream, followed by chocolate or cocoa (made from the nibs), 
 with toasted bread (preferably brown) and butter, fat bacon, 
 and lightly boiled eggs. In the afternoon, in lieu of tea, a 
 tumblerful of peptonized milk or koumiss. Each individual 
 diathesis must be considered, and the diet varied to suit each 
 separate case. Occasionally, much good accrues from the 
 use of peptic and pancreatic liquors, and malt extracts taken 
 at suitable times; or lactopeptine and ingluvin may be tried. 
 
 When the digestion is weak, it may be desirable to limit 
 the amount of butcher meat. In constipation, it may be nec- 
 essary to avoid milk and eggs. If there is great prostration, 
 small meals every two or three hours must be resorted to, 
 beginning in the morning at seven with boiled milk, sugar, 
 and a spoonful of rum or brandy, following it up with the 
 most easily assimilated food possible, such as raw-meat juice, 
 clear soups, custards, peptonized food, koumiss, or Loeflund's 
 Cremor hordeatus. In these cases it is necessary to give sup- 
 port when they awaken during the night. 
 
 Stimulant. While many cases are best treated without 
 stimulant, others derive benefit from its moderate use. The 
 quantity prescribed must be limited to that which increases
 
 Insomnia and its Therapeutics. 93 
 
 the power and tone of the heart and blood-vessels, augments 
 the appetite, promotes digestion and nutrition, and is not fol- 
 lowed by marked depression. This quantity varies greatly in 
 different persons, and can only be estimated in each individual 
 case by careful observation and consideration. Its limit will 
 probably be found, in all, not to exceed, of whiskey or brandy, 
 one or two wineglassfuls; of port or sherry, two wineglass- 
 fuls; of burgundy, claret, hock, or champagne, one pint; or of 
 Burton ale or porter one quart, in twenty-four hours. 
 
 In many cases a much less quantitj" will suffice, for if the 
 physiological amount is exceeded it retards recovery. In 
 some, when there is a congested condition of the brain, its use 
 must be avoided. The choice of the stimulant may be left to 
 some extent to the patient, but it is well to recollect that 
 whiskey and brandy retard digestion less than sherry and 
 port (Sir William Roberts), and that they owe their efficacy 
 to the alcohol they contain; while wine contains ether; and 
 beer, hops. All stimulants should be ordered to be taken with 
 meals, and when they are required as a night-cap at bedtime 
 for the purpose of promoting sleep, it is always advisable to 
 associate them with a light repast. For example, a cupful of 
 arrowroot with some brandy or whiskey with sugar ; a whipped 
 egg with brandy and sugar, and this is improved by a tea- 
 spoonful of chloric ether; white-wine whey and a biscuit; 
 caudle, made of gruel and wine with nutmeg and sugar; mulled 
 port, claret, or porter; warm spiced ale; brandy or whiskey 
 todd3 r , with or without nutmeg, taken with a biscuit, are each 
 and all suitable in selected cases. 
 
 When it is desirable to avoid ordering stimulant in such 
 convenient forms, the mistura spiritus vini gallici of the Phar- 
 macopoeia flavored with chloric ether can be obtained from 
 the chemist. 
 
 Prescribing stimulant is always a matter of grave responsi- 
 bility in these cases. Flushing, as it speedily does, the brain 
 with blood, and lessening almost instantaneously depression 
 and gloom, the temptation to resort to its frequent use be- 
 comes great. This is particularly true in cases where the 
 centres of volition are enfeebled; and in the cases of neurotics, 
 who acquire habits with great facility, it is far from being de- 
 void of risk. A medical prescription to take a certain quantity 
 of alcohol at stated times has often been exceeded during an
 
 94 Insomnia and its Therapeutics. 
 
 illness, and continued after recovery, until it has resulted in 
 chronic alcoholism; medicines and regimen have been dis- 
 pensed with, but the leave to take stimulant retained, leading 
 to moral, mental, and physical disaster. Such an event must 
 be guarded against with the utmost care. 
 
 Many neurasthenics who waken in the early morning- and 
 lie or wander about miserable and depressed, are soothed, 
 comforted, and enabled to sleep by taking a cupful of warm 
 beef tea, or milk with a spoonful of brandy or whiskey; just 
 as many a worn-out phthisical patient is strengthened on 
 awaking by a cupful of warm milk with some sugar and a 
 spoonful of rum. 
 
 The clothing sMould be light and warm; light, because 
 these patients fret under the burden of heavy clothes; and 
 warm, for the reason that they are susceptible to the influence 
 of cold and draughts. 
 
 Baths judiciously employed are often of great service. The 
 morning bath should be tepid, or if cold the patient should 
 stand with his feet in hot water and carry out his ablutions 
 quickly. The Turkish and sitz baths may be employed in the 
 slighter cases; also the needle or shower baths. The wet 
 pack at night is a powerful hypnotic, and it is generally well 
 borne. Sea-bathing is particularly invigorating, especialh r 
 when the patient can swim. Sea-air, abundant as it is in 
 ozone, has a highly tonic effect upon the system ; to dwellers 
 in offices deficient in oxygen, or in other unhealthy surround- 
 ings, it is invaluable. Unfortunately, however, as it was 
 pointed out in the first chapter, neurotics often fail to sleep 
 well at the seaside, and when this is the case sea-bathing is 
 of course contra-indicated. When it does not per se cause 
 sleeplessness it is an aid not to be neglected, the selection of 
 the watering-place depending a good deal upon the strength 
 and temperament of the patient. In this country there is no 
 lack of seaside health resorts to meet almost every descrip- 
 tion of case ; while abroad their name is legion. 
 
 Dry and bracing climates suit neurasthenics best, the ex- 
 ception being that just referred to, where there is a tendency 
 to excitement, in which case a sedative climate must be recom- 
 mended. A prolonged stay in a hilly country is invariably 
 productive of good results, and when disappointment has 
 been experienced it has probably been due to the fact of the
 
 Insomnia and its Therapeutics. 95 
 
 residence not being sufficiently prolonged. In this country 
 we have many excellent climates. Among- them, there are 
 the Sussex Downs, Malvern, Leamington, Falmouth, and the 
 Yorkshire dales. The highlands of Scotland offer many ad- 
 vantages. Mountaig air has been compared to drinking 
 champagne without the bad effects. Abroad, there are many 
 desirable resorts. The writer has seen most good accrue 
 from residences in Switzerland, Egypt, and the Cape. In 
 selecting a residence the capabilities of the place must be con- 
 sidered its amusements, social life, historical, geological, or 
 botanical attractions with reference to the tastes of the 
 patient, for unless reasonable entertainment can be had, he 
 grows weary, restless, and irritable, and fails to derive benefit 
 from the change. He must have mental occupation, and the 
 varieties to be found in a neighborhood are important factors 
 with regard to its selection. 
 
 It is very desirable that the patient should be able to live 
 in the open air, and that he should have plenty of sunshine. 
 Ladies who have broken down under the strain of nursing and 
 anxiety often recruit during long sea-voyages, where they can 
 enjoy quiet rest away from all depressing cares. These pa- 
 tients, however, must not undertake such expeditions if they 
 are very debilitated, as stormy weather and unsuitable food 
 may aggravate their state. 
 
 Business men likewise derive benefit from long cruises, as, 
 out of reach of telegrams and letters, freed from the knowl- 
 edge ever recurring of stock-exchange fluctuations and 
 market prices, their nervous systems obtain the rest they so 
 urgently require. In a certain number of cases in which ex- 
 treme emaciation and prostration are the prominent symp- 
 toms, chiefly met with among neurotic women occasionally 
 the subjects of uterine ailments the treatment suggested by 
 Dr. Weir-Mitchell appears to be exceptionally valuable. It 
 consists in removing the patient from her surroundings and 
 S3 r mpathizing friends, in isolating her for several weeks, keep- 
 ing her in bed, and filling up the day with massage, electriza- 
 tion, and large feeding. Further details upon this question 
 must be obtained from the many special works on the subject. 
 
 Electricity is an admirable remedy in many cases of neuras- 
 thenia, whether it be used in the form of central galvaniza- 
 tion or general faradization. Its effects are felt by the whole
 
 g6 Insomnia and its Therapeutics. 
 
 economy; the mental depression becomes lessened and is re- 
 placed by hopefulness; the aspect of the patient becomes 
 brighter, and the carriage and bearing 1 firmer and more elas- 
 tic; the walking 1 powers improve, the limbs being- more under 
 control; pains in the spine and muscles grow less and vanish; 
 the appetite is increased, and dyspeptic derangements disap- 
 pear ; the bowels begin to act naturally ; improved nutrition 
 manifests itself in increased body weight; and in the majority 
 of cases insomnia either disappears or is greatly amended. 
 The writer in advising galvanization directs that on alternate 
 days very weak currents should be passed from the positive 
 pole placed upon the forehead to the negative on the upper 
 part of the spine; then from the positive pole pressed close 
 into the angle of the jaw to the negative on the seventh cervi- 
 cal vertebra ; afterward, stronger currents, from the positive 
 pole situated over the cervical vertebrae to the negative in the 
 epigastrium ; and lastly, to the negative placed in a foot-bath. 
 He relies upon weak and prolonged currents, lasting from 
 twenty to sixty minutes, rather than upon strong currents ; 
 and in all cases he insists on the necessity of avoiding any in- 
 terruption of the current. Every now and again this useful 
 means of treatment fails to improve sleep, and appears to 
 aggravate the other symptoms; it is therefore necessary to 
 watch its effects. Improvement of sleep is always the pre- 
 cursor of other benefits. 
 
 The question of medication naturally arises here. The 
 remedies must be selected from among the nervine and haema- 
 tic tonics, but their administration should in every case be 
 preceded by the correction of any stomachic and biliary de- 
 rangements. It must be admitted that while some patients 
 derive considerable benefit from tonics, there is a minority 
 who are not improved by their use. When there is any cere- 
 bral congestion they are best .avoided altogether. Among 
 the multitude of tonics the following have been found reliable 
 in many cases, particularly in those with relaxed arterial ten- 
 sion: 
 
 ^ Phosphid. zinc., .... gr. ^ vel gr. ss. 
 
 Ferri. redact., gr. iij. 
 
 Ext. calumb., q. s. 
 
 Ft. pil. i. Sig. Take one after meals thrice daily.
 
 Insomnia and its Therapeutics. 97 
 
 ^ Ferri arseniat., .... gr. -fa vel gr. ss. 
 
 Mastich., . gr. ij. 
 
 Ft. pil. i. Sig. Take one after meals thrice daily. 
 
 Or, 
 
 $ Sulph. quinin., . . , * ... gr. i. 
 
 Ext. nucis vom., . . . , , . gr. ss. 
 
 Pulv. digital., . . . ", . gr. i. 
 
 Ext. gentian., . . . . . . q. s. 
 
 Ft. pil. i. Sig. Take one between meals thrice daily. 
 
 Ergotin may be added to either of these. In suitable cases 
 cod-liver oil with sulphuric ether may be advantageously rec- 
 ommended. 
 
 The bowels are not infrequently constipated. This must 
 be met loy appropriate diet, by electricity, and abdominal com- 
 presses worn during the night. If medicines are required, 
 warm and mild laxatives should be preferred, for all purga- 
 tion increases nervous exhaustion. The following have been 
 found useful: 
 
 B Aloin., gr. i. 
 
 Ext. bellad., gr. $. 
 
 Ext. hyoscy., gr. iij. 
 
 Ft. pil. i. Sig. Take at bedtime. 
 
 Or, 
 
 ]J Pil. coloc. co. vel pil. rhei. co., . . . gr. iiss. 
 
 Ext. lupul., gr. ij. 
 
 Ft. pil. i. Sig. Take one at bedtime. 
 
 In many cases, the treatment of neurasthenia upon the 
 foregoing lines is all that is required for the accompanying- 
 insomnia, but in others this symptom requires special atten- 
 tion. It is important to unravel the cause upon which it de- 
 pends in the particular case ; for it follows from the causation 
 of neurasthenia being most diverse, that the insomnia must 
 depend upon equally varied conditions. 
 
 The sleeplessness which occurs in neurasthenic conditions 
 induced by excessive brain work, shock, or depressing mental 
 emotions, by the indiscreet use of tea and tobacco, or by ma- 
 laria, syphilis, rheumatism, or gout, is discussed under these 
 various heads.
 
 98 Insomnia and its Therapeutics. 
 
 When cerebral anaemia is present, it is important to decide 
 the state of the blood-tension, for although it is usually " low " 
 in anaemic conditions, it is not invariably so, and sometimes 
 treatment directed to this point is attended by eminently sat- 
 isfactory results. The estimation of blood-pressure is always 
 a valuable guide in deciding the treatment of insomnia, not 
 specially in neurasthenia, but in all cases. If the tension be 
 " high," a few minute doses of calomel at night, with alkalies 
 during the day, are indicated. 
 
 fy Subchlor. hydrarg., . . . gr. ss. vel gr. 1. 
 
 Ext. hyoscy., .... gr. ij. vel gr. iv. 
 Ft. pil. i. Sig. Take one every night for four nights. 
 
 ] Bicarb, potass., . .... 3 iij. 
 
 Tinct. aconit., B. P., TTJ, xx. 
 
 Aquam, ad vi. 
 
 M. Sig. Take a tablespoonful, in water, before meals 
 thrice daily. 
 
 Instead of this mixture, two grains of sodium nitrite may be 
 given thrice daily between meals. Dry cupping in selected 
 cases is occasionally serviceable. 
 
 When the insomnia is due to such enervating causes as ex- 
 cessive discharges, excesses, prolonged bodily fatigue (sleep- 
 lessness dependent on physical over-fatigue is best relieved by 
 the wet pack, or a warm bath, with some liquid nourishment. 
 A suitable repast is a cupful of meat juice, containing a few 
 spoonfuls of wine or brandy, with a biscuit. The addition of 
 3 ss. of tincture of arnica is an improvement. A heavy meal 
 eaten when one is over-fatigued will not digest, and the de- 
 rangement it initiates increases the sleep disturbance. In 
 certain country districts of England there is a firmly-rooted 
 belief that primrose [primula] wine relieves the feeling of ex- 
 haustion, and promotes sleep. The writer has never been able 
 to assure himself whether its good effects are attributable to 
 the brandy it contains, the mental impression its administra- 
 tion insures, or to the constituents of the flowers. It is be- 
 yond doubt that it is occasionally efficacious. It is further 
 worth noting that the belief has lived through centuries, and 
 that even now many persons grow primroses specially for the 
 purpose of manufacturing the wino), or over-excitement, mas-
 
 Insomnia and its Therapeutics. 99 
 
 sage before bedtime tends to promote sleep ; speedily in a few, 
 more tardily in the majority of instances. It practically con- 
 sists of cutaneous rubbings, muscle kneadings, and joint move- 
 ments. It increases the activity of the circulation and lymph- 
 flow through the skin and muscles, and stimulates all the 
 processes of the economy. It likewise raises the temperature 
 of the cutaneous surface, and attracts to the integument and 
 muscles an increased quantity of blood, depleting to a corre- 
 sponding extent the blood-vessels of the brain a condition 
 favorable to sleep. 
 
 There are many remedies that in individual cases offer ad- 
 vantages, e.g., chloric ether is an excellent stimulant, which 
 conduces to sleep by allaying excitement in the nervous cen- 
 tres, either given alone, or as an adjunct, to increase the dif- 
 fusibility of more potent remedies. Along with sumbul it acts 
 as a cerebro-spinal sedative, calming excitement, subduing 
 restlessness, and thus bringing* about conditions essential to 
 sleep. Hop, containing the active principle lupulin, has long 
 been credited with hypnotic properties, and it is partly owing 
 to this that malt liquors act as hypnotics; it is a stomachic 
 tonic and cerebral sedative which allays excitement and pro- 
 motes sleep. A very old and favorite prescription combining 
 these three remedies is: 
 
 IJ Spt. chloroform., ' . f ss. 
 
 Tinct. sumbul., ss. 
 
 Tinct. lupul., i. 
 
 M. Sig. Take two teaspoonfuls in water every hour or 
 two until sleep is procured. 
 
 A very similar and valuable remedy is : 
 
 B Tinct. digital., . . , ... . TTI xx. 
 
 Tinct. sumbul., 3 i. 
 
 Tinct. lupul., 3 ij. 
 
 Aquam, ad | ij. 
 
 M. Sig. Take one-half at bedtime, in water, and repeat 
 in two hours if required. 
 
 Lupulin may be given in pill an hour before bedtime, in 
 doses of two to five grains, and it may be repeated if neces- 
 sary. The bromides and bromidia are frequently of con- 
 siderable service when there is not pronounced anaemia, but
 
 ioo Insomnia and its Therapeutics. 
 
 their use should not be persevered in for more than six nights. 
 Monobromide of camphor, cannabis indica, tannate of canna- 
 bin, hyoscyamus, are each and all useful in various cases. 
 
 The writer has obtained very satisfactory results from the 
 new hypnotic sulphonal, in doses varying- from gr. xx. to gr. 
 xl. In obstinate cases chloral hydrate may be given, but 
 never for more than a few nights. Morphine may also be re- 
 quired occasionally, but its use should likewise be restricted. 
 It is best given hypodermically with atropine, e.g. from -^ to 
 \ of a grain of morphine, with -j-J^ of a grain of atropine ; or it 
 may be combined with bromide and chloral hydrate. 
 
 $ Liq. morphin. acet., . . . iri xl. vel 3 i. 
 Hydrat. chloral, . . . . gr. xl. vel 3 i. 
 
 Brom. sodii, 3ij. 
 
 Syr. tolu., 3 iv. 
 
 Aquam, _* . . . ad iv. 
 
 M. Sig. Take one-fourth part in water, before bedtime, 
 and repeat in two hours if required.
 
 CHAPTER V. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 NERVOUS SYSTEM Continued. 
 
 HYSTERIA. 
 
 THE predisposing- cause of this affection is a nervous sys- 
 tem defective in stamina, and consequently unduly impres- 
 sionable. Such nervous textures seem liable to have their 
 functions perverted in a curious way by various exciting- 
 causes. These lead to a perversion rather than to a modifica- 
 tion of function. The victims of this disease have a tendency 
 to neurotic maladies, and their emotional centres dominate 
 their volitional. It affects females above fifteen years of age, 
 and most frequently at the epochs of puberty and the meno- 
 pause. It is, however, not peculiar to the sex, as it affects 
 males, though less frequently; being excited and developed 
 by all conditions which exhaust the reserve store of nervous 
 energy. It may be caused by violent and depressing emo- 
 tions, disappointments, over-excitement, and prolonged anx- 
 iety; by lives so devoid of healthy mental and physical occu- 
 pation as to engender introspection and self-consciousness; by 
 all diseases and excesses which enfeeble the body; and reflexly, 
 by uterine and ovarian derangements, which act prejudicially 
 on the nervous system. 
 
 All such causes are unfavorable for sleep. It is therefore 
 not surprising that this affection, in its many phases, is the 
 source of disturbed sleep, and, at times, of persistent insomnia. 
 In investigating this point, it is necessary to be careful not to 
 allow the patient to think that sleep is an object of special 
 interest, for so desirous are many of them to excite attention 
 and sympathy, that they may develop sleeplessness as a 
 marked feature. 
 
 The symptoms of hysteria are of the most varied nature; 
 we can only indicate a few very briefly. As in the allied con- 
 ditions of epilepsy and hypochondriasis, there is a paroxysmal
 
 IO2 Insomnia and its Therapeutics. 
 
 element in almost every case. There is a marked tendency to 
 emotional excitement; to laugh, cry, and scream alternately, 
 on the least provocation. The temper is .perverse and uncer- 
 tain, and the morbid craving 1 for sympathy referred to leads, 
 in some instances, to deceit, and even to disgusting practices. 
 Sufferers from hysteria are prone to disturbance of the special 
 senses, which renders them peculiarly sensitive to sounds and 
 other external stimulations one of the fruitful sources of in- 
 somnia; also to general hyperaesthesia, though at times the 
 reverse condition of anaesthesia is met with; and even paraly- 
 sis, the diagnosis of which is by no means easy. They may 
 experience neuralgic pains in various parts of the body, prom- 
 inent among which is spinal irritation, mastodynia, etc. They 
 also suffer from convulsive attacks (hysterical fits), which 
 differ from epileptic seizures in that they never come on dur- 
 ing sleep, and are never attended by injury at the onset of 
 the fit, or by biting of the tongue, etc. ; though they may re- 
 semble epilepsy in being frequently followed by deep sleep. 
 Between their paroxysmal attacks, hysterical patients fre- 
 quently suffer from functional perturbations, respiratory and 
 gastro-intestinal derangements, ef which latter flatulence is 
 a prominent symptom; and sometimes they pass enormous 
 quantities of pale urine of low specific gravity, the result of 
 high blood-tension. This condition of the blood-vessels ac- 
 counts in some degree for the sleeplessness with which they 
 are afflicted. 
 
 Treatment. In no disease is it more essential to cultivate 
 a good habit of sleep. It is especially necessary that the vic- 
 tims of hysteria should not spend too many hours in bed, and 
 that they should rise immediately after awaking, as indolent 
 dreaming in the morning tends to further enervation, and to 
 aggravate the whole condition. Every endeavor must be 
 made to obtain the confidence of the patient, not by sympa- 
 thizing with her so much as by dominating her by judicious 
 yet kindly counsel. 
 
 It is necessary to inspire her with the conviction that she 
 can implicitly trust her adviser to make her well; to do this 
 the proverbial " hand of iron in a glove of velvet " is required. 
 The diet should be plain and non-stimulating, and taken at 
 regular hours. All alcoholic drinks are, except in very ex- 
 ceptional cases, best avoided. Baths are invaluable: the
 
 Insomnia and its Therapeutics. 103 
 
 morning 1 tepid bath, followed by brisk rubbing; the spinal 
 douche, cold water poured down the spine while sitting 1 in hot 
 water; and, in suitable cases, the sitz bath. Exercise in the 
 open air, particularly in the morning, short of fatigue, is of 
 the first importance, and must be insisted on. The variety 
 must depend largely upon the strength of the patient and 
 the depth of the purse, and to some extent upon the tastes of 
 the sufferer. Change of air and scene may be called for, as a 
 means of securing healthy mental occupation. Every exer- 
 tion must be made to engender self-control. Uterine, ovarian, 
 and other derangements demand attention. Tonic remedies 
 are usually prescribed. Probably the best are phosphorus, 
 arsenic, quinine, strychnine, and the valerianates of zinc and 
 ammonium. Electricity exceeds them all in value, while it is 
 a useful aid to sleep. General faradization is the most effica- 
 cious. In many cases it is necessary to resort to special 
 means to obtain sleep for a few nights. The calming influ- 
 ences of a hot foot bath, and douching the head with tepid 
 water, deserve a trial. The late Dr. Graves, of Dublin, strongly 
 recommended the use of musk in these patients. He quotes 
 one case in which " all kinds of narcotics had been tried un- 
 successfully, and opium, in all its forms, had failed in procur- 
 ing sleep. I advised the use of musk in doses of a grain every 
 second hour, and this means proved eminently successful." 
 Musk, however, on account of its great cost, is now seldom 
 employed. The ammoniated tincture of valerian with cam- 
 phor is an excellent remedy, given once or twice before bed- 
 time. 
 
 B Tinct. valerian, ammon., . . . . 3 vi. 
 Spt. camphor., . . . . . . 3 i. 
 
 Aq. chlorof., vi. 
 
 Sig. Take two tablespoonfuls every two hours until sleep 
 is induced. 
 
 A mixture of hop, sumbul, and chloric ether also answers 
 well, and it may be repeated (p. 597). 
 
 Paraldehyde, in doses ranging from iU xxx. to Til xlv. in 
 syrup and water at bedtime is useful, all the more that its 
 taste is unpleasant. Monobromide of camphor is efficacious, 
 and amylene hydrate has been recommended. 
 
 The bromides, chloral hydrate, and even morphine by hy-
 
 104 Insomnia and its Therapeutics. 
 
 podermic injection may in some instances be called for, as it 
 was in a recent case, which was complicated by anuria of sev- 
 eral weeks' duration. In the last two cases under treatment, 
 sulphonal acted most admirably, improvement quickly follow- 
 ing- its use. 
 
 HYPOCHONDRIASIS. 
 
 Hypochondriasis is frequently accompanied by sleepless- 
 ness more or less pronounced; although it may not be ur- 
 gently complained of, being- overshadowed by the greater 
 misery of morbid depression and painful sensations. In the 
 cases in which want of sleep is a prominent symptom, its ex- 
 tent maj r be greatly exaggerated, for when the patient's at- 
 tention is attracted to it he is liable to misinterpret both the 
 quantity and quality of his sleep. In all such patients it is 
 necessary to inquire carefully into the habit of sleep, that any 
 disturbance may be remedied, aggravating as it does all the 
 other symptoms; while sound sleep sufficiently prolonged 
 tends to ameliorate them. Hypochondriasis is probably due, 
 primarily, to functional disorder of the cerebral centres, which 
 causes them to originate sensations, as of visceral or periph- 
 eral disturbance, which do not exist; and to be abnormally 
 sensitive to impressions, not usually perceived, arising in dis- 
 tant parts. Cells so perverted in function, and so preter- 
 naturally perceptive, are productive of a distorted conscious- 
 ness when awake, and are susceptible to the most trivial 
 impressions arising during sleep; hence the disturbance of 
 sleep. 
 
 In many cases the symptoms are limited to one system, 
 and upon these the thoughts are concentrated until the sensa- 
 tions gradually deepen into pain, it may be of an agonizing 
 kind, and although of central origin, most real to the sufferer. 
 Frequently all the symptoms are referred to the sexual organs, 
 the patient believing himself to be impotent or the victim of 
 venereal disease; and in the female, they may be associated 
 with severe pain in the vulva. 
 
 The morbid introspection and mental depression, which 
 are out of all proportion to the ailments complained of, lead 
 secondarily to enfeeblement of the mind, and enervation of 
 the circulatory and respiratory systems and of the digestive 
 and hepatic functions. Hence arise such symptoms as flush-
 
 Insomnia and its Therapeutics. 105 
 
 ings, vertigo, tinnitus, confusion, and weariness of thought, 
 palpitation, arterial pulsations, sighing, sense of sinking at 
 the epigastrium, disordered digestion, constipation, etc. 
 
 Hypochondriacs fall asleep when they go to bed, but they 
 very frequently awake between three and five in the morning 
 (when the circulation is most depressed) in a state of perspira- 
 tion, and lie in abject misery, tortured with dreadful forebod- 
 ings till the hour for rising. 
 
 It is of course necessary to search for organic disease, for 
 a man may be hypochondriacal when he is really ill, as well 
 as when he is not. Certain ailments also, such as varicocele, 
 and various diseases of the rectum, are not infrequent sources 
 of this affection, and the successful treament of these ailments 
 goes a long way to bring about a cure. Many cases of hypo- 
 chondriasis drift into insanity, especially if there be any heredi- 
 t&ry tendency to mental disorder. 
 
 Treatment. The causes must be traced out, and the pa- 
 tient's life arranged upon a physiological basis. If. the condi- 
 tions under which he has been living are inimical to health 
 they must be altered. 
 
 The excessive use of tobacco, alcohol, and tea should be in- 
 terdicted. Exhausting and debilitating practices must be 
 abandoned, and in women, uterine and menstrual disorders 
 rectified; although this must not be undertaken rashly, as 
 many improve more quickly and permanently by treating the 
 general health, and distracting the patient's attention from 
 her local conditions. In some of these cases the treatment is 
 begun at the wrong end. 
 
 When there is any tendency to neurotic disease, or if there 
 be a gouty or rheumatic diathesis, or a history of syphilis, 
 these morbid states afford indications for treatment. 
 
 The state of the blood-pressure is important. It is said 
 that those who have "low tension" make bad recoveries, if 
 they recover at all; while those who have well-marked tension 
 in their vessels get better comparatively easily. 
 
 Here, as in the case of Irysteria, it is most desirable to ac- 
 quire the patient's confidence, so as to inspire him with hope, 
 and thus secure that he will follow implicitly the counsel given 
 him. He must be encouraged to cultivate the solace of healthy 
 work, that his preoccupied mind may be diverted into healthier 
 channels, and new psychical centres called into operation, to
 
 io6 Insomnia and its Therapeutics. 
 
 the relief of those under whose dominion he has been living. 
 Idleness adds greatly to his wretchedness. The influence of 
 new mental conditions is well seen in the beneficial results 
 that sometimes accrue from marriage. Some years ago a 
 professional man, the victim of lithiasis, consulted the writer, 
 believing he had an aortic aneurism. So convinced was he of 
 it that he gave up his business, relinquished his literary work, 
 and was far more unhappy and distressed than if he really 
 had had an aneurism. After some years, falling in love with 
 a lady who visited his house, he began to get better, married, 
 and is now in robust health, a happy and busy man both in 
 and out of his profession. There is a fair sample of the result 
 of mental distraction, though the high arterial tension in this 
 case was a factor in its favor. New interests are to be sought 
 in change of air and scene, conditions calling into play new 
 psychical centres, at the same time invigorating the whole 
 nervous system. Residence in a bracing but not too exciting 
 climate is to be advised, or at one of the many spas, either at 
 home or abroad, where amusements and social advantages 
 can be readily obtained; but wherever hypochondriacs are 
 sent they should be accompanied by a judicious and cheerful 
 companion. Exercise in the open air is always beneficial in 
 these cases, and there is not, as in neurasthenia, much to be 
 feared from over-exertion. The upper limbs should be em- 
 ployed equally with the lower by means of dumb-bells, clubs, 
 or gymnastic exercises, so that at night the body will be all 
 proportionately tired. 
 
 Hypochondriacs mast be well fed, and that although the 
 tongue is furred and digestion impaired; these conditions im- 
 prove with good feeding. Extract of malt and cod-liver oil 
 may be given. Stimulant, except in every expectional cases, 
 is unsuitable, and had better be avoided. Bathing in the sea, 
 cold sitz baths, cold foot baths, Turkish baths, or spinal 
 douches, may be ordered in suitable cases. 
 
 General tonics, as arsenic, quinine, etc., may be tried, and 
 the bowels regulated with compound galbanum pills, U.S. P., 
 or compound asafcetida pills. Purgatives appear to cause in- 
 creased sleep disturbance in some cases by giving rise to 
 sensations in the alimentary tract which are perceived by the 
 hyper-sensitive cerebral cells. The addition of TT[ ij. or TT[ iij. of 
 the oil of chamomile flowers prevents this occurrence. In
 
 Insomnia and its Therapeutics. 107 
 
 such cases it is a most satisfactory hypnotic. It lowers re- 
 flex excitability in a very marked manner. The fresh oil, which 
 has a greenish-blue tint, is to be selected. In the rheumatic, 
 the tincture of cimicifuga in 3 ss. doses three times a day is 
 of value, and often improves sleep. Electricity, particularly 
 central galvanization of the sympathetic, is worthy of a trial. 
 
 Sleep is of the first importance. Without it there can be 
 no improvement, no brain recuperation, no increased innerva- 
 tion of the heart, etc., and no relief from the morbid depression. 
 A light supper at bedtime, and some warm milk or beef-tea 
 during- the night or toward morning 1 , are useful. Modified 
 massage before going- to bed, or a mustard plaster over the 
 abdomen or alone the spine is sometimes serviceable. A hot 
 bath before bedtime may be tried. In certain cases it an- 
 swers admirabl3 T ; though its effects are somewhat uncertain, 
 and in some instances it intensifies the wakefulness. 
 
 When the blood-tension is low digitalis and ergotin should 
 be given. 
 
 3 Ergotin., . . . . . . . gr. i. 
 
 Ext. nucis vom., . . f * . . . gr. ss. 
 
 Pulv. digital., . . . . . . gr. i. 
 
 Ft. pil. i. Sig. Take one thrice daily. 
 
 Or else, the citrate of caffeine in doses from gr. i. to gr. iv., 
 thrice daily. It acts powerfully upon the vaso-motor system, 
 but in large doses it causes headache. 
 
 When the blood-tension is abnormally high, calomel and 
 alkalies with aconite suit well. {Vide page 596.) 
 
 When there is cerebral anaemia the chloride of gold and 
 sodium in doses of gr. ^ to gr. ^ three times a day may prove 
 beneficial. In hypochondriasis in the aged, arsenic should be 
 prescribed in one or other of its varied forms. Cannabis in- 
 dica lessens depression and promotes sleep; from gr. ss. to gr. 
 i. may be given thrice daily, the last dose at bedtime. When 
 some decided hypnotic is urgently required for a few nights, 
 paraldehyde, chloral hydrate, with potassium bromide, or mor- 
 phine with atropine may be used ; but as those medicines all 
 tend to retard recovery, by interfering with digestion, they 
 must if possible be avoided. A well-shaded lamp in the bed-- 
 room is sometimes a source of much comfort, and in so far 
 tends to promote sleep.
 
 io8 Insomnia and its Therapeutics. 
 
 It is, however, on the whole, probable that perse veringly 
 tiring- the mental and bodily powers day by day, under healthy 
 and bracing conditions, is by far the best hypnotic. 
 
 INSANITY. 
 
 It is not within the scope of this work to deal with the 
 great subject of insomnia connected with insanity; nor is the 
 writer competent to undertake such a task, if fee would, his 
 experience being limited to the preliminary insomnia which 
 preludes almost every form of insanity. This, of necessity, 
 comes under the care of the general physician in the earliest 
 stages, arid at a time when the want of sleep may be the sole 
 indication that there is any departure from perfect health. 
 The following remarks will be restricted chiefly to the sleep- 
 lessness which occurs at the onset of mania and melancholia, 
 characterized, as these conditions are, by exaltation and de- 
 pression of feeling respectively. 
 
 Drs. Bucknill and Tuke, in their work on Psychological 
 Medicine, make the following remarks : " Want of refreshing 
 sleep we believe to be the frequent origin of insanity, depen- 
 dent upon moral causes. Very often, when strong emotion 
 tends to the production of insanitj 7 , it causes, in the first in- 
 stance, complete loss of sleep. In many cases, however, the 
 power of sleeping is not lost, but the quality, so to say, of the 
 function is perverted, the sleep being so distracted by agoniz- 
 ing dreams that the patient awakens jaded rather than re- 
 freshed. We have known several instances in which patients, 
 becoming convalescent from attacks of acute mania, have 
 distinctly and positively referred to frightful dreams as the 
 cause of their malady; and it is probable that a certain qual- 
 ity of sleep, in which dreams excite terror and other depress- 
 ing emotions more forcibly than waking events are likely to 
 do, is scarcely less adverse than complete insomnia to the 
 nutritive regeneration of that portion of the brain on whose 
 action those emotions depend. In such a condition it is highly 
 probable that the very portions of the brain which most need 
 a state of rest are, even during the sleeping quiescence of other 
 portions, more wastefully engaged in the activitj 7 of their 
 functions than they could be in the waking state. The main- 
 spring of insanity is emotion of all kinds. This, stimulated by
 
 Insomnia and its Therapeutics. 109 
 
 phantasy, and emancipated from the control of judgment, 
 during 1 harassed sleep, may be more profoundly moved than at 
 any other time." 
 
 Thus insomnia alone may lead to insanity. 
 
 It will be useful to glance at a classification of insanity. 
 The late Dr. Skae, of the Royal Edinburgh Asylum for the 
 Insane, stated it thus : " Intellectual and moral idiocy and im- 
 becility. Insanity with epilepsy. Insanity of masturbation 
 and pubescence. Hysterical, amenorrhceal, post-connubial, and 
 puerperal insanity. Insanity of lactation and pregnancy. 
 Climacteric, ovarian, hypochondrical, senile, phthisical, metas- 
 tatic, and traumatic insanity. Rheumatic, podagrous, and 
 sj'philis insanity. Delirium tremens. Insanity of alcoholism. 
 Malarious, pellagrous, and post-febrile insanity. Insanity of 
 oxaluria. Anaemic and choreic insanity. General paralysis 
 with insanity. Hereditary insanity of adolescence. Sthenic 
 and asthenic idiopathic insanity/' This classification, for all 
 practical purposes, may be considered as a list of diseases and 
 conditions predisposing to insanity. Among the exciting 
 causes may be enumerated conditions we have already dis- 
 cussed, such as overwork, shock, worry, grief, and many de- 
 bilitating diseases and practices referred to under the head of 
 neurasthenia; states productive of cerebral exhaustion, which, 
 in many instances, is accelerated by an increased blood-supply, 
 maintaining activity in the already enervated centres. 
 
 The predisposing and exciting causes of insanity are worthy 
 of study, for they embrace a vast number of diseases and con- 
 ditions which occasion insomnia, and that without insanity 
 supervening. The explanation of this is to be found in the 
 stamina of the nervous textures. Circulatory modifications 
 and defective nutritive changes in the brain may in those with 
 stable nervous centres cause merely insomnia; and in others 
 with unstable nervous tissues, pathological changes which 
 end in insanity. It is important never to overlook the fact 
 that insomnia, occurring in connection with any of these ab- 
 normal states, may be in reality the premonitory symptom of 
 insanity. The early recognition of this truth not infrequently 
 enables the physician to successfully avert its development. 
 
 Insomnia occurring without apparent cause, particularly 
 in those who have an hereditary tendency to insanity, and 
 whose general health is deteriorated, must ever be regarded
 
 HO Insomnia and its Therapeutics. 
 
 with suspicion, as a prodroma of mental disease. It demands 
 the same vigilant and careful treatment that it would receive 
 if the diagnosis were more definite, for pronounced mental 
 diseases may develop suddenly, and be accompanied by sui- 
 cidal and homicidal tendencies. Indeed many tragedies have 
 been enacted in instances where the sole exciting cause, and 
 the only precursory symptom, was insomnolency. 
 
 Dreams are common precursors of insanity, and at times 
 (depending upon activity smaller in degree) they anticipate in- 
 somnia. The recurrence of a peculiar and unusual dream 
 night after night, particularly if it is of a terrifying kind, 
 should always arouse suspicion. 
 
 When consulted by a well-known patient for insomnia, at 
 the commencement of an attack of mental disease, important 
 assistance can be obtained in forming a diagnosis, by consid- 
 ering the family history, sex, age, station, and occupation, as 
 well as the altered aspect and bearing almost certain to be 
 present, and the perversion of feeling often displayed. A 
 little tact will elicit a confession of some delusion, illusion, or 
 hallucination which occurs during waking moments, and which 
 the patient strives cunningly to conceal. 
 
 It is more difficult when the patient is unknown, for the 
 change in appearance, manner, and demeanor may be so slight 
 as to elude detection; in which case, some reliance must be 
 placed upon the statements of relatives and friends. This is 
 specially desirable when their evidence points in the direction 
 of altered habits and disposition referable to the emotional 
 rather than to the intellectual centres. 
 
 Mania may be ushered in by sleeplessness, and by a condi- 
 tion of depression which gives way to exaltation. It is usually 
 accompanied by a certain amount of cerebral hyperasmia, 
 which causes headache, flushing of the face, suffusion of the 
 e3 r es, a raised temperature, and throbbing of the arterial ves- 
 sels. It is not suggested that cerebral hyperaemia is the cause 
 of the mania, but it is probable that it is an important factor 
 in the production of sleeplessness; as well as being unfavor- 
 able for brain nutrition, which of itself tends to increase the 
 abnormal condition of the brain. Hypersemia, when asso- 
 ciated with exhaustion in the emotional and volitional centres, 
 renders them extremely irritable and excitable, and causes 
 them to discharge their energy upon the slightest provoca-
 
 Insomnia and its Therapeutics. \\\ 
 
 tion and to dominate over the higher or intellectual centres; 
 hence the extravagant behavior and boisterous conduct of 
 maniacs. Sleep may be absent for days and nights, and the 
 lack of it hastens the development of pronounced symptoms. 
 Occasionally the patient tries to keep awake in consequence 
 of terrifying- dreams. No improvement can take place with- 
 out sleep, and any favorable change is preceded by it. 
 
 Treatment. Complete abstention from business must be 
 insisted upon, and all sources of excitement removed, so that 
 mental rest, so far as that is possible, may be secured. 
 
 The bowels must be thoroughly unloaded by a brisk purga- 
 tive; the following is a valuable formula for a robust man: 
 
 ]J Res. scammon., gr. v. 
 
 Subchlor. hydrarg., . . . . . gr. v. 
 
 Pulv. jalap., gr. v. 
 
 Supertart. potass., gr. v. 
 
 Ft. pulv. i. Sig. Take at once. 
 
 It usually acts well, but if it fails to do so it may be fol- 
 lowed in six hours by some sodium sulphate. The application 
 of a few leeches to the temples or behind the ears is to be 
 recommended; as also an ice cap, or the use of cold evapor- 
 ating lotions. When it is possible, the patient maj 7 spend a 
 considerable portion of the day in the open air, walking or 
 driving with a suitable companion, exercise and fresh air being 
 useful adjuncts to treatment. Cases which are not pronounced, 
 or which have begun to recover, are sometimes benefited by 
 change of air and scene under judicious guidance and super- 
 vision. The resort selected must have a sedative climate, and 
 be quiet. Stimulating seaside residences and places where 
 gayety prevails should be eschewed. 
 
 The food must be generous, the meals large and frequent; 
 a foul state of the tongue is no centra-indication to this. Malt 
 extract or pepsin to aid digestion, with sound ale or stout, 
 sometimes afford good results. 
 
 Baths are of special service when the patient can be in- 
 duced to take them quietly. The hot bath prolonged for some 
 time before going to bed, with cold applications to the head, 
 is usually sleep-inducing. Dr. Newington has got good re- 
 sults from hot mustard baths. These full baths, however, 
 should never be administered except in the presence of the
 
 112 Insomnia and its Therapeutics. 
 
 medical attendant. The wet pack may be employed if the 
 full bath cannot be conveniently used. Hot foot baths plain 
 or with mustard are excellent derivatives. Besides these 
 applications it is highly desirable to insure sleep by the use 
 of hypnotics ; no time must be lost, treatment to be efficient 
 must be prompt and decidedly energetic. Chloral hydrate is 
 very suitable in such cases; its action is promoted by lithium 
 bromide. 
 
 3 Chloral hydrat., . . . gr. xl. vel gr. Ix. 
 
 Lithii brom., 3ij. 
 
 Syr. tolu., 3 ij. 
 
 Aquam, ad ij. 
 
 M. Sig. Take one-half an hour before bedtime, and the 
 other half in an hour afterward. 
 
 Hydrobromate of hyoscine is highly praised; it is said to 
 rapidly induce sleep of sveral hours' duration without any 
 bad effects, even in the midst of great excitement. It is best 
 administered hypodermically in doses ranging from -yfaj- of a 
 grain to T ^ 7 of a grain. Urethane and paraldehyde are reli- 
 able remedies. Occasionally morphine is called for; it should 
 be given in doses of from ^ to of a grain in combination with 
 of a grain of tartar emetic. If with the return of sleep the 
 mental condition does not speedily improve, the patient should 
 be sent to a retreat, for improvement takes place more quickly 
 if sent early, and it is difficult to secure proper conditions for 
 treatment at home. Active treatment will render removal 
 unnecessary in many cases, but it must not be carried on too 
 long. 
 
 Melancholia. It is often difficult, at first, to distinguish 
 between depression of spirits, hypochondriasis, and melan- 
 cholia, so very imperceptibly do these conditions glide from 
 one into the other; each being characterized by mental de- 
 pression and by an enfeebled state of the bodily health. 
 
 Melancholia, however, is always attended by some cerebral 
 change, probably depending in most cases on cerebral exhaus- 
 tion, and accompanied by a certain amount of anosmia. It 
 differs in one essential respect from hypochondriasis, in that 
 the victims are usually apathetic about what happens to 
 them, though th?y are extremely miserable ; while hypochon- 
 driacs are tenacious of life, and appear never to weary
 
 Insomnia and its Therapeutics. 1 1 3 
 
 searching 1 for health. Melancholies are not so sleepless as 
 maniacs, yet the want of sleep is often an early and prominent 
 symptom. They do not readily sleep, and if they do, they 
 awake soon to be tormented by the vilest misery that it is 
 possible for human creatures to endure. Well-directed treat- 
 ment at its onset is often attended by good results; it is fre- 
 quently efficacious in averting the necessity of removal to a 
 retreat. 
 
 Treatment. All that was written upon the subjects of 
 mental rest, food, stimulant, exercise, change of air and scene, 
 etc., when discussing the question of neurasthenia, might be 
 re-written here. Probably a larger amount of stimulant is 
 called for, generous wines being admissible, such as sound 
 Burgundy and claret. In choosing a health resort, the more 
 bracing are indicated. Turkish baths afford good results in 
 Overcoming the melancholy, and they promote sleep. Dr. 
 Clouston speaks highly of them as a means of cure when the 
 affection has developed. Mustard plasters over the stomach 
 at night are to be advised; night feeding, e.g., milk or beef- 
 tea with a spoonful of rum once or twice during the night, 
 promotes sleep. 
 
 Tonics of all kinds are called for, arsenic, quinine, strych- 
 nine, etc. In anaemic cases the syrup of the phosphates of 
 quinine, strychnine, and iron, in 3 i. doses thrice daily after 
 meals, in water, is excellent. Malt extract and cod-liver oil 
 after meals are useful. Furring of the tongue is no hindrance 
 to increased feeding; on the contrary, rather an indication 
 for it. 
 
 The bowels must be attended to; mild warm laxatives 
 being preferred to salines. 
 
 For several nights at least sleep must be secured Toy hyp- 
 notics, the best being morphine with atropine, by hypodermic 
 injection. Sulphonal and paraldehyde are both useful, as is 
 chloral hydrate, and camphor with cannabis indica is a good 
 combination. 
 
 B Camphor., gr. ij. 
 
 Ext. cannab. ind., gr. ss. 
 
 Ext. hyoscy., gr. iij. 
 
 Ft. pil. i. Sig. Take at bedtime. 
 
 In all cases suicide should be guarded against, and the 
 treatment at home ought not to be persevered in too long.
 
 1 14 Insomnia and its Therapeutics. 
 
 MYXCEDEMA. 
 
 In the report of the Committee of the Clinical Society of 
 London, nominated to investigate the subject of myxredema, 
 published in 1888, it is stated: "In a large proportion sleep is 
 noted as good, but in many of these there is excessive somno- 
 lence, especially in the daytime. In about one-third of the 
 cases wakefulness is recorded, and sleep is often disturbed by 
 horrible dreams and sensations. It may be noted that drowsi- 
 ness during the day is very common in myxoedema in both 
 good and bad sleepers/* 
 
 In a case the writer had under his care some years ago, in- 
 somnia was a prominent and troublesome symptom, and the 
 sleep that was obtained was restless and disturbed by fright- 
 ful dreams. He tried many remedies for its relief, but found 
 none efficacious except morphine. His limited experience does 
 not warrant him in saying more upon the subject.
 
 CHAPTER VI. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 NERVOUS SYSTEM Continued. 
 
 INSOMNIA DEPENDING UPON SPASMODIC NEUROSES. 
 
 CHOREA is a functional disorder of the motor centres of 
 the brain, initiated by faulty nutrition arising 1 in many diverse 
 ways. It may be brought about by hyperaemic and anaemic 
 conditions; modifications of arterial tension; toxic states of 
 the blood, as in rheumatism; valvular diseases of the heart; 
 pregnancy; strains, as in overwork; and shock, as in fright. 
 It occurs most frequent! y in those whose nervous systems are 
 susceptible to impressions; whose nutrition is materially de- 
 teriorated ; and who have a hereditary tendency to neurotic 
 disease. In about one-half of all the cases it is excited by 
 fright, depressing emotions, and mental overwork; and these 
 affect females and males in the proportion of three to one 
 (p. 565). 
 
 Sleeplessness exists to a greater or less extent in all cases, 
 and not relatively to the severity of the movements, although 
 these manifestly influence it. On the other hand, the depth 
 of the sleep exerts a powerful influence over the movements. 
 When it is sound they usually entirely cease. In slight cases, 
 sleep is uneasy and restless, though the movements are com- 
 pletely arrested. In more pronounced cases there is difficulty 
 in getting off to sleep, and when sleep follows, it is broken and 
 disturbed by alarming dreams which cause the patient to 
 awake in terror; in the worst forms of the disease, sleep is 
 sometimes impossible, and when death occurs it is mainly due 
 to this complication. Choreic insanity is always heralded b.y 
 insomnia. 
 
 Treatment. The patient must be carefully guarded from 
 all mental shock and strain ; well nourished with simple and 
 light food ; encouraged to spend as much time as possible in
 
 1 1 6 Insomnia and its Therapeutics. 
 
 the open air, and to practise systematic gymnastic exercises. 
 When the attack is at all pronounced, it is well to keep the 
 sufferer in bed, as there he improves more quickly. Tonics, 
 such as arsenic, strychnine, etc., are always indicated. Anti- 
 pyrine, which has lately come into use in the treatment of 
 this disease, appears to influence sleep favorably; the dose is 
 from five to .eight grains three times a day. 
 
 Warm baths, wet packs, or modified massage toward bed- 
 time are each useful in promoting sleep. 
 
 Alcohol in the form of white-wine whey acts beneficially in 
 almost every case, equalizing and tranquillizing the cerebral 
 circulation, and often cutting short the disease. 
 
 When there is cerebral hyperaemia, mild purgatives are 
 useful derivatives. To promote sleep, which is the most cura- 
 tive of all agents, monobromide of camphor may be given in 
 two-grain doses at 4 and 8 P.M. The following also suits well 
 in more severe cases : 
 
 IJ Chloral hydrat., 3 i. vel 3 iss. 
 
 Potass, brom., 3 ij. 
 
 Syr. tolub., 3 vi. 
 
 Aquam, ad vi. 
 
 M. Sig. Take a tablespoonful in water two hours before 
 bedtime, and again at bedtime. 
 
 In anaemic conditions of the brain, alcohol must be freely 
 pushed to a point short of intoxication, and from 5 to 10 
 minims of the solution of acetate of morphine given for sev- 
 eral successive nights. All these remedies are suitable for 
 children between eight and ten years of age. 
 
 The value of sleep in the treatment of severe chorea has 
 lately been emphasized by Dr. Charlton Bastian, and Professor 
 Gairdner, of Glasgow (" Lancet," 1889). It is of equal value 
 in every form of the disease, and that it should be so is obvi- 
 ous from the fact that sleep is the time favorable for the re- 
 cuperation of the nervous system. 
 
 Paralysis Agitans. Sleeplessness may occur at the very 
 beginning or in the premonitory stage of this disease, before 
 tremor has been noticed at all. Slight weakness of the limb 
 may be the only symptom, and that only after using it, per- 
 haps discernible in the right hand alone, after writing. It 
 mav occur also in connection with neuralgic and so-called
 
 Insomnia and its Therapeutics. 117 
 
 rheumatic pains, which occasionally mark the onset of the 
 illness. 
 
 When the disease has developed, sleeplessness may depend 
 upon various abnormal sensations seldom absent, and which 
 always distress the patient, e.g., stiffness and rigidity of the 
 muscles of the head and neck; stiffness and tension of various 
 muscles of the trunk, rendering- voluntary movements diffi- 
 cult. These are most noticeable and troublesome at night, 
 for they prevent the patient changing his position in bed, and 
 the constant desire to move about or to turn round, combined 
 with the inability to accomplish it, induces an irritability well- 
 nigh intolerable. Sensations of heat, chiefry referred to the 
 back and epigastrium; are complained of, and perspirations 
 which lead to tossing off the bedclothes. 
 
 Sleeplessness may likewise be due to the visceral disorders 
 to which these patients are liable, owing to their inability to 
 take exercise. During the earlier stages of the disease the 
 trembling movements cease during sleep, but in the later 
 stages the movements may interfere with sleep ; while the de- 
 clining bodily nutrition and the increasing nervous exhaustion 
 invariably do so. 
 
 Mental influences aggravate tremor and increase sleepless- 
 ness, but the latter is due more to the fatigue following the 
 severe paroxysms of shaking than to the mental perturbation. 
 Almost every case of paralysis agitans that the writer has 
 met with in practice, has occurred in persons who had always 
 been bad sleepers. At present he has under his care such a 
 case, a gentleman aged fifty-eight years, who has been afflicted 
 with the complaint for eight or nine years, and whose most 
 troublesome symptom is want of sleep. Throughout his life, 
 though he has worked as hard as it was possible for any man 
 to work, and has rendered signal service to his country in 
 more than one department, he has not slept on an average 
 more than four or five hours a night. 
 
 Treatment. The food and stimulant must be carefully 
 regulated, especially that taken at the last meal of the day; 
 and all disorders of digestion and constipation remedied. 
 Change of air and frequent change, suited to the temperament 
 of the patient, does much to improve sleep. The patient's bed 
 should be such that he may repose comfortably, and be able 
 to change his position with as little difficulty as possible; an
 
 1 1 8 Insomnia and its Therapeutics. 
 
 iron or brass bedstead with an unyielding- hair mattress suits 
 best. It is always a comfort having some one sleeping in an 
 adjoining 1 room to assist the patient in turning if required. 
 
 If it is necessary to resort to special treatment for sleep- 
 lessness, galvanization, mustard over the epigastric region, 
 modified massage, and hot foot-baths, are each useful. Hyp- 
 notics are occasionally required for four or five nights, for the 
 purpose of forming a better sleeping-habit. Paraldehyde in 
 full doses at bedtime is exceedingly useful. Also, 
 
 5 Chloral hy drat., ... . . . 3iiss. 
 
 Potass, bromid., 3 i. 
 
 Liq. morph. acet., . . . . . 3 ss. 
 
 Syr. aurant., . . . . . . 3 i. 
 
 Aquam, . . . . . . ad iij. 
 
 M. Sig. Take one-half at bedtime and the other in two 
 hours if required. 
 
 Sulphonal in 20-grain doses, acted extremely well in one 
 case. Occasionally remedies directed to the cure of the dis- 
 ease, by controlling* tremor, improve the power of sleep, but 
 this is not always so. In a recent case ^ of a grain of hyos- 
 cyamine was prescribed twice daily; its physiological effects 
 speedily and markedly manifested themselves dilatation of 
 the pupil, dryness of the mouth and throat, noises in the ears, 
 confusion of thought, delusions, incoherent speech, and giddi- 
 ness ; but, although the tremor literally disappeared, the in- 
 somnia was aggravated. 
 
 Dr. Taylor, of Lower Tooting, kindly brought under the 
 writer's notice a case of many years' duration, which was 
 complicated with spasmodic wry-neck, where both affections 
 yielded to the use of scutellaria continued perseveringly dur- 
 ing nine months. 
 
 Spasmodic Wry-Neck. When the spasmodic movements 
 which accompany this affection do not cease during sleep, 
 considerable relief may be obtained from a specially con- 
 structed pillow, assisting, as it does, to control the movements. 
 
 INSOMNIA PROM PAROXYSMAL NEUROSES. 
 
 Epilepsy. Many epileptics suffer from sleeplessness. 
 Restlessness and disturbed sleep prelude the attacks equally 
 with sound sleep. 
 
 i
 
 Insomnia and its Therapeutics. 1 19 
 
 Among- the predisposing- causes of epilepsy, the most fre- 
 quent is a tendency to neurotic disease; while among 1 the ex- 
 citing causes are some which we have already considered as 
 sources of insomnia. For example, Dr. Russell Reynolds found 
 that in twenty-seven cases out of sixty-three the disease was 
 excited by fright, grief, worry, and overwork; and Dr. Gowers 
 found that fright caused 10 per cent of all the cases he in- 
 vestigated under the age of ten years, in males and females 
 in equal proportions, and between ten and twenty years in the 
 proportion of three males to four females. 
 
 The pathology of epilepsy has not yet been definitely as- 
 certained, but it is generally believed that in the initial stage 
 of the seizure there is profound cerebral anaemia ; for besides 
 the marked pallor of the face, Dr. Hughlings Jackson found 
 on ophthalmoscopic examination that the retinas were blood- 
 less. This accords with the convulsions which attend acute 
 cerebral anaemia from sudden and profuse bleedings, but the 
 exciting cause of this anaemia in epilepsy is still a mystery. It 
 seems not unreasonable to argue that the conditions which 
 give rise to it, and cause epilepsy, acting in a less degree may 
 excite a modified cerebral anaemia sufficient to account for 
 wakefulness. 
 
 Such cases of insomnia are easily enough recognized where 
 there is a history of epilepsy, but if there is not, the cause may 
 elude detection; for the seizures, the petit mal and the haut 
 mal, may occur only during sleep, and their existence be un- 
 suspected, the patient himself having no knowledge or recol- 
 lection of the attacks. He usually complains of languor, pain 
 in the back and in the muscles of the body generally, fulness 
 and weight in the head in the morning, which requires for its 
 removal more than one good night's sleep. Should his tongue 
 be bitten, or petechial spots be found about his head, neck, or 
 chest, or if he has passed his urine unconscious^ in bed, and 
 has been heard to utter a piercing cry, the diagnosis will be 
 tolerably clear. A little care will suffice to trace the sleep 
 disturbance to its true origin. If sound sleep does not follow 
 the epileptic attack, the patient may become irascible, rest- 
 less, and even violent during the day, and sleepless at night, 
 and unless proper means are adopted, this may continue until 
 a severe seizure ensues. 
 
 Treatment. It is practically that of the disease. The rec-
 
 I2O Insomnia and its Therapeutics. 
 
 ognition of the causation is the important point. The pa- 
 tient's life must be carefully considered and arranged, for, as 
 the late Dr. Latham wrote: "That by knowing 1 what a man 
 is, and how he lives habitually, the physician often arrives at 
 a much better judgment and a better treatment of his dis- 
 eases." All debilitating- practices must be interdicted, and the 
 exciting 1 causes, so far as possible, removed. Food should be 
 nutritious, but bland and unstimulating; and alcohol, in most 
 cases, should be dispensed with. Bathing 1 , under suitable con- 
 ditions, and well regulated exercise, are useful adjuncts to 
 treatment. All mental strain should be avoided. It is said 
 that patients are less liable to night seizures if they sleep with 
 the head well raised upon a high pillow. Sleep in these cases 
 is certainly improved by this, and one patient, who was for 
 many years under treatment, seldom, if ever, had a fit during 
 the night, except when his head got off the pillow, and on to 
 the same level as his body. Sleeplessness is an indication for 
 pushing energetically the medication of this affection. 
 
 Whenever altered sleep at night, or changed demeanor 
 during the day, indicates an approaching fit, 3 I. of potassium 
 bromide, with 10 to 15 grains of chloral hydrate, may be given 
 at night until the crisis appears to be passed. Dr. Russell 
 Reynolds thinks belladonna valuable when there is disturbed 
 sleep. In two cases the writer believed he obtained good re- 
 sults from the administration of nitrite of sodium in two-grain 
 doses, thrice daity. A whiff of amyl nitrite improves sleep. 
 
 Migraine. Sleeplessness is not infrequently met with in 
 the victims of this distressing complaint. Much has been 
 written concerning the pathology of migraine. The writer is 
 disposed to accept Dr. Liveing's view, that it is practically a 
 nerve storm, the condition arising from the irregular accumu- 
 lation and erratic discharge of nerve energy bringing about 
 anaemic and hyperaemic states of the brain. "A nerve-storm 
 traversing more or less of the sensory tract from the optic 
 thalami to the ganglia of the vagus, or else radiating in the 
 same tract from a focus in the neighborhood of the quaclri- 
 geminal bodies." As it was argued in connection with epi- 
 lepsy, so the theory may be advanced here, that these causes, 
 acting in a less degree, may give rise, not to migraine, but to 
 disturbed sleep. The predisposing and exciting causes of mi- 
 graine are closely allied to those of insomnia. Among the
 
 Insomnia and its Therapeutics. 121 
 
 former are hereditary tendency, neurotic temperament, and 
 adynamic states of the system; and among- the latter, over- 
 work, excitement, depressing- emotions, excesses of all kinds, 
 and curtailment of sleep. When the attacks are severe they 
 prevent sleep. 
 
 Treatment. Everything tending to promote good sleep 
 and to establish the patient's health on the highest level be- 
 tween the attacks should be aimed at. The details of the 
 daily life ought to be arranged so that the food, mental work, 
 and corporeal exercise should bear relation the one to the 
 other, and be in proportion to the strength. Turkish baths 
 or the needle or spray baths are often suitable. Alcohol is 
 best avoided by the majority; in the smaller number it must 
 be carefully prescribed. 
 
 Cannabis indica, with valerianate of zinc, taken for a time, 
 improves sleep and controls the attacks. 
 
 $ Ext. cannab. ind., gr. ss. 
 
 Valerian, zinc., gr. ij. 
 
 Ext. gentian., q. s. 
 
 Ft. pil. i. Sig. Take one pill twice or thrice daily. 
 
 When the attack threatens, ten grains of antipyrine may 
 be given every thirty minutes for four doses; or two grains 
 of the citrate of caffeine in a little aerated water, the patient 
 lying quiet, in a darkened room, with a hot bottle to the feet, 
 and a mustard and linseed poultice over the stomach. Dr. 
 James Little advocates the addition of twenty grains of so- 
 dium salicylate to the citrate of caffeine, to be repeated in 
 two hours if required. Should these remedies not improve 
 sleep, paraldehyde or bromidia may be given at bedtime for 
 a few nights. When the attack of migraine is so severe as 
 to prevent sleep, -- of a grain of morphine tartrate with -j-^ 
 of a grain of atropine may be administered hypodermically ; 
 or if morphine is contra-indicated, from five to ten grains of 
 butyl-chloral hydrate should be given in some syrup and 
 water. 
 
 Nightmare. In this disorder, as well as in night-terrors 
 and somnambulism, there are unequal degrees of " particular 
 sleep " (p. 502) in the cerebral centres, ca.using disturbance of 
 "general" and, probably, of unusually sound sleep. 
 
 Nightmare is brought about by a vivid and alarming
 
 122 Insomnia and its Therapeutics. 
 
 dream, implying 1 great activity in some of the ps3 r chical cen- 
 tres, while the motor centres are slumbering 4 . The dream is 
 usually of such a nature as to impress the sleeper with a most 
 painful sense of immediate bodily danger, from which he should 
 instantly extricate himself. Unable to move, his agitation 
 and fright increase, until he wakes perhaps in the act of 
 groaning or shouting for help. When he is thoroughly roused 
 he is quite free from all discomfort, and relieved to find his 
 misery has been caused by a dream, although he may try not 
 to fall asleep again, for fear of a recurrence. 
 
 The most frequent exciting cause of nightmare is disturb- 
 ance in the gustro-intestinal canal, such as is caused by eating 
 indigestible food, or by drinking a variety of wines at a late 
 dinner shortly before retiring to bed. It is sometimes due to 
 an exhausted or neurasthenic state of the nervous system, and 
 it is liable to occur in persons of gouty habit. 
 
 Treatment. The general health must be attended to, the 
 diet regulated, the bowels unloaded, and the sleeping condi- 
 tions improved, if they are in any way defective. Potassium 
 bromide may be given for several nights in 3 ss. to 3 i- doses, 
 to equalize and tranquillize the cerebral circulation. 
 
 Night-terrors. Closely allied to nightmare, but differing 
 from it in its pathology, is the condition known as night- 
 terrors. It is commonly met with in children between the 
 ages of one and four years who are the victims of dreams, 
 which appear to affect the cerebral centres of emotion to a 
 greater extent than the higher centres. 
 
 The pathognomonic symptom is that they wake within 
 the first two hours of sleep, when it is deepest, in a state of 
 great agitation, screaming, violently, and evincing a strong 
 desire to get away from something (as a wild animal), which 
 they evidently think is attacking them; they beseech their 
 father or mother to remove it, and fail to recognize the parent 
 they are entreating, who may at the very time have the child 
 in his arms. As the centres of consciousness awake the child 
 realizes its happier surroundings, and becomes gradually paci- 
 fied, although it always takes some time to restore its confi- 
 dence, and admit of its falling asleep. This terror does not 
 often recur the same night, though it is liable to do so on 
 those which follow. 
 
 Dr. Ringer, in his " Handbook of Therapeutics," points out
 
 Insomnia and its Therapeutics. 123 
 
 that squinting 1 sometimes occurs along 1 with it, and that it may 
 afterward become permanent. 
 
 The predisposing cause of this affection is an impression- 
 able and excitable nervous system. 
 
 The exciting causes are teething, gastro-intestinal derange- 
 ments, whooping cough, febrile disturbances, and improper 
 sleeping conditions. 
 
 Treatment. It is desirable to remove or relieve the excit- 
 ing cause of the attacks, and to adopt measures for invigor- 
 ating the nervous system. The food must be carefully ar- 
 ranged, so as to avoid over- as well as under-feeding. The 
 sleeping room ought to be of a comfortable temperature, and 
 thoroughly ventilated, and the bedclothes light and warm. 
 A shaded light, and the presence of a nurse in the immediate 
 vicinity, are great comforts to a nervous child in going to 
 sleep, giving it confidence, and preventing its emotional from 
 dominating over its other centres : they are therefore valuable 
 prophylactics. Where digestive derangements are present 
 mild laxatives are called for. 
 
 5 Pulv. rhei, gr. ij. 
 
 Bicarb, sodii, gr. iij. 
 
 Pulv. aromat. co., . ... gr- i- 
 Ft. pulv. Sig. Take one twice daily. 
 
 The bromides are very valuable in these cases, and Dr. 
 Ringer says that they remove the squinting. 
 
 5 Brom. potass., 3 i. 
 
 Syr. aurant., 3 iij- 
 
 Aquam, ad vi. 
 
 M. Sig. Give a tablespoonful at 4 P.M and at bedtime. 
 
 A warm bath should likewise be given at bedtime. If the 
 attacks do not quickly subside, the little patient should be 
 awakened two hours after falling asleep, so as to prevent sleep 
 froni becoming too profound. 
 
 Somnambulism. In briefry alluding to this subject in the 
 introductory chapter, it was pointed out that the state de- 
 pended upon an unequal distribution of sleep, and that it in- 
 volves certain areas, in varying degrees of depth. Somnam- 
 bulism is virtually an acted dream. 
 
 It may take the form of sleep-crying, sleep-talking, sleep-
 
 124 Insomnia and its Therapeutics. 
 
 eating, or sleep-walking, for these conditions are closely allied 
 to each other, and all necessitate correlated muscular move- 
 ments. The following 1 remarks have reference mainly to 
 sleep-walking, in which the movements are as quickly and as 
 unhesitatingly performed as if they were directed by con- 
 sciousness, and not merely taking place solely under the do- 
 minion of the basal ganglia. They are sensori-motor acts; 
 and they have been rightly described as " subhuman rather 
 than superhuman/' Somnambulists having conceived their 
 dream, stage it so precisely that they are able to act it with 
 admirable exactness. Their concentration renders them ob- 
 livious to all unconnected objects or disturbing agents, so that 
 they perform as well in a dark as in a lighted room, and with 
 their eyes closed as well as open. They are unconscious of 
 sounds or noises not associated with their conception; they 
 may be shaken, and may themselves cough and sneeze with- 
 out being awakened. It is recorded that the food of which 
 they were partaking has been changed, and that their snuff 
 has been replaced by sawdust, without their apparently per- 
 ceiving any difference. (Wood.) 
 
 Among the predisposing causes of somnambulism must be 
 ranked hereditary tendency, which may long remain unde- 
 veloped, and yet appear under the influence of exciting causes. 
 It is certainly met with in the gouty, and in those of neurotic 
 temperament, and it is related in some degree to hysteria, 
 epilepsy, and catalepsy. Most common in youth, it affects in 
 almost equal proportion males and females. Dr. Anstie 
 ("Lancet," 1873) wrote: "Of 23 somnambulists and 19 habit- 
 ual sleep-talkers, belonging to 24 families, 12 somnambulists 
 were males and 11 females, 13 sleep-talkers were males and 6 
 were females." It commonly disappears when adult age is 
 attained; when it does not, females are more frequently af- 
 fected than males. The worst of all cases are those occurring 
 in males in middle age. 
 
 The exciting causes in children are mental excitement, over- 
 work, fright, physical exhaustion, digestive disturbances, and 
 an overloaded bladder. 
 
 In adults it arises from the same mental causes, derange- 
 ments of the hepatic and digestive functions, and over-eating 
 and over-drinking. In females it also arises from uterine and 
 ovarian disorders, and menstrual irregularities.
 
 Insomnia and its Therapeutics. 125 
 
 It is said to arise from sleeping with the head low, and it 
 must be added that it may occur in apparently healthy per- 
 sons. Somnambulism may exist in various degrees; begin- 
 ning as simple sleep-talking, it may increase till it ends in 
 sleep-walking. At first the sleeper may merely rise from bed 
 and walk round the room to perform some trifling act, and 
 then return to bed; but, as the habit grows, he may success- 
 fully elude articles of furniture, unlock doors, open windows, 
 walk out of doors, along dangerous roofs or beside the edge of 
 precipices, and perform feats he could not possibly undertake 
 during waking moments. Cases are recorded in which sleep- 
 ers have swum across rivers, thrashed corn, ridden on horse- 
 back, and pursued their usual daily occupation. 
 
 The case of somnambulism which occurred among Dr. 
 Guthrie Rankin's patients is worth recording. A young wo- 
 man, worn out by much anxious nursing, lay down upon her 
 bed with her clothes and slippers on, thoroughly exhausted. 
 By-and-by she rose in her sleep, left the house, and proceeded 
 to walk across the country through fields in which snow lay 
 a foot deep, opening gates and climbing fences, evidently bent 
 on reaching the house of a relative some miles distant. Being 
 missed from her room, she was traced, and found walking, 
 almost perished with cold, in a deep sleep. There appears to 
 be a certain amount of anaesthesia associated with sleep- 
 walking. 
 
 In a recent case the patient rose from his bed, and dream- 
 ing the house was on fire, opened the window, and threw him- 
 self out. The rapidity with which such incidents can take 
 place is somewhat remarkable. Another patient who had lost 
 part of a previous night's sleep, was left by his visitors in the 
 drawing-room at 10 P.M., when he sat down to read by the aid 
 of a lamp. He fell asleep, and slumbered until awakened by 
 a noise, when he discovered that in walking about the room 
 in a state of nudity he had knocked over a table. It was just 
 10 :30 P.M. In half an hour he had read, fallen asleep, con- 
 ceived his dream, undressed, folded his clothes most carefully, 
 laid his socks over the top of his boots (anything but his usual 
 custom), extinguished the lamp, and started on his peregrina- 
 tions. So far as he is aware he has not repeated this experi- 
 ence, although fully twenty years have elapsed. 
 
 After the dream-act is concluded the actor returns to bed,
 
 126 Insomnia and its Therapeiitics. 
 
 sleeps until his usual hour for rising in the morning 1 , and when 
 he awakes he either does not recollect anything- of his escapade, 
 or remembers it only as a dream. When the event is not re- 
 membered, it may recur to him in a subsequent somnambulis- 
 tic state. If the sleep-walker is awakened incautiously, he is 
 generally much agitated and frightened, and his movements 
 become uncertain and clumsy. Sleep-walking leads the actors 
 into situations which endanger life, and yearly many deaths 
 are recorded from accidents so arising, and terminating fatally. 
 Either they lack the dexterity with which they are popularly 
 credited and seem to possess, or awaking at a critical moment, 
 coolness and precision desert them, and lead them to ruin. 
 
 The subject is important from a medico-legal standpoint; 
 indeed, from every point of view somnambulism is the source 
 of much anxiety to the afflicted and to their relatives. 
 
 Treatment. Should the victim be found in his wanderings, 
 he ought not to be awakened, but led as gently as possible 
 back to bed, abrupt awaking being apt to give rise to shock, 
 which may mark the onset of other nervous diseases. The 
 prophylactic treatment is important. The general health 
 must be attended to, and all neurasthenic conditions remedied. 
 The mind and the body should be daily exercised in something 
 like relative proportion, undue fatigue or excitement of either 
 being avoided. The food must be light and nutritious, late 
 meals shunned, and alcoholic drinks avoided or moderately 
 used, especially toward night. The bowels should be regularly 
 evacuated. The sleeping room should be cool, the mattress 
 firm, the clothes light, and the pillow well raised. Warm 
 baths should be taken at night, and Turkish or cold sitz baths 
 during the day are beneficial in most cases. 
 
 If in spite of these remedies the habit continues, it may be 
 necessary to waken the sleeper between the first and second 
 hours of sleep, when it is deepest, so as to prevent the sleep 
 becoming too profound. Monobromide of camphor may be 
 given in 4-grain doses at six P.M. and at bedtime. In some 
 cases it is necessary to chain somnambulists by the leg to the 
 foot of the bed, and in all to see that the doors and windows 
 are securely fastened.
 
 CHAPTER YIL 
 
 INSOMNIA DEPENDING UPONS AFFECTION OF THE 
 NERVOUS SYSTEM Continued. 
 
 FROM AFFECTIONS OF THE BRAIN AND ITS MEMBRANES. 
 
 IN Chapter II. we alluded briefly to the causation of active 
 and passive cerebral congestion, and of cerebral anaemia. 
 This must be taken along- with the following remarks upon 
 their S3 r mptoms and treatment. 
 
 Active cerebral congestion or hypercemia exists in many 
 degrees. When it is general and severe it may speedily pass 
 into the more pronounced form of inflammation, in which the 
 early symptoms of headache and insomnia are replaced by 
 those of stupor and coma. It is only to the slighter cases 
 that we wish to refer. 
 
 The symptom which prominently characterizes cerebral 
 hyperaemia is sleeplessness, or sleep disturbed by dreams of a 
 vivid and distressing kind. Tubercular meningitis is so fre- 
 quently preceded by dreams of this latter description, that 
 when they occur persistently in children they should be re- 
 garded with suspicion as precursors of that disease. Cerebral 
 hypereemia is usually accompanied by headache, flushed face, 
 throbbing vessels, giddiness increased by stooping, an altered 
 mental condition, irritability, restlessness, and defective mem- 
 ory; and in children by convulsions. The pupils are usually 
 contracted, the vision is impaired, with flashes of light from 
 the eyes, and motes floating before them; there are noises in 
 the ears, and other abnormal sensations are felt, depending 
 upon perversions in the sensory centres and nerves. The 
 pulse is hard and frequent, although it is sometimes slow. 
 The gastro-intestinal functions are deranged, and these de- 
 rangements not infrequently aggravate the other symptoms. 
 In the cases which depend upon overwork, such as have al- 
 ready been discussed, the aspect maybe altered; it maybe
 
 128 Insomnia and its Therapeutics. 
 
 pale and haggard, and differing very decidedly from the florid 
 countenance just described, being suggestive of anaemia rather 
 than of hypereemia. In such eases the pulse must be used as 
 a guide, for it is invariably hard and incompressible. 
 
 It may be here noted that the difficulties in diagnosis be- 
 tween anaemia and hyperaamia of the brain are much greater 
 than might be supposed, for the reason that many of the 
 symptoms which characterize the one may be said to charac- 
 terize the other. These opposite conditions lead to mal-nutri- 
 tion of the cerebral cells, and these cells display symptoms of 
 their starvation, which are alike in both states. Reference 
 will be made presently to the resemblance which exists be- 
 tween acute cerebral anaemia in children, and hydrocephalus. 
 The ophthalmoscope and sphygmograph give little or no help 
 in the diagnosis. It is only by carefully considering all the 
 facts that a correct conclusion can be arrived at. Plethora in 
 the one case and anaemia in the other may be leading features; 
 though some of the cases of sleeplessness which occur in con- 
 valescence from severe disease, in reality owe their origin to 
 hypostatic congestion due to the lying posture, rather than to 
 the anaemia from which they are suffering, a fact not to be 
 lost sight of in the treatment of these cases. 
 
 Treatment. Whatever be the cause of the cerebral con- 
 gestion, the treatment must, to a greater or less extent, be 
 conducted upon antiphlogistic principles. The patient must 
 rest in bed with a well-raised pillow to keep the head high, 
 with light and warm bedclothes; in a darkened, quiet, cool, 
 and well-ventilated room. The food should be fluid and non- 
 stimulating. Moderate depletion, by leeches behind the ears, 
 or by dry or wet cupping, is, in most cases, the best means for 
 insuring speedy relief, and that, in the pale and haggard- 
 looking patients we have just referred to. The trifling loss 
 of blood is quickly made up, and the immediate effects are of 
 the happiest kind; it may, however, require to be repeated 
 upon two, three, or more occasions. 
 
 In the slighter cases the application of cold to the head, 
 by means of ice-bags or Leiter's tubes, or evaporating lotions, 
 is generally all that is required; particularly if it is used coin- 
 cidently with derivatives, such as hot sponging to the spine; 
 mustard over the lower limbs or epigastric region; or the 
 mustard foot-bath.
 
 Insomnia and its Therapeutics, 129 
 
 Free purgation by means of calomel, jalap, and scammony 
 is called for. 
 
 $ Subchlor. hydrarg., gr. ij. 
 
 Res. scammon., gr. ij. 
 
 Pulv. jalap, co., . 3 i. 
 
 F. pulv. i. Sig. Take at bedtime. 
 
 The following may be prescribed at the same time : 
 
 $ lod. potass., . . . . . . 3 i. 
 
 Bromid. potass., . ... ; . 3 iv. 
 
 Tinct. aconit. (B. P.), . . . Tf[ xxxvi. 
 
 Spt. ammon. arom., . . . . .3 iij. 
 
 Aquam, . ad f vi. 
 
 M. Sig. Take a tablespoonful in water every four hours. 
 
 When the heart's action is not powerful, 3 ij. of chloral 
 hydrate may be substituted for the aconite. In very slight 
 cases a saline, such as a teaspoonful of Carlsbad salts in half 
 a teacupful of warm chamomile tea at bedtime, acts as an 
 excellent hypnotic. It may be given also in the morning. In 
 convalescence, electricity and the use of sitz baths are useful 
 remedies. 
 
 When cerebral congestion arises in children as the result 
 of teething, sleeplessness is a most troublesome symptom. 
 The swollen and tense gums should be thoroughly incised; 
 the head kept cool by means of cold applications; warm or 
 tepid baths frequently repeated ; and the bowels relieved by 
 gentle laxatives. Bromide of potassium, monobromide of 
 camphor, or chloral Ir^drate may be given every three or four 
 hours. 
 
 Passive Congestion of the Brain. The symptoms of this 
 affection closely resemble those of the active variety; indeed, 
 the most marked difference that exists is in the symptom 
 under consideration. Wakef ulness is not nearly such a prom- 
 inent or constant feature as disturbed sleep, though that is 
 keenly felt and badly borne. When the patient gets off to 
 sleep he is disturbed by frightful dreams, from which he 
 awakes in terror probably a more distressing condition than 
 lying awake. This is due to the anaemia with which it is in- 
 variably associated, for the blood in the veins is useless for 
 the purposes of nourishment.
 
 130 Insomnia and its Therapeutics. 
 
 Treatment. The remarks on regimen in the last para- 
 graph may be held as applicable here. It is necessary to raise 
 the head on a high pillow to favor the return of blood to the 
 heart. Any exciting cause, such as cough, must be specially 
 treated, at the same time that every effort is made to improve 
 the tone of the circulatory system. 
 
 Tonics, diuretics, and mild purgatives are called for. 
 
 $ Ext. ergotae liq., 3 iij. 
 
 Tinct. digital., 3 ij. 
 
 Liq. strychn., 3 i. 
 
 Aquam chloroform., . . . ad vi. 
 
 M. Sig. Take a tablespoonful in water three times a day. 
 
 Here, as in most anaemic conditions of the brain, morphine 
 is admissible, and may be used hypodermically in doses of -fa 
 to of a grain; although remedies which are less prone to 
 disorder the secretions may be tried first; these are paralde- 
 hyde, ure thane, etc. 
 
 Bartholow recommends galvanization of the head in pas- 
 sive cerebral congestion. 
 
 Cerebral Anosmia. The diseases which give rise to this 
 affection were enumerated in Chapter II. 
 
 The symptoms vary very considerably with the extent of 
 the cause and the degree of anaemia it induces. 
 
 In acute cases the symptoms are rapidly and severely de- 
 veloped ; in chronic cases, although existing in a marked de- 
 gree, they are less keenly felt, and so are better borne. The 
 symptoms may range from a succession of violent convulsions, 
 the result of a profound and sudden loss of blood, to a passing 
 feeling of faintness depending upon sharp pain. When it is 
 suddenly produced the effects are chiefly felt by the special 
 senses, and by the great centres in the medulla oblongata, 
 just as in Flemming's experiments on the compression of the 
 carotids, in which unconsciousness was mistaken for sleep. 
 The patients complain of dimness of vision, noises in the ears, 
 vomiting, sweating, rapid pulse, sighing respirations, etc., in- 
 dicating the prostration of these several centres, while in- 
 somnia is always an urgent source of distress. 
 
 In chronic cases and it is with these that we are more 
 immediately concerned sleeplessness, or sleep disturbed by
 
 Insomnia and its Therapeutics. /i^l 
 
 dreams, and general restlessness, are usually prominent symp- 
 toms. They present a striking contrast to the drowsiness and 
 languor which prevail throughout the day, when the patient's 
 mental condition is one of weariness and irritability, and his 
 thoughts and memory are confused and defective. The other 
 striking features are briefly, pallor of the surface of the body; 
 coldness of the extremities; pinched face; throbbing or pul- 
 sating noises in the ears, sometimes resembling the noises of 
 the seashell; dimness of vision, flashing of light from the eyes, 
 dilated pupils; intolerance to noise and light; small and com- 
 pressible pulse, frequently " splashing," and generally, al- 
 though not constantly, of low tension. The cardiac sounds 
 are enfeebled, with bruits in the veins of the neck ; respira- 
 tions are less frequent than natural. Digestion is slow, and 
 the bowels are constipated. 
 
 In the cerebral anaemia of children, so closely resembling 
 the early stages of hydrocephalus, which occurs in cases of 
 severe and copious diarrhoea, the patient is very restless, and 
 usually sleeps little if at all; the face is pale, eyes sunken, 
 features pinched, the fontanelles depressed below the level of 
 the bones, while the muscular system generally is relaxed and 
 flabby, and the bodily surface pale and cool. The effects of 
 this state are keenly felt by the nerves and the nervous cen- 
 tres, which, being improperly nourished, show it in their ex- 
 citability. The psychical, motor, and sensory centres each in 
 their own peculiar way exhibit evidence of this, and discharge 
 their energy under unusually slight stimulations; one of the 
 commonest indications of this being wakefulness and restless- 
 ness. 
 
 Treatment. In acute cases, raising the foot of the bed so 
 as to lower the head, with the hypodermic injection of mor- 
 phine, is of the greatest use. Under no circumstances can the 
 tonic and stimulating properties of morphine be so well studied. 
 The hypodermic injection of sulphuric ether and strychnine 
 may also be resorted to. 
 
 In chronic cases the treatment must be directed to the 
 constitutional state ere relief can be obtained. Careful atten- 
 tion to hygienic conditions is absolutely necessary, so that all 
 undue fatigue be avoided, and that the largest amount of 
 oxygen and sunlight be secured for the patient by day, and 
 the greatest freedom from external disturbing agencies by
 
 132 Insomnia and its Therapeutics. 
 
 night. The digestive powers must be improved up to the 
 highest possible point, and the food should be nutritious, and 
 on the lines of that suggested for neurasthenic conditions 
 (p. 590). Alcohol, in the form of red wine, Burgundj T or claret; 
 or malt liquor, as ale or stout, in quantity calculated to im- 
 prove assimilation, must be given. Iron in one or other of its 
 forms, and arsenic, are the remedies to be relied on, and they 
 are best combined with laxatives. 
 
 arsen., ....... 3 ss. 
 
 Mist, ferri co., ...... x. 
 
 Decoct, aloe, co., ...... 3 ij. 
 
 M. Sig. Take two tablespoonfuls thrice daily, after meals. 
 
 The tincture of the muriate of iron of the Edinburgh Phar- 
 macopoeia combined with sodium or magnesium sulphate acts 
 well. Blaud's pills and arseniate of iron are likewise suitable 
 remedies. 
 
 The Sleeplessness of Convalescence. This practically 
 depends upon the same cause, i.e., cerebral-cell starvation. 
 Evidence of this may sometimes be obtained in the exagger- 
 ated reflexes which can be elicited, e.g., in patients recovering 
 from fevers. In this state it is important for the patient to 
 avoid over-fatiguing himself by too much talking, or by sitting 
 up too long, etc., as these indiscretions accelerate the pulse, 
 and they may raise the body temperature, thereby prevent- 
 ing sleep ; moreover, care must be taken to avoid over-feeding. 
 Alcohol is an invaluable tonic and hypnotic, a glassful of 
 champagne at bedtime frequently acting like a narcotic. 
 Light food combined with a stimulant, once or twice during 
 the night, is the best form of sleeping agent. Digitalis, strych- 
 nine, and quinine in small doses are useful (p. 595). Sponging 
 with tepid water frequently is soothing, while gentle frictions 
 are also provocative of sleep. Change of posture relieves any 
 hypostatic congestion of the brain. If a t^pnotic is called 
 for, morphine in small doses is the most suitable. 
 
 Degeneration of the Cerebral Arteries. This is a factor 
 in the causation of cerebral hemorrhage, and it appears to 
 exercise a decided influence upon the nutrition of the cortical 
 substance of the brain. 
 
 The symptoms are, displays of emotional feeling upon the
 
 Insomnia and its Therapeutics. 133 
 
 most trivial excitement; drowsiness during 1 the day, even to 
 the extent of falling 1 asleep during" meals, and often prolonged 
 sleep at night. But in a certain proportion of cases there is 
 troublesome dreaming-, if not pronounced wakefulness at night. 
 To such an extent is this true, that dreaming in advanced 
 years may be held as suggestive of pending apoplexy. Dreams 
 are the source of great annoyance. A physician who had re- 
 tired into well-merited private life, told the writer that the 
 only miserable time he had was when he was asleep dream- 
 ing; he died shortly afterward of apoplexy. This is no un- 
 common experience. In some cases wakefulness is a marked 
 feature; the arteries, hard and resistent, are no longer capable 
 of responding to the vaso-motor constrictors, so that when 
 sleep should naturally occur, the blood-supply is not moder- 
 ated, and consequently sleeplessness results. 
 
 Treatment. The sleeping conditions require attention. 
 The bedroom should be comfortably heated, and the bed well 
 warmed before lying down, to avoid any chill, which by re- 
 pelling the blood from the peripherj 1 - is apt to aggravate the 
 evil by increasing the cerebral hyperaemia. The feet should be 
 warmed, and the head well raised. The writer has frequently 
 got good results 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. A light repast with a little stimulant at bedtime, just 
 enough to excite some vascular determination to the stomach, 
 without accelerating the heart's action, is frequently, sufficient 
 to deplete the cerebral vessels. The sumbul and hop mixture 
 (p. 597), or henbane and camphor (p. 611) are sometimes use- 
 ful, but as they cannot modify the pathological conditions, 
 the% r must be used with caution. The bromides and chloral 
 hydrate are best avoided. 
 
 It seems convenient here, in connection with this subject, 
 to add a few remarks upon some other forms of insomnia met 
 with in the aged. We have already laid some stress upon the 
 increased amount of sleep they require, and in many instances 
 get. A good sleeping-habit has probably much influence over 
 the prolongation of life. The statistics of forty-four centen- 
 arians, collected by the Collective Investigation Committee 
 of the British Medical Association (1886), proved that thirty- 
 four were good sleepers, five were bad, and seven were moder-
 
 134 Insomnia and its TJicrapeutics. 
 
 ate sleepers. Returns made in twenty-nine cases, indicating 
 the number of hours slept, showed that the average was eight 
 and a half hours; three slept twelve hours, eight slept ten, 
 one slept four, and two slept six hours. Upon the whole these 
 figures show a fair amount of repose. 
 
 Dyspeptic Derangement. This is a fruitful source of sleep- 
 lessness. Digestion being slowly and imperfectly performed, 
 the patient complains of weight and oppression over the epi- 
 gastric region, flatulence and heartburn, the tongue being 
 usually dry and the appetite feeble. This depends upon im- 
 perfect innervation of the processes, which leads up to defec- 
 tive nutrition of the whole system. The heart growing weak, 
 and propelling a smaller quantity of blood feebly, the nervous 
 centres become still further impaired. These sufferers are 
 usually drowsy during the day ; they drop off to sleep in their 
 chair, but at night on assuming the recumbent posture they 
 wake up and become sleepless. In less pronounced cases these 
 symptoms are only apparent after indiscretions in eating and 
 drinking, which embarrass the enfeebled digestive powers. 
 
 Treatment. This consists in aiding digestion with alcohol. 
 It is best given with meals in quantities short of producing 
 catarrh of the stomach; it is likewise useful at bedtime and 
 during the night. A tablespoonful of whiskey diluted with 
 water or milk, taken at bedtime with a biscuit, grapes or 
 raisins, and repeated if necessary during the night, is a most 
 useful hypnotic. About four or five A.M., when the circulation 
 is depressed, it has no rival. An elderly lady, upward of 
 eighty years of age, who for a few years has derived great 
 benefit from this regimen, practically sleeping quite well, re- 
 turned to bed one night, having eaten her biscuit and, as she 
 thought, sipped her stimulant, but found she could not sleep. 
 After tossing uneasily for some time she resolved to exceed 
 the prescription by repeating it; when she rose to do so she 
 discovered she had forgotten to drink her quantum, which she 
 then took and was soon asleep, showing that the stimulant is 
 required as well as the food. A cardiac tonic is often usefully 
 combined with the stimulant. Here is a prescription for a 
 mixture which a lady, now considerably over eighty years of 
 age, has had at her bedside for the last thirteen years, and 
 she has generally required to take it once or twice during 
 every night.
 
 Insomnia and its Therapeutics. 135 
 
 $ Tinct. valerian., 3 iv. 
 
 Spt. ammon. arom., . . .-.. .. . 3 ij. 
 
 Spt. chlorof., . i . . . 3iij. 
 
 Tinct. lavand. co., . . . . . , 3 iij. 
 
 Infus. digital., . . . . . ad iv. 
 
 M. Sig. Take a tablespoonf ul in water every four hours 
 when required. 
 
 The use of bromides, hydrate of chloral, and other hyp- 
 notics, is inadmissible. The food requires to be skilfully 
 arranged. 
 
 Pruritus senilis is a distressing source of sleeplessness in 
 the aged, and requires careful management. It is usually 
 met with in persons above sixty years of age, in whom the 
 skin is suffering from the effects of defective nutrition. Many 
 of these afflicted persons are gouty. 
 
 It assumes many forms, and is influenced by various cir- 
 cumstances, such as alterations of temperature, and is inva- 
 riably aggravated by the heat of the bed. It prevents sleep, 
 while the scratching still further increases the distress, just 
 as the wearing of flannel does. It most frequently affects the 
 region of the anus and genitals, and the lower limbs. 
 
 Treatment. The first aim must be to regulate the diet 
 and correct digestive derangements, for these aggravate the 
 itching. Indeed, exacerbations are apt to be caused by indis- 
 cretions in eating and drinking. The emunctories should be 
 kept active. Mild mercurials and the mineral acids are very 
 suitable remedies. To promote the action of the skin frequent 
 washings are required. Baths containing borax, bran, or oat- 
 meal are soothing and grateful. Tonics, such as arsenic, 
 strychnine, and quinine, often yield good results, although 
 arsenic in some instances appears to increase the distress. In 
 some cases cannabis indica administered internally, by lessen- 
 ing the conductivity of the sensory nerves, promotes sleep by 
 relieving the itching. Warm baths at night often promote 
 sleep. The use of lanolin has been strongly recommended, 
 and the writer has found it useful mixed with two parts of 
 cerat. galena; and also, with one part of the oleate of zinc 
 and two of pure white vaseline. Boracic acid ointment and 
 lotion, and ointments containing tar, huile de cade, carbolic 
 acid, and menthol are all serviceable. Menthol and carbolic
 
 136 Insomnia and its Therapeutics. 
 
 acid from their odor sometimes prevent sleep. The lotions 
 and ointments should be used warm, as cold applications are 
 prone to initiate wakefulness in the aged by exciting- cerebral 
 hyperaemia. 
 
 For twenty years the writer has obtained good results 
 from a prescription of Dr. Bowling, of Kentucky, as quoted by 
 Tanner: "I direct that the affected parts be sponged for a 
 minute or so with good apple vinegar, and then allowed time 
 to dry. After this they are to be smeared over with citrine 
 ointment (unguentum hydrargyri nitratis). The applications 
 are to be made twice a day. The cure is usually effected in a 
 week." 
 
 Intro-cranial Tumors. Sleeplessness occurs in the major- 
 ity of these cases as a consequence of the headache from which 
 the patient commonly suffers. Headache appears early in 
 the disease, and is often the only symptom of the organic 
 mischief; it usually persists night and day, and tends to grow 
 worse at night. It may be excruciating in character, and ex- 
 ceed in severity all headaches depending upon functional dis- 
 orders, or even inflammatory diseases of the brain and mem- 
 branes. 
 
 It prevents sleep, or interrupts it if it has ensued; and this 
 characteristic is always suggestive of organic disease. 
 
 The sleeplessness itself becomes a source of aggravation, 
 intensifying the suffering, and increasing the mental and 
 physical exhaustion, 
 
 Treatment. From the fact that the pain is increased by 
 any active or passive congestion of the brain, such as is caused 
 by visual and auditory stimuli, coughing, stooping, etc., the 
 head should be well raised on a high pillow, in a darkened, 
 quiet, and cool room; and the food should be light and non- 
 stimulating. Cold sometimes relieves pain: ice-bags and 
 Leiter's tubes are convenient modes of applying it. If it is 
 disagreeable to the patient, tepid lotions may be applied. 
 Purgation, by relieving the hyperaemia, is useful. The follow- 
 ing has rendered good service : 
 
 $ lodid. potass., 3 ij.- 3 iv. 
 
 Brom. potass., . . ... . 3 iv. 
 
 Aq. menth. pip., ad vi. 
 
 M. Sig. Take a tablespoonful every four hours in water.
 
 Insomnia and its Therapeutics. 137 
 
 When there is much arterial tension, TTUj.-TTUij. of tincture 
 of aconite B.P. may be added to each dose. 
 
 When a hypnotic is required to induce sleep, morphine is 
 the only reliable remedy, chloral hydrate having no influence 
 over pain. Morphine should be used in as small doses as is 
 compatible with the end in view. It must not be forgotten 
 that coma is apt, in such cases, to supervene spontaneously. 
 
 Cannabis indica has been strongly recommended. 
 
 When the diagnosis of such tumors is clearly made out, 
 they pass into the domain of the surgeon. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE SPINAL. 
 CORD, NERVES, ETC. . 
 
 Insomnia in diseases of the spinal cord and nerves is 
 chiefly, if not altogether, due to pain, which may be persist- 
 ently present, or excited by muscular movements. It is pro- 
 posed to refer briefly to one or two of these affections. 
 
 Spinal Meningitis. Sleep is speedily interfered with by 
 the constitutional disturbance which attends the onset of this 
 malady. There are also present excessive pain in the back, 
 which shoots down the limbs, and is greatly increased by all 
 voluntary movements, and considerably intensified by pres- 
 sure; muscular rigidity and spasm, associated with frequent 
 startings; Ir^peraesthesia in the early stages, with formication 
 and tingling; and if it extends to the cerebral meninges, head- 
 ache and vertigo. The reflexes in the beginning are exagger- 
 ated ; while paralysis, usually preceding loss of sensation, af- 
 fects the rectum and bladder, and may, by atrophic changes, 
 give rise to bed-sores. 
 
 In consequence of these disturbing agencies sleep is gen- 
 erally very broken, and when it ensues it is dream-laden, or 
 disturbed by sleep-talking, and is apt to be rudety terminated 
 by an exacerbation of pain excited by involuntary muscular 
 movements. 
 
 Treatment. The early recognition of the disease is of vast 
 importance, as there is a risk of its being mistaken in the 
 earlier stages for rheumatism, with which disease it is occa- 
 sionally associated. The greatest care must be taken to avoid 
 bed-sores by keeping the bed scrupulously clean and smooth; 
 the bowels and bladder being duly watched. Cupping, dry
 
 138 Insomnia and its Therapeutics. 
 
 and wet, along 1 the whole course of the spine, frequently re- 
 peated, with the use of mercurial purgatives, is invaluable. 
 The following- mixture has been found useful. 
 
 $ lod. potass., 3 ij. 
 
 Brom. potass., 3 iv. 
 
 Liq. ergot, ext., . . . . . . 3 iv. 
 
 Aq. chlorof., . ad 3 vi. 
 
 M. Sig. Take a tablespoonful in water every four hours. 
 
 It sometimes induces sleep; when it fails morphine must 
 be resorted to; or opium combined with small doses of tartar 
 emetic. 
 
 If the potassium salt induces iodism, one of three courses 
 may be adopted. The dose may be increased; or 3 ij. of tinc- 
 ture of belladonna may be added to the mixture; or the medi- 
 cine may be taken diluted with a large quantity of water. 
 
 Dr. Ross speaks well of warm baths and moist packs as 
 soothing and conducive to sleep. 
 
 Myelitis. The symptoms of this disease are essentially of 
 the same character as those of meningitis constitutional dis- 
 turbance, etc., and sleeplessness. The insomnia requires the 
 same treatment. 
 
 Locomotor Ataxy. Sleeplessness is not infrequently asso- 
 ciated with this affection, having begun during the course of 
 the disease which originated it, such as severe continued fevers, 
 etc. It may continue throughout the initial stages of the 
 secondary affection, and be perpetuated. 
 
 When the disease has developed, sleeplessness usually de- 
 pends upon the severe lightning-pains, severe and enduring 
 pain in the back, girdle sensations, gastric crises, formication, 
 and pronounced general restlessness, impelling the patient to 
 change his position frequently. 
 
 Treatment. It must be that of the disease. Turkish baths 
 and hydropathic treatment are in most cases beneficial, par- 
 ticularly if conjoined with electrization. Nitrate of silver and 
 iodide of potassium are reliable remedies. Recently excellent 
 results have been obtained, so far as relief from pain is con- 
 cerned, from antipyrine and antifebrine, the former in doses of 
 15 grains, frequently repeated, the latter in doses of 8 grains. 
 These remedies promise to be the best hypnotics in this affec- 
 tion. When the pains are violent, as during gastric crises,
 
 Insomnia and its Therapeutics. 139 
 
 morphine must be given freely. The writer has known as 
 much as 20 grains required in 24 hours. Suspension seems, in 
 some cases, to afford good results. 
 
 Infantile Paralysis. Sleep is often very disturbed at the 
 onset. 
 
 Neuralgia. Sleeplessness is often caused by the pain that 
 this ailment induces, as well as by the constitutional state 
 which gives rise to it. It is chiefly seen in the debilitated, or 
 in those who are suffering from some toxic condition. 
 
 Hence it is met with in the anaemic and weakly, and in 
 those afflicted by gouty, rheumatic, sj^philitic, or malarial 
 poisons. The disease is characterized by severe, even agoniz- 
 ing, unilateral, periodic, and paroxysmal pain. The parox- 
 ysms frequently select sleep as the time for their occurrence, 
 and they are usually more severe during the night. The pain 
 is attended by tenderness on pressure over some portion of 
 the nerve; and occasionally is accompanied by swelling, ery- 
 thematous or herpetic changes in the skin over the nerve. 
 
 The sensation of pain being transmitted to the brain keeps 
 it in a hyperaBmic state, which is incompatible with sleep, at the 
 same time that it increases the force of the heart's action. 
 Neuralgias receive different names as they affect different 
 cranial nerves, plexuses of spinal nerves, or internal organs or 
 viscera. 
 
 Treatment. It is divided into curative and palliative; the 
 latter is often concerned with the promotion of sleep. 
 
 Antipyrine and antifebrine are distinct gains to the materia 
 medica. They both possess the power of relieving pain, espe- 
 cially that of neuralgia, without disturbing the digestive pro- 
 cesses. The dose of the former is from 10 to 20 grains thrice 
 daily, and of the latter from 5 to 15 grains. 
 
 Morphine and cocaine by hypodermic injection are the relia- 
 ble remedies for pain ; the dose should be limited to that which 
 will ameliorate it. Antipyrine may also be administered hy- 
 podermically, either alone or with cocaine. 
 
 Local applications of menthol, aconite, veratria, belladonna, 
 chloroform, opium, heat, blisters, and electricity are each and 
 all useful. Electricity is at once curative and an aid to sleep. 
 
 In the angemic and weakly, special attention should be paid 
 to diet, and probably wine must be allowed. Various tonics, 
 as iron, arsenic, phosphorus, and quinine, by improving- the 
 general health and by relieving pain,, admit of sleep.
 
 140 Insomnia and its Therapeutics. 
 
 In those suffering 1 from gouty, rheumatic, syphilitic, and 
 malarial poisons, the remedies must be directed against these 
 states. 
 
 In neuralgia of the fifth cranial nerve, gelsemium with hy- 
 drobromic acid and quinine; or the butyl-chloral hydrate will 
 probably suit best. 
 
 In brachialgia, rest for the limb, antipyrine, Warburg's 
 tincture, sal ammoniac with belladonna, and nerve stretching. 
 
 In herpes zoster, arsenic and quinine. 
 
 In lumbago, dry cupping, acupuncture, antipyrine, and sal 
 ammoniac. 
 
 In sciatica, fly blisters, dry cupping, acupuncture, turpen- 
 tine, potassium iodide, and nerve stretching. 
 
 In ovarian neuralgia, blisters and potassium bromide are 
 the remedies which have afforded the writer the best results. 
 
 In all cases the emunctories must be attended to. Much 
 relief is occasionally gained by the judicious administration of 
 a purgative. 
 
 Other painful affections, such as biliary or renal calculi, 
 and like acute ailments, are best treated with morphine in 
 adequate doses. Neuromata should be removed. Cancers and 
 similar chronic painful diseases necessitate the continued use 
 of morphine or cocaine ; the former dusted over the open sore 
 has afforded Dr. Thomas Keith excellent results. Given hy- 
 podermically, the dose should be kept as small as possible, for 
 unfortunately a time arrives when it no longer acts as a seda- 
 tive; on the contrary, it seems to act as an irritant, while it 
 demoralizes the whole man. Pure hypnotics have no influ- 
 ence in such cases. They operate, for the most part, directly 
 on the cerebral cells. No remedy is of any avail in painful 
 affections which does not act on the sensory-nerve endings and 
 lessen their excitability and transmitting functions. Bella- 
 donna, morphine, aconite, etc., possess such properties hence 
 their usefulness. Cocaine injected subcutaneously relieves 
 pain, apparently by constricting the arterioles and so render- 
 ing the nerve terminals bloodless. 
 
 Irritants, such as insects or pediculi; itching, from urticaria 
 and like affections; blistered surfaces, etc., are all able to in- 
 terfere with sleep; but their presence being recognized and 
 their cure effected, sleep will return. Temporarj' relief can be 
 obtained and sleep induced by hyoscj^amus, cannabis indica, 
 camphor, etc.
 
 CHAPTER VIII 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 NERVOUS SYSTEM Concluded. 
 
 IT is proposed, in concluding 1 these chapters, to briefly dis- 
 cuss insomnia depending 1 upon the influence of certain toxic 
 agents upon the economy. 
 
 Alcoholism. The varying 1 effects of alcohol upon sleep and 
 sleeplessness are due to the susceptibility of the person who 
 consumes it, to the quantity and quality taken, and likewise 
 to the intermingling of various kinds of drinks. 
 
 Persons intolerant of alcohol, or unaccustomed to its use, 
 ma3 T be rendered sleepless by a very small quantity, probably 
 by its exciting the action of the heart and causing cerebral 
 hypersernia. If such persons suffer from insomnolency from 
 any cause, alcohol invariably aggravates the symptom. 
 
 In those who are accustomed to its strictly moderate use, 
 a small dose at bedtime acts as a hypnotic, probably by estab- 
 lishing a temporary gastric congestion and a corresponding 
 cerebral anaemia. Such persons only realize its Iwpnotic prop- 
 erties when they tr3 r to abandon its use. They then experience 
 for some nights great difficulty in falling asleep, greater diffi- 
 culty indeed than they would have believed possible. 
 
 In this temperate class, a larger quantity of alcohol pro- 
 duces sleep disturbance, and especially when the spirits or 
 wines are impure or unsound, or when they are injudiciously 
 mixed. The quality and admixture appear to exercise as great 
 a pernicious influence as the quantity. 
 
 When an overdose of alcohol is taken (and that is a relative 
 quantity) profound or drunken sleep follows, in which the pupils 
 become very contracted. If such a person is disturbed or 
 aroused the pupils dilate, an occurrence that has been made 
 use of in distinguishing between alcoholic and opium poison- 
 ing; for in the latter they do not dilate. While the utility of 
 this means of diagnosis is very great, it is really only what
 
 142 Insomnia and its TJicrapcutics. 
 
 happens in deep sleep, and is in no respect peculiar to alcoholic 
 excess. 
 
 The majority of persons who habitually consume alcohol 
 in quantity exceeding 1 physiological limits, although short of 
 inducing delirium tremens, eventually suffer from alcoholism. 
 This is attended by well-marked symptoms during life, and 
 by structural changes in the brain and nervous system which 
 can be studied after death. To the latter we shall refer first. 
 
 The dura mater is frequently found adherent to the cranial 
 bones, the arachnoid devoid of its normal transparency, the 
 pia mater thickened, the convolutions, particularly those of 
 the frontal lobes, shrunken and atrophied, and an increased 
 amount of fluid in the ventricles and in the arachnoid spaces. 
 In post-mortem examinations made of the bodies of a very 
 large number of persons who had been addicted to drinking 
 the writer never failed to note these atrophic changes in 
 greater or less degree. Organic changes in the liver, stomach, 
 etc., were equally constant. 
 
 During life the patient presents symptoms of mental en- 
 feeblement, in which the intellectual, emotional, and volitional 
 centres participate, as evidenced by incapacity, irritability, 
 and vacillation; eventually he becomes demoralized, deceitful, 
 and untruthful. He complains of headache, depression of 
 spirits, occasional attacks of giddiness, weakness of vision, 
 scintillations, muscce volitantes, and impairment of hearing. 
 He is restless, his muscles tremble and twitch. The tremors 
 are worse in the morning, and manifest themselves mostly in 
 the Upper limbs; the twitchings are most marked at night 
 when he tries to fall asleep. He suffers from abnormal sensa- 
 tions of heat and cold, and from formication in the limbs, at 
 times from severe neuralgic pains. His movements are often 
 ataxic, and at times he is paratyzed from multiple neuritis. 
 He is the subject of chronic gastric catarrh, and of liver de- 
 rangements. Such a patient comes for advice, not on account 
 of his general condition, but for sleeplessness and mental de- 
 pression, the former becoming- very marked in the later stages. 
 Sleep is either absent or disturbed by frightful dreams, night- 
 mare, and general restlessness. It is the reverse of refreshing, 
 and the patient gets up in the morning feeling miserable, and 
 full of dread and dismay. Sleeplessness depends conjointly 
 upon the noxious effects of the poison on the cerebral cells,
 
 Insomnia and its Therapeutics. 143 
 
 hyperaemia of the brain, the vaso-motor paresis which follows, 
 and the accompanying digestive troubles. 
 
 In cases less pronounced, such as are induced by alcohol 
 only slightly in excess of physiological limits, sleep may be 
 deep and heavy in the early part of the night, but it terminates 
 about four or five o'clock, and does not return till nearly the 
 hour for rising. A history of wakefulness occurring at that 
 hour, and accompanied with restlessness, should always sug- 
 gest, at least, the possibility of its being alcoholic. 
 
 Treatment. All stimulant must at once be withdrawn 
 from those who can bear its withdrawal, and materially re- 
 duced in the case of those who are enfeebled. The food must 
 be carefully arranged. The first indication is to unload the 
 liver and restore the digestive powers. This may be accom- 
 plished by means of a calomel purge, followed in the morn- 
 ing by a dose of one of the natural saline waters, and an alka- 
 line mixture before meals. 
 
 I Bicarb, potass., . . ... 3 iij. 
 
 Tinct. nucis vom., . . . . . 3 ij. 
 
 Liq. arsen. sodii, . 3 ss. 
 
 Tinct. capsic., . . . . . . 3 ss. 
 
 Infus. cascaril., ad f vi. 
 
 M. Sig. Take a tablespoonful in water thrice daily before 
 meals. 
 
 The nux vomica by influencing the vaso-motor centres 
 acts in many cases as a hypnotic. Warm applications, as a 
 mustard plaster or a compress over the stomach and liver, 
 are useful adjuncts to treatment. For some nights it is neces- 
 sary to administer a hypnotic to insure sleep. There are 
 many which act admirably; probably the best are hydrobro- 
 mate of hyoscine, chloral hydrate, paraldehyde and sulphonal; 
 but the monobromide of camphor and amylene hydrate are 
 also suitable. Antipyrine relieves headache, nausea, and the 
 sense of sinking, and occasionally promotes sleep. 
 
 During convalescence, electricity, change of air and scene, 
 sea-bathing, and a mixture of strychnine and quinine with 
 dilute nitro-muriatic acid, are the best remedies to establish 
 health and restore sleep. 
 
 The Morphine Habit. Morphine taken for any length of
 
 144; Insomnia and its Therapeutics, 
 
 time leads to sleep disturbance, while its discontinuance is fol- 
 lowed by pronounced insomnia. 
 
 Disturbed sleep from this cause is difficult to diagnose, for 
 the reasons that, in the earty stages of mild cases, the objec- 
 tive symptoms are less marked than those in the case of alco- 
 hol, and that there is usually a strong desire on the part of 
 the patient to conceal the fact that he is addicted to the use 
 of narcotics; indeed, he may be striving to abandon the habit. 
 In the later stages, and in pronounced instances, this difficulty 
 disappears. 
 
 The practice of taking morphine by the mouth or hypo- 
 dermically has increased rapidly of late years, and has largely 
 displaced the consumption of opium in the solid and liquid 
 forms. Many of the persons addicted to it are quite above the 
 suspicion of such a habit, and discharge high and important 
 duties with ease and eclat. 
 
 The quantity taken may range from half a grain to twenty 
 or more grains in the course of twenty-four hours. 
 
 Such patients complain that their nights are wakeful, 
 though quiet; or if sleep does come on it is disturbed by 
 dreams, and in the morning they awake unre freshed, miser- 
 able, and dispirited. After a time, longer or shorter, depend- 
 ing upon the strength of the patient and the quantity taken, 
 morphine produces well-marked modifications in the nervous 
 S3 r stem generally. The intellect is enfeebled; the emotional 
 centres display their weakness in increasing excitability, and 
 the volitional in demoralization; the control of the will is in 
 abeyance; the disposition is changed; men deeply religious 
 and scrupulously punctilious grow deceitful and untruthful. 
 They suffer from severe neuralgic pains in the limbs; from 
 hyperaesthesia or anaesthesia; from muscular twitchings and 
 tremblings, the twitchings being more marked during the 
 night when they are at rest in bed; and from perversion of 
 the special senses and defective vision. The eyes are dull and 
 expressionless, the pupils generally contracted, but not alwaj-s 
 so. They suffer from the effects of enfeeblement of the vaso- 
 motor centres, as well as of the centres which control the car- 
 diac, respiratory, and digestive functions, etc. Itching of the 
 skin is occasionally very troublesome. 
 
 Treatment. This obviously consists in breaking off the 
 habit, which in all cases is extremely difficult. The persistent
 
 Insomnia and its Therapeutics. 145 
 
 insomnia which accompanies the attempt, lasting through 
 days and nights, may endanger life. Much difference exists 
 in the ability of persons to abandon the habit. In a recent 
 case in which insomnia, neuralgic pains in the limbs, general 
 emaciation, etc., were clearly due to morphine that had been 
 taken for some 3 r ears subsequent to a painful illness, the pa- 
 tient abandoned it from the moment he was advised to do so; 
 but the struggle was such that he said, if he ever again ac- 
 quired the habit, he would not attempt to give it up. Such 
 an experience is by no means uncommon, though it is not the 
 usual one. The habit appears to be more easily relinquished 
 if the drug has been used for the relief of pain, especially if 
 the pain abates. 
 
 Many patients, who during days and weeks have taken 
 enormous doses of morphine for pain, are able to abandon the 
 practice easily and quickly. The writer has known a patient 
 do this, who had taken for some time as much as seventeen 
 grains every twenty-four hours. A good deal depends upon 
 their temperament. 
 
 Where the patient can at once and forever give it up he 
 should do so. Dr. B. W. Richardson, who has given the sub- 
 ject much careful consideration based upon the observation of 
 a large number of cases, thinks that in aggravated instances 
 a gradual plan is to be preferred ("Asclepiad," 1884). With 
 this the writer is in accord. The trial necessitates the isola- 
 tion of the patient, and the services of two trustworthy nurses, 
 and careful feeding. Ammonia and wine must be adminis- 
 tered when there are symptoms of great weakness. As soon 
 as possible strychnine and arsenic should be given. 
 
 5 Liq. arsen. hydrochl., 3 ss. 
 
 Liq. strychnin., 3 i. 
 
 Tinct. quinin., 3 xivss. 
 
 M. Sig. Take a teaspoonful in water before meals thrice 
 daily. 
 
 Since the introduction of sulphonal, the writer has had one 
 such case under his care, and his experience of this remedy 
 was so satisfactory that in future he will give it an extended 
 trial. Change of air and scene are generally required in the 
 convalescing stage. 
 
 The Chloral Habit. Chloral hydrate taken for any length
 
 146 Insomnia and its Therapeutics. 
 
 of time, even in strictly medicinal doses, is apt, like opium and 
 morphine, to create a habit, particularly in those possessing- a 
 neurotic temperament. 
 
 It is in many respects a more dangerous medicine than 
 morphine. At first the mental depression and melancholia 
 from which the patient suffers are alleviated by a dose of the 
 drug 1 ; after a time it fails to soothe, and it may even excite. 
 The victim gravitates into a pitiable state of mental weakness 
 and demoralization, becoming- childish, vacillating-, and un- 
 truthful; sometimes dejected, at other times excited, and 
 having suicidal tendencies. The symptoms are due to cere- 
 bral anasmia and enervation of the heart, lungs, etc. 
 
 The large number of deaths which have followed the use of 
 this drug points to the care with which it should be prescribed. 
 The sleeplessness of the chloral habit is the symptom which 
 calls for the most urgent consideration in the attempt to 
 break that habit. 
 
 Treatment. This consists in isolating the patient, so as to 
 render it impossible for him to get or take the drug surrepti- 
 tiously. He must be fed with light and nutritious food at 
 short intervals, and stimulated with diffusible agents, such as 
 ammonia and camphor. In convalescence, citrate of caffeine 
 acts most beneficially, while change of the physiological con- 
 ditions of life does much to complete the cure. Supervision, 
 however, is necessary for several months. Strychnine is like- 
 wise serviceable in combination with tincture of hydrastis. 
 
 Cocaine Habit. The . administration of cocaine appears 
 to be accompanied by a risk of forming a habit which is at- 
 tended by sleeplessness. Several such cases have come under 
 observation. Of the poisonous qualities of the drug there is 
 abundant evidence. 
 
 In December last, the writer saw in consultation a case of 
 chronic cocaine-poisoning, complicated by small doses of chloral 
 hyd rate ; but the symptoms of the former poison predominated. 
 It was characterized by great excitement, hallucinations chiefly 
 connected with sight and hearing, and associated with ani- 
 mals. The patient believed her skin was full of small insects, 
 and that her room was infested by serpents and other reptiles. 
 The lower limbs were so enfeebled that she was almost para- 
 plegic; while her sleeplessness was of the most pronounced 
 kind. She was isolated, well and carefully nursed, and fed
 
 Insomnia and its TJicrapeutics. ' 147 
 
 with suitable food. She took with the greatest benefit gr. 20 
 of sulphonal for several nights; and during her convalescence, 
 which was rapid, a mixture containing nux vomica. 
 
 In February, 1889, after an operation for hemorrhoids, she 
 became afflicted with pain at the entrance to the vagina, for 
 which her attendant prescribed a 22-per-cent ointment of 
 cocaine, and being ignorant of its nature she used it freely. 
 Speedily she began to develop peculiar symptoms, which in- 
 creased, until the former symptoms of sleeplessness, hallucina- 
 tions, and paresis of the limbs were all markedly present: the 
 knee-jerk was greatly lessened if not alogether absent. Their 
 import was recognized, and traced to their true origin. The 
 remedy was abandoned, and she steadily recovered. 
 
 Tea and Coffee. These pleasant, refreshing, and sustain- 
 ing beverages are used almost universally in the morning at 
 breakfast to dispel any traces of sleep. It has been astutely 
 remarked that we drink alcohol at night to woo, and tea hi 
 the morning to drive away, sleep. Tea and coffee have a very 
 decided effect upon the nervous system. In strictly moderate 
 quantity they promote mental activity, which is evidenced by 
 an accelerated rapidity of thought and clearness of judgment; 
 and they strengthen and invigorate the body. They are 
 largety used by the wearied and jaded on account of the men- 
 tal exhilaration they induce an animation which is not fol- 
 lowed lay depression. They are employed to relieve many 
 forms of headache; and so positive are their anti-hypnotic 
 properties that they are used (by those who wish to continue 
 their labors into the night) to prevent sleep. For a like rea- 
 son they are called into requisition in narcotic poisoning; and 
 they have been prescribed in many febrile and inflammatory 
 diseases to dispel slight stupor. 
 
 Tea and coffee have been credited with the power of acting 
 upon different regions of the cerebrum, and so producing vary- 
 ing effects. They certainly act somewhat differently on the 
 economy; coffee being less stimulating and restorative than 
 tea, and thus less productive of wakefulness; but it is more 
 prone to derange the biliary organs. 
 
 They each contain several similar principles. Three of 
 these may be named : a volatile oil ; alkaloids, theine and caf- 
 feine; tannin and caffeo-tannic acid. 
 
 A Volatile Oil. It is this that imparts the characteristic
 
 148 Insomnia and its Therapeutics. 
 
 aromatic taste and odor to tea and coffee. According 1 to the 
 analysis of Mulder, black tea contains 0.60 and green tea 0.79 
 per cent. This is one of the constituents of tea and coffee that 
 influence the brain and. nervous system. Taken in excess it 
 causes a train of nervous symptoms, among- the most marked 
 of which are tremors and sleeplessness. On account of the 
 larger quantity that green tea contains, it is usually selected 
 as a remedy in cases of opium-poisoning. As the oil is im- 
 bedded in the cellular tissue of the leaf, it is evident that time 
 is required for its complete extraction. This explains, to a 
 certain extent, why tea infused for a long- time is more apt to 
 render persons wakeful. When the oil has been extracted (being- 
 volatile) it is easily driven off by boiling, and even by exposure 
 to the air. Mr. John Borland, F.C.S., of Kilmarnock, has sug- 
 gested that the oil enters into combination with the theine 
 and forms a compound which is more soluble than the tannate, 
 and consequently is absorbed more quickly in the stomach. He 
 bases this opinion on the fact that theine is readily soluble in 
 several volatile oils at 180 Fahr., while it is only soluble in 
 75 parts of cold and in 9^ of boiling 1 water. He has suggested 
 also that an infusion of tea containing milk and cream favors 
 this combination, as the tannic acid precipitates the casein 
 of the milk and allows the theine to unite the volatile oil. He 
 argues from this that an infusion of tea containing milk or 
 cream should stimulate more quickly than one without these 
 additions. The writer has met with no facts to bear this out 
 so far as tea is concerned. He has, however, been often told 
 by patients that they could drink cafe noir after dinner and 
 sleep soundly, while cafe au lait rendered them wakeful. 
 
 Alkaloids. Theine and caffeine. These are obtained from 
 tea and coffee respectively. They appear to resemble each 
 other very closely, if, indeed, they are not essentially the same 
 substances. It has, however, been pointed out by Mays that 
 theine injected hypodermically possesses certain local anaes- 
 thetic properties, and that it interferes with sensation in frogs; 
 effects that are not caused by caffeine. 
 
 Theine exists in green and black teas in almost identical 
 quantities, and in amount considerably exceeding that found 
 in coffee. It appears to be a tolerably constant or equable 
 constituent of tea. Paul and Cownley, who analyzed twenty 
 samples of Indian and Ceylon teas differing- widely in price,
 
 Insomnia and its Therapeutics, 149 
 
 reported that the theine varied from 4.66 per cent in the high- 
 est class, to 3.22 per cent in the lowest. They likewise pointed 
 out that an ordinary spoonful of tea contains about sixty 
 grains, and that an infusion of that quantity of an average tea 
 (4 per cent) yielded in five minutes over half of the two and a 
 half grains it contained, about one to one and a quarter grains 
 of theine. (The size of the particles of tea with reference to 
 the quantity that ordinary spoons are capable of holding, is a 
 point of some importance. Dr. E. Smith, who first attracted 
 attention to this point, formulated a table, from which the 
 following items are extracted : 
 
 irir.H r.t too Weight of a spoon- Number of spoon- 
 
 ful in grains. fuls in a pound. 
 
 Black: 
 
 Oolong, . . . . .39 179 
 
 Congou, inferior quality, . . 52 138 
 
 Flowery Pekoe, .... 62 113 
 
 Souchong, 70 100 
 
 Congou, fine, .... 87 80 
 
 Green : 
 
 Hyson, 66 106 
 
 Fine Imperial, .... 90 77 
 
 Scented Caper, .... 103 68 
 
 Fine Gunpowder, ... 123 57 
 
 Retailers who are alive to the fact that the smaller the tea 
 the more there is consumed, try to supply it in as broken a 
 state as possible. This is worth bearing in recollection, as 
 teaspoonfuls of tea may be very different quantities.) 
 
 Theine and caffeine exert a decided influence over the 
 medullary centres, increasing the force of the heart, and at 
 first raising the blood-pressure. They also act as diuretics. 
 Tea and coffee produce much more marked wakefulness than 
 the quantity of theine and caffeine they contain would do if 
 taken alone. This is due to the volatile oil. 
 
 Tea contains a large amount of tannin, and coffee of caffeo- 
 tannic acid. The former impedes in a very decided manner, 
 and the latter in a less marked way, salivary and gastric 
 digestion. This well explains the dyspepsia and wakefulness 
 which follow the use of tea after dinner in certain cases. Tea, 
 retarding the solution and digestion of starches and albumi- 
 noids, is obviously the reason why that most objectionable of
 
 150 Insomnia and its Therapeutics. 
 
 all meals, " high tea," so frequently disturbs sleep. It appears, 
 however, to delay the digestion of some nitrogenous foods 
 more than others, as it does not retard that of smoked, dried, 
 or cured fish or flesh. 
 
 According to Mulder, green teas contain a larger quantity 
 of tannin than black teas; he states the proportion to be 17.80 
 and 12.88 respectively. The bulk of the tannin is given off by 
 infusion very quickly. Sir William Roberts, who investigated 
 this subject, wrote: "Some persons have supposed that by in- 
 fusing tea for a very short time only two or three minutes 
 the passing of the tannin into the solution could be avoided. 
 This is a delusion; you can no more have tea without tannin 
 than you can have wine without alcohol." It would, however, 
 seem to be equally proved that more tannin is given off by 
 long infusion. 
 
 Some experiments with reference to this point were made 
 by Dr. Hale White, and recorded in the "British Medical 
 Journal," 1889. 
 
 "A, was the finest Assam; B, the finest China; C, common 
 Congou; no green of any kind being used." 
 
 Percentage of tannin by weight Percentage of tannin by weight 
 Mark of sample. extracted by infusion for extracted by infusion for 
 
 3 minutes. 15 minutes. 
 
 A 11.30 17.73 
 
 B 7.77 7.97 
 
 C 9.37 11.15 
 
 It is therefore evident that an infusion of tea cannot be 
 made -without its containing tannin, notwithstanding the 
 statements to the contrary which are made in some quarters; 
 and that long infusion extracts tannin and theine in larger 
 amounts. 
 
 The effects of tea, like alcohol, upon the human economy 
 are so diverse in different individuals that an analysis of the 
 facts must be attempted. 
 
 For all practical purposes tea-drinkers may be divided into 
 four groups. 
 
 1. Those who can drink tea in almost any quantity and at 
 any hour with impunity, and sleep naturally. This is a very 
 limited class. 
 
 That the use of tea is productive, in the healthy, of less 
 harm than is popularly supposed, seems evident. Careful
 
 Insomnia and its Therapeutics. 151 
 
 inquiries made of twenty gentlemen who had followed the oc- 
 cupation of tea-tasting- in London during- several years, elicited 
 the fact that not one of them suffered from sleeplessness; on 
 the contrary, they were all good sleepers. In most instances 
 they affirmed that they slept better when attending- to their 
 business than when they were on holiday. These experts of 
 Mincing- Lane taste and value, on an average, at least a hun- 
 dred and fifty samples of tea every morning before the auction 
 sales begin. Some of them complained that an unusually 
 heavy morning's work induced a sense of sinking in the epi- 
 gastrium and nausea, which luncheon relieved. Not one of 
 them was sensible of any loss of taste, nor were they affected 
 with nervousness. Three complained of constipation and one 
 of diarrhoea. They were unanimously of opinion that their 
 profession was not detrimental to health. 
 
 This evidence, while it goes to prove the tolerance of cer- 
 tain persons to tea, must be accepted with this reserve, that 
 it seems probable if any one of these gentlemen had found 
 himself rendered sleepless early in his career, he would have 
 abandoned the calling. It is also to be remembered that the 
 tasting is done in the morning, and therefore is not so likely 
 to disturb sleep as drinking tea at night. 
 
 2. Those who can drink tea of particular quality and in fair 
 quantity at any hour, and sleep soundly. These constitute a 
 class who are, under certain conditions, sensitive to certain 
 varieties of tea, and who occasionally have their sleep inter- 
 fered with from this cause. For example, they are rendered 
 wakeful by green or Indian teas, or very new teas, especially 
 if these are over-infused. This, however, really depends upon 
 their general health at the time. When they are overworked 
 or slightly dyspeptic they are apt to suffer in this way. Many 
 of these persons exhibit idiosyncrasies; some can drink tea 
 immediately before going- to bed and sleep soundly, who would 
 be rendered wakeful if they took tea shortly before or after 
 dinner. This class embraces a larger number than is gener- 
 ally supposed, and they usually fail to connect their sleep dis- 
 turbance with the use of tea. 
 
 In such cases, the origin of the wakefulness having been 
 determined, two things are necessary. Attention should be 
 directed to the health, so as to amend the temporary derange- 
 ment. They must be advised to select a China or Ceylon tea,
 
 152 Insomnia and its Therapeutics. 
 
 preferably the former, as it contains less tannin (p. 648); to 
 infuse it only five minutes; and not to drink it too hot. It 
 might be mentioned that 2 per cent of the bicarbonate of soda, 
 as suggested by Sir William Roberts, to counteract the effects 
 of the tannin, may be added to the tea* that is, about one 
 grain to each ordinary spoonful. 
 
 3. This embraces a class of persons who possess nervous sys- 
 tems either congenitally feeble or weakened by various debili- 
 tating causes. For example, many young persons of a neurotic 
 diathesis, and neurasthenics and d3 T speptics, are peculiarly 
 sensitive to the use of tea of all kinds, even in small quantities. 
 These persons are liable to exhibit the same train of symp- 
 toms as accrues from the abuse of tea. In this class the tea 
 is not at fault at all; it simply renders more apparent a de- 
 parture from health already existing. A man toiling into the 
 night may be rendered wakeful by tea, but it must not be 
 overlooked that he might have been wakeful without it. 
 There is little doubt that tea has to bear more blame than 
 it is entitled to. In every case where it appears to unduly 
 disturb sleep the state of the health should be narrowly 
 scanned. 
 
 In such cases the use of tea must be interdicted, and means 
 adopted to remedy the enfeebled condition. 
 
 4. This includes a number of persons of both sexes and of all 
 ranks of life, who have acquired a tea-drinking habit, and who 
 suffer from sleeplessness as a symptom of their excesses. The 
 symptoms they exhibit are all referable to the brain and 
 nervous system. These may be stated thus : sleeplessness, or 
 sleep disturbed by dreams or nightmare; headache; irrita- 
 bility of temper, developing in some instances into hysterical 
 excitement; depression; hypochondriasis; disorders of the 
 special senses, auditory and visual disturbance (a form of tea 
 amblyopia has been described); neurosal palpitation; dys- 
 pepsia; intestinal torpor, with its concomitant symptoms of 
 flatulence and constipation; neuralgia, and muscular enfee- 
 blement and tremors follow. 
 
 In these cases the use of tea must either be abandoned 
 altogether or reduced to the lowest possible point. If any is 
 taken it should be weak, and neither long infused nor too hot. 
 The following will be found a useful remedy.
 
 Insomnia and its Therapeutics. ,153 
 
 3 Liq. strychn., . 3 i. 
 
 Tinct. quinin., . . . . . . 3 vi. 
 
 Spt. ammon. arom., . . . 3 vi. 
 
 Aq. chlorof., . . , . ._ ad vi. 
 M. Sig. Take a tablespoonf ul thrice daily in water. 
 
 For four or five nights four grains of the monobromide of 
 camphor may be given. As tea is nob a cumulative poison it 
 is soon eliminated from the system. 
 
 [It may not be out of place to add a few remarks on the 
 various teas met with in commerce. For much of the informa- 
 tion they contain the writer is indebted to Mr. G. Morison. 
 
 China teas may be divided into three large classes. 
 
 Green Teas. These owe their peculiar properties to their 
 mode of manufacture rather than to any constituents they 
 originally contain. Black tea could be manufactured from the 
 same leaves, and this would be devoid of many of the char- 
 acteristic properties of green tea. The chief varieties are 
 Pinhead Gunpowder, Young Ifyson, Gunpowder and Hyson. 
 The first two are the finest. They are now little used in this 
 country. Practically they are not put into blended teas except 
 by special request. Consequently, the sleeplessness induced 
 by some teas is not to be largely accounted for by the presence 
 of green tea. A large proportion of the green tea sold in 
 London for home use is consumed in the district of which Not- 
 tingham is the centre. 
 
 Scented Teas. These consist of Caper, Canton, and Foo- 
 chow, Orange Pekoes, and Oolong. The first two are scented 
 with jessamine, orange blossom, etc. Tea very readily absorbs 
 the flavor or perfume of adjacent articles. These scented 
 teas, which are tolerabty astringent, are used chiefly in Eng- 
 land for blending purposes, imparting, as they do, point and 
 pungencjr. They are most largely consumed in the great 
 centres of Birmingham, Manchester, and Nottingham. 
 
 Black Teas. These teas are divided into two large classes, 
 Kaisow and Moning, which are again subdivided. 
 
 Kaisow : this embraces the Seumoo, Sueykut, Ching Wo, 
 Paklin, Lapsen-Souchong, Paklum, and Newmake. 
 
 Moning : this includes Kintuck, Ningchow, Oonfa, Kutoan, 
 and Shamtam, the last name suggesting the lowest quality. 
 
 The names of many familiar teas will be found wanting
 
 154 Insomnia and its Therapeutics. 
 
 from these lists, for the reason that they have disappeared 
 from commerce. The black teas of China are much used in 
 Great Britain. They are not too astringent. The better 
 qualities are full-bodied and aromatic. The Ching Wo and 
 Kintuck have probably the most flavor. 
 
 Indian Teas. These are in great request in this country. 
 They probably represent one-half of the whole tea consumed. 
 They come principally from Assam, Cachar, Sylhet, Darj eel- 
 ing-, andKangra Valley, although a quantity also comes from 
 Neilgherry and Travancore. 
 
 They are all more astringent than China teas ; the Assam 
 most of all (see p. 648). The Cachar and Sylhet are not so 
 pronounced in character. The Darjeeling, Neilgherry, and 
 Kangra Valley teas are chiefly used for flavoring, though they 
 are sometimes drunk alone, which the others could not well 
 be. Indian as well as Ceylon teas are divided into classes 
 according to the leaves from which they are obtained. The 
 smaller or younger leaves, being more succulent than those 
 which are fully grown, yield the finest teas. In order of value 
 they are met with in commerce as Broken Pekoe, Pekoe, Pekoe- 
 Souchong, and, the lowest quality, Souchong or Congou. 
 Broken Pekoe contains the tips, Pekoe the first three leaves 
 of the plant, Pekoe-Souchong the leaves of older growth. 
 
 Ceylon Teas. These are much in request owing to their 
 soft, silky, and pleasant flavor. They are often drunk with- 
 out being blended. They are more astringent than China, but 
 less so than Indian teas. 
 
 Java Teas. These teas have of late years been imported 
 in considerable quantity into this country for mixing and 
 blending purposes. Being unusually good-looking teas, they 
 improve the appearance of China and Indian teas. On ac- 
 count of their unpleasant flavor they are seldom drunk alone.] 
 
 Tobacco. Much difference of opinion exists as to the 
 benefits derived from tobacco in moderation. Many consider 
 it obnoxious, but, on the other hand, it is difficult to believe 
 that such a widely-spread custom as smoking, carried on 
 through centuries, should be specially deleterious. 
 
 Many aged persons have smoked throughout their lives 
 not only with impunity but apparently with advantage. In 
 the statistics accumulated by the Collective Investigation
 
 Insomnia and its Therapeutics. 155 
 
 Committee of the British Medical Association, thirteen out of 
 forty-five centenarians used tobacco. Seven smoked much 
 (four females); two smoked little (one female); three smoked 
 moderately (one female); while one chewed tobacco. 
 
 Used in nioderation, it probably promotes sleep in the ma- 
 jority of persons, many finding 1 a pipe or cigar before going to 
 bed indispensable. There is a minority upon whom tobacco 
 always acts deleteriously, and whose sleep is disturbed by it. 
 This disparity depends upon the stability of the nervous sys- 
 tem of the smoker, and to some extent on the strength of the 
 tobacco. 
 
 The first effect of tobacco on the nervous sj^stem is that of 
 a stimulant; the second, that of a depressant. In excess it 
 causes headache, mainly occipital; giddiness; mental depres- 
 sion; and in some instances it impairs the senses of hearing 1 , 
 smell, and vision ; in the latter case, amblyopia and scotoma 
 are met with. Sleeplessness is a frequent symptom, and it 
 usually appears about four A.M. Depressing- the great centres 
 in the medulla oblongata, it leads to vaso-motor paresis, and 
 to defective innervation of the heart, lungs, and digestive 
 organs. Affecting- the spinal cord and nerves, it produces 
 trembling- and weakness of the limbs. 
 
 Sleeplessness is due jointly to vaso-motor paresis, cardiac 
 enervation, and digestive derangements. 
 
 It is most commonly met with in smokers who have reached 
 middle life, whose nervous systems are beginning- to feel the 
 strain of work, or whose metabolism is being imperfectly per- 
 formed on account of a defective liver. The diagnosis is as- 
 sisted by the aspect of the patient, who generally presents 
 some symptoms of vaso-motor paresis. 
 
 Treatment. This consists in avoiding tobacco. As it is 
 not a cumulative poison it is quickly eliminated from the sys- 
 tem. For a few nights the wakefulness may be increased, but 
 sleep will soon return. During these nights the administra- 
 tion of four grains of the inonobromide of camphor is desirable. 
 Tonic remedies are called for to restore the tone of the nerv- 
 ous system generally.
 
 CHAPTEE IX. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 ALIMENTARY CANAL. 
 
 GASTRIC DYSPEPSIA. 
 
 SLEEPLESSNESS, more or less pronounced, is a common if 
 not constant symptom of every variety of digestive derange- 
 ment. It occurs in the acute attack which follows an occa- 
 sional indiscretion in -eating 1 ; likewise in many chronic forms, 
 and in these latter it may be the sole symptom of the derange- 
 ment. 
 
 Sleeplessness of the most obstinate and intractable kind 
 can be initiated and perpetuated by diverse dyspeptic condi- 
 tions, so obscure in their nature as to elude detection for 
 lengthened periods of time. In short, it may be caused by 
 many disorders arising primarily in the alimentary tract, and 
 by others, induced secondarily by disturbances (as fevers, etc.) 
 in the economy. 
 
 The analysis of insomnia from such causes is so intimately 
 and inextricably associated with the whole question of diges- 
 tion, that at the risk of appearing to digress from the subject 
 immediately under consideration, it is proposed to review 
 some points bearing upon the physiology and pathology of 
 the processes of digestion. This is the more called for when 
 we reject that it is only by unravelling the nature of the dis- 
 order, and by instituting a well-matured plan of treatment 
 for its rectification, that the sleep disturbance its symptom 
 can be successfully alleviated. To attempt to deal with 
 such cases by means of hypnotics or narcotics, the majority 
 of which tend to derange the secretions, is worse than useless. 
 It is to court failure and to aggravate the evil. For the un- 
 conscious and perfect performance of digestion, certain condi- 
 tions are essentially necessary. Integrity of all the structures 
 concerned : stomach, liver, intestines, and the various secre-
 
 Insomnia and its Therapeutics. 157 
 
 tory glands. A vigorous nervous system. A normal blood 
 supply. Healthy secretion. Suitable ingesta. When either 
 one or more of these requisites fail, digestion is imperfect, and 
 consequently leads, among other evils, to insomnia. 
 
 We must now proceed to study the causes of dyspepsia in 
 the order given, with special reference to their influence upon 
 the character and amount of sleep. 
 
 Defective Structures. All inherent or acquired debility of 
 the stomach, as well as any abnormality in the viscus, initiates 
 dyspepsia. Among the abnormal conditions may be enumer- 
 ated, alterations in size, such as contraction from prolonged 
 fasting and other causes. Dilatations, either primary, from 
 enfeeblement of the muscular walls, which may not only inter- 
 fere with their contractile po\ver, but permit of distention of 
 the viscus under certain circumstances; or, secondary, from 
 organic obstruction of the pylorus. Atrophy or hypertrophy 
 of the walls, and cancerous growths, must be mentioned; as 
 likewise affections of the mucous membrane, e.g., catarrhal, 
 inflammatory, ulcerative, and degenerative changes. These 
 latter may not be accompanied by marked symptoms, as the 
 mucous membrane (except near the orifices) is comparatively 
 little sensitive. 
 
 In like manner all alterations in the calibre and structures 
 of the intestines become disturbing agents, while modifications 
 of the secretory glands, and impairment of the tissues of the 
 liver, uniformly lead to faulty hepatic, intestinal, and gastric 
 digestion. 
 
 When the tissues are all inherently strong, they are capa- 
 ble of discharging their functions easily and well; if one is 
 weak, the strength of the whole is impaired. 
 
 Defective Nervous Arrangements. Central. The whole 
 evolution of digestion is under the dominion of special nervous 
 centres, and of cerebro-spinal and sympathetic nerves. The 
 presence of food in the mouth instigates afferent impulses 
 which are transmitted along cerebro-spinal nerves to the 
 medullary centres; these reflexly produce hyperaemia of the 
 salivary glands, and excite a flow of saliva. When the food 
 passes into the stomach impressions similarly aroused are con- 
 veyed by the vagi, which reflexly institute congestion of the 
 gastric glands, and as the result of the stimulation, gastric 
 juice is poured out. Like arrangements control and regulate
 
 158 Insomnia and its Therapeutics, 
 
 the periodic formations of bile, and of the pancreatic and in- 
 testinal juices. 
 
 A stable nervous system is required for the adequate in- 
 nervation of the secretory glands, so that the various secre- 
 tions may be normally excited (and not over-excited) by the 
 normal stimuli. The medullary centres which control the 
 secretory functions are themselves dominated by the highest 
 centres in the brain. The psychical centres are in concord 
 with the whole digestive metamorphoses, each one reacting 
 on the other. 
 
 Acute psychical disturbance, e.g., fright, is able to arrest 
 digestion at any stage. It can inhibit the vaso-motor adjust- 
 ments, and incite contraction of the arterioles of the various 
 secretory glands, and .so cause arrest of the secretions. In 
 the case of the salivary glands this is indicated by the dry- 
 ness or stickiness of the tongue, which is popularly spoken of 
 as sticking to the roof of the mouth. The gastric glands 
 evince the same disturbance. The late Dr. Beaumont has re- 
 corded among his observations upon the person of Alexis 
 St. Martin (a young Canadian, the subject of a gastric fistula), 
 that mental emotion checked the secretion of the gastric 
 glands, and that the villous coat of the stomach became dry 
 and red, and at other times pale and moist, having lost its 
 smooth healthy appearance. 
 
 Less sudden mental activity, such as overwork, anxiety, 
 grief, worry, etc., acts similarly, and if more slowly, not less 
 surety. Sensations produce different effects in accordance 
 with their character. Depressing emotions delay and derange, 
 while pleasurable sensations quicken and promote, digestion. 
 Conversely, digestive derangements react upon the brain, 
 causing depression, irritability, and restlessness, as well as 
 headache, giddiness, and disorders of the special senses. 
 
 From this it is obvious that if impressions originated in 
 deranged processes, and conveyed to the brain during waking 
 moments, can occasion such decided effects, then sensations 
 produced by like phenomena, and similarly transmitted dur- 
 ing sleep, must necessarily disturb the repose of the brain, 
 and lead to molecular movements in the cells, and to a conse- 
 quent hypersemia: this is specially true when the cells are 
 irritable and impressionable. 
 
 Everything that interferes with the integrity and nutrition
 
 Insomnia and its TJicrapeutics. 159 
 
 of the nervous system leads to digestive derangements. This 
 is frequently seen in cases of exhaustion of that system brought 
 about by insomnia from whatever cause. It is often notice- 
 able in middle age, when the effects of the strain of life begin 
 to tell upon the structures. Many intractable dyspepsias, 
 characterized "by extreme pain and bulimia, originate in the 
 enfeeblement induced by fatigue, excesses, and debilitating 
 diseases. 
 
 The nervous system, in addition to governing the forma- 
 tion of the various ferments, presides over the churning and 
 peristaltic muscular movements of the stomach, which are 
 essential for the efficient chymification of the food. These 
 movements begin shortly after the food enters the viscus, and 
 cease when gastric digestion approaches completion, when the 
 P3'lorus, relaxing, permits the contents to be discharged into 
 the duodenum, where the movements are propagated through- 
 out the intestinal canal. Although these peristaltic contrac- 
 tions are under the control of special ganglionic plexuses in 
 the muscular coats of the stomach and intestines, they are 
 likewise influenced by the vagi. Fright can arrest them alto- 
 gether, or excite them so as to produce diarrhoea, by unduly 
 hastening the transit of the intestinal contents. Conversely, 
 during sleep, disorderly or arrested movements occurring 
 before the completion of digestion initiate sensations which 
 are transmitted to the brain and bring about awaking. 
 Enervation of the system impairs the movements, and this is 
 a frequent cause of slow digestion, constipation, and of flatu- 
 lent distention of the stomach and bowels. 
 
 Peripheral. Undue irritability of the nerve endings may 
 cause pain and gastric discomfort. The nerves being com- 
 posed largely of fibres, which permit of 'considerable dispersion 
 of the nervous currents, pain is obscurely and indefinitely de- 
 scribed and localized ; var3 7 ing from mere uneasiness, a feeling 
 of weight, and gnawing, to excruciating even agonizing 
 pain; while it may radiate through the chest and abdomen, 
 through the shoulders and down the limbs. The time of its 
 onset in relation to food is very often indicative of its cause, 
 as in ulceration. (It seems probable that modification of the 
 terminal endings of the nerves causes the large and abnormal 
 appetite which occurs in some forms of dyspepsia.) Excessive 
 n\uscular movements may be excited by poisons and irritating
 
 160 Insomnia and its Therapeutics. 
 
 ingesta; or they may be paralyzed by causes, such as peritoni- 
 tis, gastric and enteric ulcers. Locally limited by tight lac- 
 ing, and the constrained postures necessitated by some occupa- 
 tions. Interfered with by growths in the walls of the stomach, 
 by dilatations of the stomach, and by adhesions in the abdo- 
 men. 
 
 In health the complex functions of the nervous S3 r stem 
 connected with digestion are executed so unconsciously that a 
 man would not be aware he possessed a stomach were it not 
 for the recurring sensations of hunger. 
 
 During sleep, digestive functions are practically suspended, 
 the medullary centres relax their activity, digestive fluids are 
 not secreted, and the movements of the gastro-intestinal canal 
 almost, if not entirely, cease. This cessation of movement 
 affords a strong argument against sleeping after meals. 
 Everything which prevents the digestive quiescence induces 
 disturbed sleep. 
 
 It has already been pointed out that external stimuli ap- 
 plied to the body during sleep produce contraction of the 
 cutaneous arterioles and a concurrent cerebral hyperaemia. 
 Internal influences act in a similar way. The vagi convey 
 sensations arising from internal derangements to their roots 
 in the medulla, and these sensations, extending to the adja- 
 cent centres, instigate cerebral hyperaemia, which awakens 
 the steeper. For example, if a man takes a large and indi- 
 gestible meal shortly before going to bed, when he falls asleep 
 the circulation of the blood becomes slower, and the move- 
 ments of the stomach abate; digestion is arrested. Impres- 
 sions originated by this interruption produce, in the manner 
 described, cerebral congestion and consequent activity, and 
 as the influx of blood affects the motor or psychical centres, it 
 occasions diverse symptoms. The sleeper becomes restless and 
 dreams, or suffers from nightmare or sleep-walking, or he 
 may awake to find himself feverish and oppressed, and tossing 
 from side to side, or turning round and round as if he were 
 trying to convert himself into a wheel. Eventually, the nerv- 
 ous impressions spread to, and affect, the centre for vomiting; 
 under its co-ordinating influence emesis occurs, and relieves 
 the stomach of its disturbing contents. The origo mail being 
 removed, the cerebral circulation becomes quiet, and sleep re- 
 turns.
 
 Insomnia and its Therapeutics. 161 
 
 When the derangement is more pronounced, sleep may be 
 prevented; when it is less marked, restlessness and dreams 
 are the only features. Many cases of wakefulness, lasting- for 
 two or three hours during- the night, are due solely to arrested 
 muscular movements in the stomach or in the intestines. 
 
 It goes without saying- that such sleep disturbance is more 
 commonly met with in those whose digestive arrangements 
 are weak, and liable to become deranged. 
 
 Dyspepsia may be instigated through the ramifications of 
 the nervous system in sympathy with other organs. For ex- 
 ample, gastric symptoms are of common occurrence in connec- 
 tion with diseases of the heart, kidneys, and uterus, and they 
 thus act secondarily as disturbers of sleep. 
 
 Abnormal Vascular ization. The constituents of the vari- 
 ous digestive juices being obtained from the blood (the late 
 Dr. Chambers wrote: "The daily quantities of these fluids, as 
 estimated, mainly, from the results of Drs. Bidder and Schmidt's 
 experiments, may be reckoned, at least, to equal the following : 
 Of saliva, 3| pints; of gastric juice, 12 pints; of bile, 3| pints; 
 of pancreatic juice, 1 pints; of intestinal juice, ipint; mak- 
 ing in all nearly three gallons "), it is essential for the forma- 
 tion of these fluids that the glands which elaborate them, 
 should, in response to proper stimulation, become hyperasmic. 
 If the supply of blood is deficient in quantity or altered in 
 quality, the constitution of the juices suffers corresponding 
 modifications. Coincident with the onset of digestion, a great 
 influx of blood takes place into the vessels of the stomach, 
 which, besides contributing to the formation of the gastric 
 juice, stimulates the muscular movements of the viscus. 
 
 Probably the consequent depletion of the distant parts ex- 
 plains the chilliness of the extremities, and the drowsiness, 
 which sometimes follows a full meal. 
 
 If anything deprives the stomach of an adequate san- 
 guineous supply, such as happens when active brain-work en- 
 tailing hyperaemia is continued during and immediately after 
 meals, digestive derangements ensue. 
 
 On the other hand, abnormal and persisting determination 
 of blood to the stomach or intestines becomes a source of dis- 
 turbance, by occasioning catarrhal and inflammatory diseases 
 of the mucous membrane of the stomach, e.g., in alcoholic ex- 
 cess. Dr. Beaumont observed in St. Martin that stimulating
 
 1 62 'Insomnia and its Therapeutics. 
 
 liquors and overloading- the stomach led to these vascular 
 derangements, occasionally causing- red spots and abraded 
 patches on the mucous membrane; at other times, deep red 
 patches from venous congestion. In these catarrhal condi- 
 tions mucus is formed, which delays digestion by coating the 
 food and preventing the gastric juice from acting upon it. 
 
 Passive congestion of the stomach and bowels, depending 
 upon obstruction to the free return of blood to the heart, such 
 as occurs in some diseases of the heart and liver, occasions 
 digestive troubles, and at times increased peristaltic move- 
 ments. 
 
 When the blood supply is altered, as in anaemia, in which 
 there is an insufficiency of oxygen-carrying corpuscles, or 
 when it is imperfectly aerated by vitiated air, or laden with 
 the materies morbi of a disordered metabolism, as in gout, di- 
 gestion is invariably imperfect. Blood charged with peptones, 
 digestive products (ptomaines?), or with uric acid, is unsuit- 
 able alike for the digestive processes and for cerebral nutri- 
 tion. To this subject we must revert presently. 
 
 In the majority of Cases of insomnia arising from gastric 
 dyspepsia it seems almost certain that there is no marked 
 mal-nutrition of the cerebral cells; consequently, they are not 
 unduly perceptive. On the contrary, they are only aroused 
 into activity by sensations sufficiently pronounced to disturb 
 sleep under normal conditions. 
 
 In a minority of such cases, a close study of their peculiar- 
 ities, renders it probable that they are brought about by the 
 morbid products of a deranged digestion entering the circula- 
 tion and so affecting the cerebral cells as to cause awaking. 
 
 The influences of such blood on the bodily tissues can be 
 well studied in the various affections of the skin, which so fre- 
 quently appear in their train. 
 
 Faulty Secretion. The secretions are individually and rel- 
 atively important, effecting, as they do, the chemical changes 
 in digestion. If the digestive changes are to be satisfactorily 
 accomplished in the aggregate, each ferment must in rotation 
 perform its proper and adequate share of the work. The 
 saliva dissolves the saline matters, and converts the starches 
 into dextrin and maltose; the gastric juice acts on the pro- 
 teids or the albuminoids, and changes them into true peptones, 
 etc.
 
 Insomnia and its Therapeutics. 163 
 
 When food is eaten hurriedly, and saliva consequently not 
 secreted in adequate amount, a twofold error is instituted. 
 The food starches are not broken up and changed by the dias- 
 tase into dextrin, etc. When the food is swallowed, the de- 
 ficient quantity of saliva fails to stimulate the flow of gastric 
 juice, for, like all weak alkalies, it is a powerful stimulant of 
 that peptic fluid. The insufficient gastric juice fails to con- 
 vert all the proteids into peptones, so that practically the 
 grea.t bulk of the starches, albuminoids, and fats are passed 
 undigested into the intestines, where the pancreatic and in- 
 testinal fluids have to perform, unaided, the whole metamor- 
 phosis. 
 
 In robust health these secretions may be able to overtake 
 this work, but when weakness leads to their scanty formation 
 they fail, and, fermentation and putrefactive changes ensuing, 
 still further complications follow. 
 
 Secretions deficient in Quantity. Each of the digestive 
 fluids may be secreted in too scanty amount. It will suffice 
 to illustrate this by referring to the saliva and gastric juice 
 only. They are scanty in febrile diseases, as well as in some 
 affections of the nervous system. 
 
 Excessive in Quantity. The saliva is increased in certain 
 exhausted conditions. Sir William Roberts believes that py- 
 rosis is merely a paroxysmal neurosis, which depends upon an 
 acid condition of the stomach, causing copious gushes of saliva 
 into the mouth. In certain catarrhal conditions of the stom- 
 ach, e.g., the alcoholic, saliva is formed in excess; it either 
 dribbles on to the pillow, or is unconsciously swallowed during 
 sleep. The gastric juice is frequently secreted in abnormal 
 quantities, giving rise to acidity of the stomach. This appears 
 to be particularly the case when the nervous system is faulty. 
 
 Morbid in Quality. In fevers the saliva may be acid, 
 and, in consequence, devoid of its diastastic power; this also 
 may be the case in diabetes. The gastric juice occasionallj- 
 contains abnormal proportions of hydrochloric acid and pep- 
 sin, or either too much or too little acid, the one condition 
 delaying digestion as much as the other. In some feverish 
 states it exercises no influence on digestion at all. Occasion- 
 ally organic acids may be formed in the stomach: that of 
 acetic fermentation will be immediately referred to; that aris- 
 ing from the fermentation of grape or cane sugars, starches or
 
 164 Insomnia and its Therapeutics, 
 
 milk, forming lactic acid, while that depending upon the ran- 
 cidity of fat, forms butyric acid. Both these are instigated by 
 the presence of organisms, and may, of themselves, cause 
 catarrhal conditions to arise. Such acrid and disordered con- 
 tents irritate the nerve endings and cause sensations inimical 
 to sleep. 
 
 These fermentative changes lead to formations of large 
 quantities of gas, which, prevented from escaping by the 
 closed pyloric opening, sometimes lead to dilatation of the 
 stomach. 
 
 Flatulence usually indicates slow digestion. Butyric acid 
 causes heartburn by irritating the cardiac end of the gullet. 
 
 We shall require, hereafter, to refer to derangements of 
 the biliary, pancreatic, and intestinal secretions. 
 
 Unsuitable Ingesta. All food should have some propor- 
 tionate relation to the age, temperament, and occupation of 
 the individual, and to the weather and climate. 
 
 In the young, when growth and waste are equally rapid, 
 and digestion is vigorous, much food is relatively required; in 
 adult life, when growth is completed, and waste and repair 
 alone need to be daily balanced, less food is necessary; in the 
 aged, when repair is effected with difficulty, a yet smaller 
 quantity of nourishment is wanted. 
 
 Men of sanguine temperament, usually possessing vigorous 
 digestions, have occasion for more food than those belonging 
 to the lymphatic or neurotic classes. The food of neurotics 
 should always be carefully arranged, because, while they re- 
 quire to be nourished up to the limit of their digestive powers, 
 if that be exceeded it causes derangements. 
 
 The physically active need more food than those who pur- 
 sue sedentary occupations. A highland deer-stalker, trudg- 
 ing all day in invigorating air, can consume and digest food 
 in quantity and quality utterly unsuited to a clerk spending 
 the bulk of his life in an imperfectly oxygenated atmosphere. 
 A man hunting five days a week can eat with impunity articles 
 of diet he cannot digest at all while leading an inactive life in 
 town. A lady can frequently digest better during the season 
 when she is dancing for several hours almost every night, 
 than when she is leading a less active life. In consequence, 
 such persons sleep more soundly. Food should be modified 
 according to the temperature of the weather, just as it re-
 
 Insomnia and its Therapeutics. 165 
 
 quires adaptation to different climates. The Briton has found 
 by experience that he can only maintain his health when 
 residing 1 in extreme climates by adopting 1 , in a large measure, 
 the food of the country. 
 
 Overfeeding is a common source of Dyspepsia. A man 
 who habitually eats more than is required to compensate his 
 mental and bodily waste and it is a prevalent error throws 
 a tax upon his digestion. While he is vigorous, and his powers 
 are in excess of his absolute requirements, it may not cause 
 him any inconvenience, particularly as a certain proportion 
 of the food evades digestion, and escapes with the faeces ; but 
 whenever anything occurs, such as overwork, to disturb or 
 decrease his energies, digestion fails, and troubles begin. 
 
 if the food consists of a superabundance of albuminoids, it 
 may not be all chang-ed into true peptones, and these elements, 
 putrefying in the stomach, give rise to eructations of sulphu- 
 retted hydrogen. Fats in excess retard digestion, and often 
 give rise to butyric acid fermentation. 
 
 Unlimited quantities of fluid are injurious by diluting the 
 gastric juice; very hot liquids, though at first stimulating, 
 eventually enervate the mucous membrane. Iced fluids dis- 
 turb digestion, by contracting the arterioles of the stomach, 
 and by lowering the temperature below the point (98-100 
 Fahr.) necessarj 7 " for perfect digestion. 
 
 Dyspepsia in children, from eating rich and tempting food 
 in excess, is a common source of sleeplessness. 
 
 Underfeeding. Among the poorer classes indigestion is 
 largely caused by the habitual use of tea and bread, which 
 they consume abundantly on account of their cheapness; the 
 temptation to do so being increased by the facts that tea is 
 easily prepared, the appetite is appeased, and a feeling of 
 well-being is sustained for a long time, evidently by its retard- 
 ing digestion. These persons are practically semi-starved, as 
 such a diet does not contain all the essentials necessary for 
 the nourishment of the economy. 
 
 Among the richer classes it is not uncommon to meet with 
 instances in which the amount of food is voluntarily limited. 
 Afraid of growing stout, they curb, their appetites, eat little 
 or no luncheon, and take only a meagre dinner; and this habit 
 tends to grow until a positive dislike to food occurs. Such 
 men become dyspeptic and neurasthenic.
 
 1 66 Insomnia and its Therapeutics. 
 
 Men actively engaged in business often forget to eat lunch- 
 eon; the accustomed hour passes and with it the appetite 
 disappears. Ladies are culpable in this respect. All forms of 
 slight starvation affect the nervous system, the enfeeblement 
 of which leads to dyspepsia from defective innervation. 
 
 Children suffer occasionally from insufficient nourishment, 
 chiefly from improper feeding, or from the milk they get being 
 defective in quality. They grow restless, feverish, and sleep- 
 less, and cry unceasingly, the crying in many cases being sug- 
 gestive of the cause of their discomfort; they are soothed and 
 fall asleep when suitably fed. It seems probable that many 
 infants have their sleep disturbed by lying on the left side 
 after taking a full meal. 
 
 Unsuitable Food. Food insufficiently and improperly 
 cooked, as well as that difficult of solution, causes dyspepsia. 
 The object of cooking is to develop the flavor, and render the 
 foods acceptable to the senses of taste, smell, and sight, so 
 that they may, through the agency of the mind, as well as 
 reflexly through the mouth and palate, excite the flow of the 
 various secretions; it also aims at changing the structure and 
 composition of the food, so as to render it more easy of diges- 
 tion. It has the disadvantage, in some instances, of tempting 
 the person to eat too much; this is specially the case in those 
 who lead luxurious and inactive lives. 
 
 Raw starch is exceedingly difficult to digest. Cooking 
 bursts its cellulose capsules, swells up its contents, and exposes 
 them to the action of the salivarj 7 " ferment which transforms 
 them into maltose. So with vegetable matters; they are 
 swelled up and softened by boiling, and are thus more easily 
 acted upon by the digestive fluids. The texture of animal 
 food is changed by cooking, the connective tissue is softened, 
 and its muscular fibres lose their cohesion; so that it can be 
 triturated and minutely disintegrated by mastication, and 
 prepared for gastric digestion. 
 
 Lumps of food bolted hurriedly arrest gastric secretion, 
 and so may originate circulatory modifications which may 
 induce wakefulness. The looseness of texture in meat is most 
 marked after an animal is killed, before the after-death stiff- 
 ening sets in; and secondly after it has been kept for some 
 days. Every one can appreciate the difference in digestibility 
 which distinguishes tender, juicy, and well-cooked beef from
 
 Insomnia and its Therapeutics. 167 
 
 that which is tough, stringy, and dry, though it may have 
 been cooked with equal care. This difference depends upon 
 the keeping. 
 
 Meat, poultry, and particularly game ma3 r be kept too 
 long; after the textures are relaxed changes occur, which cul- 
 minate in putrefaction. Such meats are poisonous. Cheese 
 and many other articles of diet undergo decay and become 
 noxious. 
 
 All badly-cooked meats are indigestible. The partaking 
 of too many articles of food at one meal is a frequent source 
 of trouble. A man may be able to eat and digest a full meal 
 of bread and cheese, who would experience great discomfort 
 from a mere morsel of cheese taken at the end of a large din- 
 ner. It is nevertheless probably true that the quantity taken 
 has more to account for than the quality, if consumed in strict 
 moderation. Many substances are indigestible and are better 
 avoided, such as pastry and unripe fruit. Condiments and 
 hot spices are injurious in excess. Stimulants taken to excess 
 cause h3 r peraemia of the stomach with increased secretion of 
 mucus. Sir William Roberts found that spirits in modera- 
 tion did not retard digestion, but that sherry did so in a very 
 marked way; port, claret, hock, and champagne also did this 
 in an increasingly less degree in the order given; he found 
 that Burton ale retards digestion, and also tea and coffee. 
 Spirits and wine give rise to dyspepsia when taken in an in- 
 judicious quantity, or when many varieties are mixed. They 
 not unfrequentiy produce acetous fermentation by the trans- 
 formation of the alcohol into aldehyde after giving off some 
 acetic acid. 
 
 Defective Arrangement of Meals. Some people content 
 themselves with two large meals daily, breakfast and dinner; 
 eventually they find themselves unable to digest the latter. 
 This arises from defective innervation of the processes and 
 from deficient and defective secretions; their blood, the source 
 of the secretions, being impoverished, fails to furnish the 
 proper constituents. After a late and large meal their condi- 
 tion is one of exhaustion combined with a surfeit of food, which 
 is fatal to sleep. When the last meal is taken too long before 
 going to bed it often causes sleeplessness from want, though 
 there may be no sensation of hunger. Frequently repeated 
 meals are quite as injurious as too infrequent.
 
 1 68 Insomnia and its Therapeutics. 
 
 Each full meal requires four or five hours for its complete 
 digestion; to crowd in food, in the intervals, is to disturb and 
 render incomplete the digestive processes. Taken for the 
 purpose of building- up strength, it defeats its object and be- 
 comes a source of weakness. In health, all fillips between 
 meals are best eschewed. It must be added that in many dis- 
 eases, as inflammations, fevers, etc., improper feeding gives 
 rise to deranged digestion ; and this is of importance in this 
 inquiry, as the sleeplessness which so frequently attends these 
 ailments is more commonly due to dyspepsia than is supposed, 
 and this form of sleeplessness only yields to the treatment of 
 what may be designated the subsidiary disorder. An over- 
 loaded stomach in such cases completely prevents sleep, until 
 vomiting relieves it of its burden. 
 
 Idiosyncrasies. Many cases of dypspesia arise in persons 
 from eating articles of food, not ordinarily difficult of diges- 
 tion, but to which, from some peculiarity in their constitution, 
 they are intolerant. Many seem to be unable to digest fat, 
 milk, eggs, cheese, shellfish, mackerel, onions, and such like 
 common dietetic articles, and if perchance they partake of 
 them it is at the cost of sleep. The majority of persons who 
 exhibit such idiosyncrasies are either neurotic or gouty. They 
 suffer most in advancing years. They display a like intoler- 
 ance to the use of many drugs, so that their medication is 
 rendered difficult. 
 
 Having thus touched upon some of the causes of disordered 
 digestion, a passing reference must be made, from a diagnos- 
 tic standpoint, to a few of the symptoms which usually char- 
 acterize the recognized forms of gastric derangement. 
 
 Symptoms of Dyspepsia. The tongue is large, teeth- 
 indented, sodden, and covered by a white fur in derangements 
 arising from atonic conditions of the system; it is clean and 
 froth} 7 in neurasthenic states. It is foul and thickly furred, 
 with red tip and prominent papillae, and associated with red- 
 ness of the gums and throat and dryness of the lips, in catar- 
 rhal affections of the stomach. When the catarrh has arisen 
 from alcoholic excess, the tongue trembles on being protruded. 
 It is clean, red, and glazy in certain cases of irritative dyspep- 
 sia; and coated with a blankety fur when derangement de- 
 pends upon excessive smoking. 
 
 The breath is offensive in catarrhal conditions, and more
 
 Insomnia and its Therapeutics. 169 
 
 or less heavy in all derangements, the mouth having", in many 
 cases, a clammj' disagreeable taste in the morning-. 
 
 The appetite is increased in neurasthenic dyspepsia to such 
 an extent as to amount, in some cases, to a craving- for food, 
 which eating- and drinking- temporarily alleviate. 
 
 It may be increased in certain catarrhal states, in which 
 there is usually a preference for highlj" -seasoned dishes and 
 savories, thirst being- very marked. It is often fairly good in 
 atonic dyspepsia, but thirst is uncommon. It is decreased in 
 acute gastric catarrh, and in derangements depending upon 
 diminished secretions; while it is perverted in hysteria, preg- 
 nancy, etc., arising either from central or peripheral irritation. 
 
 Epigastric discomfort, depending upon the accumulation 
 of gas in the stomach, and amounting to a sensation of dis- 
 tention and oppression, is common in atonic dyspepsia, when 
 the muscular movements of the viscus are sluggish, two or 
 three hours after meals. It may be so marked as to require 
 the clothes to be loosened for its relief; occurring during the 
 night, it leads to sleep disturbance. The nature of the eructa- 
 tions, voluntary or involuntary, affords a guide to the fer- 
 mentative process; the gas may be tasteless, simply carbonic 
 acid, or sour, when the contents of the stomach are acid, etc. 
 
 Acidity combined with flatulence is an indication of slow 
 digestion. The aciditj r may arise from an excessive secretion 
 of gastric juice, or from the formation of an abnormal acid. 
 
 Pain ranges from mere discomfort, which is seldom want- 
 ing in any case, up to severe excruciating pain. It is most 
 severe in the neurosal complaints, and in central affections, 
 such as hypochondriasis. The pain, in acute catarrhal ail- 
 ments, is variable, but it can always be elicited by pressure. 
 In chronic gastric catarrh it may amount only to uneasiness, 
 and be temporarily relieved by eating and drinking. Pain 
 from ulceration comes on quickly after food is taken; from 
 chronic atonic dyspepsia, in two or three hours, being mostly 
 associated with defective secretions. In functional disorders 
 it is not aggravated by food ; when it comes on during the 
 night it is usually from arrested or irregular muscular move- 
 ments, and from distention with flatulence. Pain referred to 
 the stomach is not always due to derangements of digestion. 
 
 Vomiting occurs in acute gastric catarrh shortly after 
 eating, and is preceded by nausea; in chronic catarrh it is
 
 170 Insomnia and its Therapeutics. 
 
 common in the morning 1 , as it is in the reflex irritation of 
 pregnancy. It occurs in ulceration almost immediately after 
 taking food, and in slow digestion after the lapse of two or 
 three hours; in dilatations and in pyloric obstruction at dis- 
 tant intervals and in excessive quantities. The vomited mat- 
 ters should always be scanned for mucus, abnormal ferments, 
 sarcince ventriculi, bile and blood. In affections where bile 
 regurgitates into the stomach, it destroys digestion by ren- 
 dering the acid contents alkaline, and it stains the vomited 
 matters green. 
 
 The bowels are often loose in catarrhal, and constipated in 
 atonic and neurasthenic conditions. 
 
 The general symptoms vary; restlessness, irritability, and 
 headache being associated with gastric catarrh, while languor 
 and despondency, increased after eating and accompanied by 
 a tendency to flush, are the concomitants of atonic derange- 
 ments. 
 
 The complexion is often muddy, the skin is dry and harsh, 
 sometimes flabby and greasy, or affected by eczema or other 
 form of skin disease. The hands and feet are, in many in- 
 stances, cold and chilly during the day, and hot and burning 1 
 at night. Cardiac and respiratory disturbances take the 
 form of palpitation, intermission, and irregularity of the heart's 
 action; and of cough and asthmatic seizures, which are most 
 apt to come on at night during sleep. The urine may be acid 
 and scanty, containing uric acid, urates or phosphates in ex- 
 cess, oxalate of lime crystals, or traces of albumin and sugar, 
 the latter commonly from improper ingesta. 
 
 Hiccough, eructations, heartburn, acidity, burning sensa- 
 tions in the hands and feet, are all able to prevent sleep; while 
 flatulent distention of the stomach and bowels, by embarrass- 
 ing the action of the diaphragm, and mechanically impeding 
 the movements of the lungs and heart, may disturb sleep, and 
 cause dreams, nightmare, or sleep-walking. Painful sensa- 
 tions are likewise inimical to sleep. 
 
 Thus the forms and symptoms of digestive derangements 
 which give rise to insomnia are numerous. In many instances 
 no difficulty exists in the diagnosis, but in others it is not 
 so. It then requires persevering investigation to deduce its 
 genesis, and it is sometimes surprising how little assistance 
 is derived from the patient or his history. Seeking advice for
 
 Insomnia and its Therapeutics. \J\ 
 
 sleep disturbance of long 1 duration, he may affirm that his 
 digestion is perfect, and repudiate, even indignantly, any sug- 
 gestion to the contrary; and yet upon pushing the inquiry a 
 confession is elicited that for some years he has been slightly 
 languid, prone to flush, and somewhat flatulent after eating, 
 and not hungry in the morning. Directing treatment to these 
 symptoms the insomnia disappears. 
 
 When indigestion can, in waking- moments, cause such cir- 
 culatory derangements as to lead to pronounced flushing, it is 
 not surprising that during sleep it can set up cerebral hy- 
 peraemia. 
 
 Treatment. The treatment of dyspepsia must necessarily 
 vary with the cause. As digestive derangement is frequently 
 a local indication of some departure from health, rather than 
 a primary affection, the treatment requires to be conducted, 
 in the majority of instances, on general as well as on special 
 principles. 
 
 Everything which tends to strengthen and impart tone to 
 the nervous system, and to improve the chemical metamor- 
 phoses of the formation and depuration of the blood, amelior- 
 ates the symptoms. It is certainly the right way to begin 
 the treatment; but whatever course may be adopted the fol- 
 lowing rules apply to all cases. 
 
 It is essentially necessary that all dyspeptics should eat 
 slowly and deliberately. The masticatory movements not 
 only increase the pulse rate and the flow of blood to the secre- 
 tory glands, thus inciting the active formation of the juices, 
 but they incorporate the starches with the saliva, and disin- 
 tegrate the albuminoid foods to prepare them for further di- 
 gestion. Everything-, therefore, which prevents complete mas- 
 tication should be remedied, and the gums and teeth kept in 
 good working order. It is important to eat in moderation; 
 the majority of people probably eat too much. Eating slowly 
 is practically equivalent to eating less, for the appetite is 
 appeased by a smaller quantity, while that taken is more 
 thoroughly digested and assimilated. The food of every-day 
 life should be arranged so as to embrace suitable and propor- 
 tionate quantities of nitrogenous, carbonaceous, saccharine, 
 and oleaginous elements; and these (as has been already 
 pointed out) should bear some relation to the age, tempera- 
 ment, occupation, etc., of the individual, and to the strength
 
 172 Insomnia and its Therapeutics. 
 
 of his digestive powers. Morevover, the food ought to be 
 varied from day to day. This promotes digestion and assimi- 
 lation in a very marked way. Many errors are committed in 
 this respect. As an example, the writer may mention the 
 case of a lady of advanced age, who consulted him some years 
 ago for serious sleep disturbance dependent on a skin affection ; 
 on inquiry he found that for a few years she had dined every 
 day upon salt-fish pie. In such a case the wonder was, not 
 that she was suffering, but that she kept so long free from 
 disease. 
 
 The dietary, then, must be carefully considered in every 
 case, so that the patient may be told distinctly what to eat 
 and what to avoid. As a rule, liquids should be taken at the 
 end of meals only. Meals should be fixed at regular intervals, 
 the last being taken not earlier than three hours before bed- 
 time, and composed of digestible articles. 
 
 Good cooking is of paramount importance. I*t is useless 
 to prescribe a special diet if it is badly prepared. If, for ex- 
 ample, a sole (which is delicate and light) is cooked in luke- 
 warm oil, so as to be thoroughly saturated with grease, it is 
 rendered most obnoxious. Roasting, broiling, and grilling are 
 the best forms of preparation, but these require the cook's art. 
 Boiling and stewing come next. Frying and hashing are to 
 be avoided as unsuitable. Dyspeptics should never eat re- 
 cooked meat. 
 
 Fresh meat should be well kept, and the lighter and more 
 digestible varieties preferred. Well cooked and pleasantly 
 flavored, it stimulates the flow of the salivary and gastric 
 juices, which in their turn influence the gastric movements, 
 for the muscular activity is in ratio to the acidity of the con- 
 tents of the viscus. Lemon juice with fish and the judicious 
 use of condiments have advantages. The most easily digested 
 fishes and vegetables should be selected. Mutton, poultry, 
 and game are the most admissible meats. Fats and fatty 
 meats and fishes are best eschewed, especially when they are 
 hot; and also veal, pork, and hard salted meats. Clear soups 
 in moderation rather aid than hinder digestion; in other in- 
 stances, all liquids increase discomfort. Vegetables and 
 starches should be thoroughly cooked; stale bread, toast and 
 biscuit crumble easily, and are therefore to be chosen. New 
 bread is very obnoxious. Potatoes should be eaten sparingly.
 
 Insomnia and its Therapeutics. 173 
 
 Boiled milk diluted with water, lime water, or peptonized, 
 has a large field of usefulness. Koumiss is excellent, and can 
 easily be prepared at home. 
 
 Spirits, wines, and malt liquors, if they seem to promote 
 digestion, may be allowed, but these require consideration in 
 each case. A small quantity of whiskey or brandy in an alka- 
 line effervescing" water toward the end of a meal is frequently 
 a distinct aid to digestion, particularly when cold extremities 
 and drowsiness result from eating. Claret and champagne in 
 other cases suit better. When prescribed it must be in quan- 
 tities far short of that which could induce gastric catarrh. 
 
 Many dyspeptics get into a bad habit of eschewing every 
 article of diet which causes them inconvenience; this must be 
 discouraged. Eating "down" seldom answers. 
 
 All severe muscular exercise or mental work immediately 
 before or after eating is undesirable, and is certainly incom- 
 patible with good digestion. 
 
 The Turkish bath taken twice or thrice a week at suitable 
 hours is most useful. The effects of dyspepsia on the integu- 
 ment are so marked that in most cases an unusual amount of 
 epidermis peels off in the process of shampooing. A morning 
 bath regulated to the strength of the patient, and sea-bathing, 
 show their influence upon the appetite and digestive powers, 
 and therefore are to be recommended. 
 
 Exercise short of fatigue is an exceedingly valuable adjunct 
 to treatment; in every case it must be proportionate to the 
 patient's stamina. The use .of dumb-bells or clubs after the 
 morning bath is advantageous, quickening as it does the cir- 
 culation of the blood through the whole muscular system, and 
 toning the abdominal muscles, by which the processes of di- 
 gestion are invigorated. These processes are still more braced 
 by exercise in the open air; that follows necessarily from the 
 recuperation of the nervous and circulatory systems which is 
 brought about. Walking and cycling, tennis and golf, shoot- 
 ing and fishing, are usually useful in different cases, but riding- 
 is par excellence the most healthful form of exercise. Lord 
 Palmerston happily put it, " that the outside of a horse was 
 the best thing for the inside of a man." 
 
 Change of air and scene is sometimes called for. Diges- 
 tion and nutrition being accomplished more easily and per- 
 fectly on dry porous soils, an improvement takes place which
 
 174 Insomnia and its Therapeutics. 
 
 permits of amended sleep ; this is specially true of dry elevated 
 places. For such patients, there are many suitable climates 
 in Britain and abroad, but in advising change the peculiarities 
 of each case must be specially considered with reference to the 
 particular resort. Change of air being the most expensive 
 remedy that can be prescribed, care is requisite for its precise 
 recommendation. 
 
 In addition to the general regimen and dieting it is often 
 necessary to treat symptoms. 
 
 Flatulence, with sensations of oppression and distention 
 in the epigastrium, and often accompanied by eructations, was 
 deemed by the late Dr. Leared to depend upon impaired mus- 
 cular movements of the stomach and bowels, consequent upon 
 enervation. This is the reason that the enfeebled, the anaemic, 
 and the neurasthenic are so often afflicted with flatulence. 
 
 Eructations of Gas. When these occur the nature of the 
 gas affords indications for suitable treatment. When they 
 are acid, the starches and sugars, which are easily changed 
 into lactic acid, should be limited; when they are acrid and 
 oily, the fats must be diminished in quantity; when composed 
 of sulphuretted hydrogen, the albuminoids ought to be cur- 
 tailed; when they are tasteless, and caused by eating unripe 
 fruit, badly-cooked vegetables, or by the use of peas or beans, 
 these obnoxious articles should be avoided. Remedies which 
 will give tone to the nervous centres, and increase the acidity 
 of the chyme, are valuable. Weak alkalies with strychnine 
 are usually the most efficacious. 
 
 IJ Bicarb, potass., 3 iij. 
 
 Tinct. nucis vom., 3 ij. 
 
 Tinct. cardam. co., . . . . . 3 vi. 
 Aquam, ad vi. 
 
 M. Sig. Take a tablespoonful in water, before meals, thrice 
 daily. 
 
 An acid given after meals attains the same object, particu- 
 larly if it be combined with pepsin. The following pill suits 
 well: 
 
 $ Sulph. quinin., 
 
 Acid, carbolic, crys., 
 
 Ext. nucis vom., aa gr. ss. 
 
 Pepsin, porci, gr. iiss. 
 
 Ft. pil. i. Sig. One before meals at which meat is taken.
 
 Insomnia and its Therapeutics. 175 
 
 For immediate relief from distention, charcoal in capsules, 
 naphthalin in doses varying 1 from gr. v. to gr. x., or sodium 
 sulpho-carbolate, gr. x. to gr. xv., are all effective. 
 
 The bowels in all cases should be carefully attended to, 
 and when necessary acted upon by means of aperients, such 
 as rhubarb, infusion of senna pods, or cascara sagrada. 
 
 Acidity may depend primarily upon excessive, scanty, or 
 disordered secretion of the gastric juice. An acid, such as 
 dilute nitric acid, or the oxide of silver, given before meals, 
 acts as an astringent. When the acidity depends upon the 
 formation of an abnormal acid, the starches, sugars, and fats 
 must be carefully and judiciously managed, and tea and coffee 
 must be sparingly taken. Washing out the stomach by 
 means of emetics and copious draughts of warm water every 
 night for three or four nights is an efficacious method of rid- 
 ding the stomach of abnormal ferments. It is marvellous to 
 witness the improvement that follows. The last three patients 
 to whom the writer prescribed this treatment improved at 
 once, and gained considerably hi weight. The first gained 
 twent\'-two and a half pounds in three months; the second, 
 eight and a half pounds in a month; and the third, six and a 
 half pounds in the same time; in each instance they were 
 sleeping soundly and well when they passed out of observa- 
 tion. For immediate relief : 
 
 # Acid, carbolic, crys., . , . , gr. xij. 
 
 Liq. bismuth., . . . . . . 3 x. 
 
 Glycer., 3vi. 
 
 Aquam, . . . . . . ad fvi. 
 
 M. Sig. Take a tablespoonful, in water, for a dose. 
 
 Or, 
 
 $ Carb. bismuth., gr. x. 
 
 Bicarb, sodii, gr. vi. 
 
 Pulv. aromat. co. gr. iij. 
 
 Ft. pulv. i. . M. Sig. Take one for a dose. 
 
 Spanish juice is a serviceable, if homely, antidote. It is spe- 
 cially useful when the secretions are perverted, and its efficacy 
 is enhanced by sipping hot water. Widely different opinions 
 have been expressed as to the action of this remedy, some be- 
 lieving that it relieved solely by stimulating an increased flow
 
 176 Insomnia and its Therapeutics. 
 
 of alkaline saliva, which being swallowed, neutralized the acid 
 contents of the stomach; while others have pointed out that 
 if that were its only modus operandi cane sugar would act 
 equally well. Dr. George Keith, who advises its use as a 
 hypnotic, points out that, as a matter of observation, although 
 cane sugar may in this way temporarily relieve, the acidity 
 is speedily aggravated; which never occurs after liquorice. 
 Spanish juice seems also to exert a soothing influence over 
 the mucous membrane of the stomach, as the liquid extract of 
 liquorice likewise does in a lesser degree (see below). What- 
 ever may be its precise mode of action, its usefulness in a 
 large number of cases is undoubted. It is most conveniently 
 prescribed in the form of Pontefract cakes. 
 
 Pain. When it is neurosal, arsenic with belladonna should 
 be prescribed. A case lately under treatment exemplifies a 
 usual experience. A lady, sleepless for months, came suffer- 
 ing from severe and persistent gastric pain with considerable 
 emaciation; she had lost nearly two stones in weight. One 
 dose of morphine and atropine having been taken at night, 
 which secured a sound sleep, she was advised to take a mix- 
 ture of arsenic and belladonna; when forthwith she lost her 
 pain, regained sleep, and made an excellent recovery. 
 
 When it depends, as it frequently does, upon scanty secre- 
 tions, weak alkalies before meals, and pepsin after, answer 
 well. Where the peripheral endings of the gastric nerves are 
 irritable, small doses of morphine, dilute hydrocyanic acid, 
 and bismuth are called for. In ansemie cases the following is 
 an excellent formula : 
 
 IJ Liq. bismuth., f i. 
 
 Cit. ferri ammon., 3ij. 
 
 Acid, hydrocyan. dil., TH, xvi. 
 
 Ext. glycyrrh. liq., 3 ss. 
 
 Spt. chlorof., ill viij. 
 
 M. Sig. Take a teaspoonful in water, thrice daily, before 
 meals. 
 
 The liquorice extract was originally introduced to modify 
 the disagreeable taste, but it added to the efficacy of the mix- 
 ture. 
 
 Pain, awaking the patient at night, must be relieved by 
 opiates, antispasmodics, and poultices.
 
 Insomnia and its Therapeutics. 1 77 
 
 Vomiting of frequent recurrence requires treatment. It 
 is sometimes arrested by counter-irritation and simplifying 1 
 the food ; restricting 1 it to ice, iced champagne, milk and lime 
 water, or koumiss. Among the most suitable remedies may 
 be mentioned minim doses of ipecacuanha wine, dilute hydro- 
 cyanic acid with calumba, cerium oxalate, bismuth carbonate, 
 magnesium salicylate, or the hypodermic injection of mor- 
 phine. Cocaine is sometimes useful. Rest in bed is always 
 essential in obstinate cases. 
 
 Hiccough usually yields to a mustard plaster externally 
 and an alkaline mixture internally. When these fail, ft[ v. of 
 chloroform on a knob of sugar, or a hypodermic injection of 
 morphine must be given. 
 
 Pyrosis. The writer has almost never required to use 
 any other medicine than ferro-alumen in 3-grain doses, with 
 ffi ij. of dilute hydrocyanic acid; and he has seldom been dis- 
 appointed with the results. 
 
 Eegurgitation of Food. This is relieved by arsenic (Til ij. 
 to TTI iij. of Fowler's solution) before meals; likewise by the 
 following pill: 
 
 IJ Ext. belladon., gr. 
 
 Sulph. quinin., gr. i. 
 
 Ext. hyoscy., gr. ij. 
 
 Ft. pil. i. Sig. Take one three times a day, an hour after 
 meals. 
 
 The urine in many cases yields indications for treatment. 
 
 Sleep usually returns with the relief of the derangement; 
 it is, however, occasionally useful to administer some special 
 remedy for a few nights to induce sleep, and so gain the bene- 
 fit of its powerful recuperative influence. Dr. George Keith 
 advocated the use of Spanish juice at bedtime as an aid to 
 sleep, and that in cases in which no disorder of the gastric 
 secretions existed. From six to twelve Pontefract cakes is 
 the usual dose. The writer has repeatedly obtained good 
 effects from their use, while they act as a slight aperient. In 
 some instances the benefit derived was so striking that the 
 patients asserted they must contain some opiate. In a variety 
 of cases they are of undoubted efficacy. Here is also a good 
 and unobjectionable draught :
 
 178 Insomnia and its Therapeutics. 
 
 I Bicarb, potass., gr. xv. 
 
 Tinct. lupul., 3 i. 
 
 Tinct. lavand. co., 3 ss. 
 
 Infus. anthem., ad 3 ij. 
 
 M. Sig. Take at bedtime. 
 
 Nutmeg* too is useful. Spiritus myristicae 3 ss., in an ounce 
 or two of peppermint water, acts in a similar manner. Nut- 
 meg has for centuries been credited with possessing hypnotic 
 properties, and not without some good reason. The late Dr. 
 Cullen, however, thought it should not be prescribed in the 
 case of persons with a tendency to apoplexy. 
 
 Among the more potent agents suitable, may be mentioned 
 hyoscyamus, cannabis indica, morphine, codeine, belladonna, 
 etc.; and among the less active (although of undoubted value) 
 camphor, valerian, the oil of chamomile flowers, etc. It must 
 be borne in mind that the treatment must be directed to the 
 alleviation of the disorder which originates the disturbing 
 sensations, and to the lessening of the conductivity of the 
 sensory nerves. Pure hypnotics are useless for such purposes. 
 
 INTESTINAL DYSPEPSIA. 
 
 In the last section we discussed derangements chiefly con- 
 nected with gastric or acid digestion ; we have now to consider 
 some which are associated with intestinal or alkaline diges- 
 tion. This process is carried on by means of the bile and the 
 pancreatic and intestinal juices. 
 
 The bile furthers intestinal digestion in several important 
 respects; the following are the chief. It is expelled from the 
 gall-bladder when the acid chyme enters the duodenum, and 
 it precipitates the pepsin and any of the proteids which have 
 only been transformed into acid albumin, instead of into true 
 peptones, and in that way prepares them for the subsequent 
 action of the pancreatic and intestinal juices. It possesses 
 feeble diastatic properties which act on the unchanged starches. 
 It emulsifies some of the neutral fats, and aids in their absorp- 
 tion, as fats pass through bile-moistened membranes with 
 some facility. It acts as a powerful antiseptic, and excites 
 the muscular contractions of the intestines. It is thus evident 
 that any disease interfering with the formation of bile must
 
 Insomnia and its Therapeutics. 179 
 
 not only induce disorders of intestinal digestion, but lead to 
 mat-assimilation, 
 
 The pancreatic juice, which is strongly alkaline, contains 
 three important constituents, which combine the properties of 
 the saliva and tho gastric juice. These are, amylopsin, tryp- 
 siu, and steopsin. The first acts on the unchanged starches, 
 And changes them into dextrin and sugar; the second breaks 
 up the proteids, and converts them into peptones; while the 
 third saponifies and emulsifies fats. The processes are largely 
 promoted by the intestinal movements. The intestinal juices 
 contain similar properties. Absorption goes on in the intes- 
 tines through the agency of the blood-vessels and the lacteals. 
 
 The sources of intestinal dyspepsia are really the same as 
 those enumerated as inducing gastric disorders: Defective 
 structures; defective innervation; defective vascularization; 
 faulty secretions; faulty ingesta. . 
 
 The most common exciting causes are imperfect salivary 
 and gastric digestion, leaving the bulk of the chemical changes 
 to be effected by the pancreatic and intestinal juices. In per- 
 sons of limited digestive energy these are insufficient to ac- 
 complish this completely ; hence, fermentative and putrefactive 
 changes occur which render the contents of the colon acid, 
 and the leucin and tyrosin may be converted into indol and 
 skatol, substances from which the faeces derive their odor. 
 
 It may be occasioned by a too scanty formation of bile ; or, 
 what is practically the same, an excessive acidity of the 
 chyme, neutralizing the alkaline constituents of the bile and 
 pancreatic fluids, and so terminating the alkaline processes. 
 It is frequently excited by defective muscular movements. 
 
 The symptoms of intestinal indigestion may be conspicuous 
 by their absence; when they do occur they differ from those 
 of gastric origin. They come on some hours after meals, the 
 sensations being referred to the right hypochondrium and 
 umbilical regions, rather than to the epigastric. The tongue 
 is coated with a thick yellowish fur; the breath is usually 
 heavy, and the appetite impaired or fitful. There may be 
 flatulence in the bowels (borborygmus), often in very consid- 
 erable amount, the weakened intestinal walls admitting of 
 great distention. 
 
 This accumulation of gas is due to the decomposition of 
 the various aliments, and the gases being absorbed into the
 
 180 Insomnia and its Therapeutics. 
 
 blood leads, in some cases, to severe general disturbance 
 even to collapse. Pain is usually of a griping or spasmodic 
 nature, and yields to heat and pressure. Arising during the 
 night, it is frequently due to arrested muscular movements. 
 There may be nausea and vomiting from reflex irritation, the 
 latter being ineffectual, and not attended by the relief that 
 follows the vomiting in gastric disturbance. 
 
 The bowels are sometimes relaxed, but generally they are 
 constipated, the motions being pale, dry, and offensive; and if 
 the pancreatic secretions be faulty, fat may be detected in 
 them. 
 
 The urine is scanty, high-colored, and either deposits uric 
 acid or urates on cooling. 
 
 The aspect is sallow and earthy, the conjunctivas tinged 
 with yellow pigment. These patients look ill, they are de- 
 pressed and desponding, and at times hypochondriacal. Gid- 
 diness and disorders of the special senses are common. There 
 is often much emaciation, the nervous system feeling acutely 
 the non-absorption of fats, etc.; and as absorption of these 
 nutrients takes place in the upper half of the intestinal canal 
 all derangements of digestion in that portion lead to enfeeble- 
 ment and enervation of the whole body. The heart and lungs 
 participate in this weakness. The blood badly formed, and 
 laden with waste products nourishing the tissues inadequate!}', 
 adds to the prostration. Such persons are apt to be shivery 
 and miserable. 
 
 The cerebral cells, partially starved, grow susceptive, and 
 responsive to slight stimulations; this they show at night in 
 sleeplessness and restlessness, the latter of an almost exag- 
 gerated kind, compelling the patient to get out of bed and 
 wander up and down his room. So marked is this, that the 
 writer, for many years, has believed the pathogeny of fidgets 
 to be reflex irritation excited by duodenal and intestinal dis- 
 order. 
 
 Intestinal dyspepsia is a much more frequent source of 
 sleep disturbance than the gastric form, and one of greater 
 diagnostic obscurity, for the reason that there may be no 
 symptom to indicate abdominal discomfort; in short, no symp- 
 tom other than obstinate wakefulness. Intestinal digestion, 
 which is not normally completed for some hours after the in- 
 gestion of a full meal, is even more slowly effected in such
 
 Insomnia and its Therapeutics. 181 
 
 patients. If sleep supervene, and the intestinal movements 
 slacken or cease, the processes are interrupted, and so de- 
 rangements are initiated which disturb and terminate sleep. 
 
 Many patients who awake at one or two o'clock in the 
 morning, and lie awake till five o'clock, are roused by intes- 
 tinal disturbance, and are kept from sleeping until the move- 
 ments complete the digestive processes. Moreover, the per- 
 sistence of imperfect intestinal digestion, leading to defective 
 nutrition, renders the cerebral cells abnormally sensitive to 
 all disturbing agencies in the economy. They are thus per- 
 turbed by insignificant distant sensations, which in robust 
 health they would not perceive. 
 
 Treatment. All that was said upon the treatment of the 
 general condition in gastric disorders applies here, exercise 
 being probably more called for, by quickening the circula- 
 tion it facilitates the chyle currents. Turkish baths are par- 
 ticularly beneficial. Every means calculated to improve in- 
 nervation and vascularization should be adopted. 
 
 Intestinal digestion is not easily impressed by medication ; 
 practically it can only be improved by rendering salivary and 
 gastric digestion more complete. Where excessive acidity of 
 the gastric contents exists, it should be neutralized with lime 
 water, lithium, or magnesia. When diarrhoea is present, 
 opium must be given. Constipation must be relieved. When 
 the pancreatic fluid is deficient some temporary benefit may 
 be derived from the use of Benger's pancreatic liquor in lime 
 water, or mixed with sodium bicarbonate two hours after 
 meals; and also from the judicious administration of malt ex- 
 tract. Sleep is often improved by the nightly use of massage, 
 and also by the application of an abdominal compress. 
 
 Heat, stimulating the completion of the digestive processes, 
 favors the return of sleep. For example, a bag containing hot 
 water applied over the abdomen, and a drink of warm water 
 on awaking, seldom fails to act beneficially. 
 
 When flatulence is a marked symptom, the administration 
 of turpentine is desirable. That drug possesses, in addition 
 to its powerful carminative, some hypnotic properties. The 
 late Dr. Warburton Begbie recorded : " Occasionally the oil 
 has been observed to cause sleep." 
 
 Wakefulness is frequently obviated by a draught like the 
 following at bedtime.
 
 1 82 Insomnia and its Therapeutics. 
 
 IJ Bicarb, potass., gr. xv. 
 
 Sulph. sodii, 3 i. 
 
 Tinct. lupul., . ' . . 3 i. 
 
 Infus. anthem., . . . . . ad f ij. 
 M. Sig. Take at bedtime. 
 
 In other cases a similar draught, in which TH, x. of the tinc- 
 ture of belladonna is substituted for the sodium sulphate, 
 suits even better; and a little syrup of ginger may be added 
 to either. Such draughts, taken during the night on awaking, 
 often induce sleep. 
 
 When sleep is urgently required it is sometimes useful to 
 administer a hypnotic for a few nights to allow the nervous 
 system to recuperate; but as they are obviously not curative 
 agents, their use must be dispensed with if possible. Hyos- 
 cyamus, tannate of cannabin, and lupulin are the most suitable 
 hypnotics. 
 
 CONSTIPATION. 
 
 The contents of the small intestines are liquid. As that 
 portion of the alimentary tract secretes digestive fluids 
 abundantly, these compensate for the withdrawal of the 
 nutrient constituents, which are rapidly absorbed. The pro- 
 cesses of secretion and absorption are therefore here balanced. 
 The contents of the large intestin.e are more consistent, and if 
 they are retained for any length of time they become drj r and 
 hard, for in the large intestine secretion is limited, while ab- 
 sorption is considerable. The powers of absorption are well 
 demonstrated by the rapid way that the rectum appropriates 
 liquid given by enemata. (See page 659.) The consistency 
 of the contents of the colon is thus the result of time, for if 
 they are rapidly passed from above downward, as they are 
 in diarrhoea and after the administration of saline purgatives, 
 the motions are quite liquid. 
 
 Among the causes of constipation must be enumerated : 
 
 Defective structures, which comprise all lesions interfering 
 with the integrity of the intestines. The graver diseases 
 include deep ulcerations and cancerous growths; the more 
 trivial, hemorrhoids and fissure of anus. Those external to 
 the bowel comprise tumors and displacements of the womb, 
 etc., occluding the lumen. 
 
 Impaired nervous arrangements, central or peripheral.
 
 Insomnia and its Therapeutics. 183 
 
 Mental depression and organic cerebral diseases frequently 
 induce obstinate constipation. Neurasthenic conditions and 
 the use of some poisons in excess, lead to the enervation of the 
 whole processes of digestion, and to a relaxed state of the 
 muscular system, with defective movements. It is very 
 common to meet with constipation in men and women of 
 slothful habits, who spend their days in heated and badly- 
 ventilated rooms, and who take no exercise. It depends 
 mainly upon an enervated condition of the muscles involved in 
 digestion, viz., the abdominal, and the intestinal, and the dia- 
 phragm. This relaxed state is ;the source of constipation in 
 many aged persons. The habitual neglect of the calls of nature 
 (which is a common source of constipation) brings about a 
 condition in which the nerves fail after a time to respond to 
 their normal stimuli. Indeed, any interference with the in- 
 tegrity of the nerves supplying the rectum and anus, may 
 cause constipation by destroying the usual reflex arrange- 
 ments. The w r ant of sleep, though mentioned thus late, is a 
 far more frequent source of constipation than is generally 
 imagined. It is thus the cause of, as well as the result of, 
 constipation. 
 
 Abnormal vascularization : this chiefly depends on anasmia 
 and imperfectly oxygenated and deterged blood, and on dis- 
 eases which retard the free return of blood to the heart, such 
 as obstruction of the portal circulation. It may also depend 
 on the presence of poisons, as lead. 
 
 Faulty chemical changes, such as arise from defective 
 secretions, as occur in some fevers and debilitating diseases, 
 or when the system is drained of excessive quantities of fluid, 
 as in diabetes, over-lactation, etc. 
 
 Faulty ingesta : this includes food too astringent, or too 
 bland in character, e.g., when large quantities of tea, red 
 wines, and starches are consumed. 
 
 The effects of constipation are very varied. The absorp- 
 tion of gases formed by the fermentative and putrefactive 
 changes in the fasces causes headache, vertigo, disorders of 
 vision and hearing, feelings of lassitude, and, in many instances, 
 profound depression and gloom. Such patients are tormented 
 by constant forebodings of ill; their aspect is dejected, com- 
 plexion muddy, tongue furred, breath heavy, appetite and 
 digestion bad; and they are often neuralgic.
 
 184 Insomnia and its Therapeutics. 
 
 If the fasces are allowed to accumulate for weeks or even 
 months, the noxious materials absorbed by the blood cause 
 very pronounced symptoms, chiefly referred to the nervous 
 centres. There is generally, although not necessarily, an in- 
 crease of temperature; quick pulse, at times irregular; per- 
 sistent vomiting; emaciation and prostration. There may be 
 cough, palpitation, and liquid diarrhrea ; in short, many of the 
 symptoms resembling those of enteric fever. In all cases sleep 
 is interfered with, dreams and nightmare being concomitants 
 of the milder cases. 
 
 The chief causes of disturbed sleep are increased arterial 
 tension and hyperagmia of the brain. This is brought about 
 mainly through the centres in the medulla, and activity is thus 
 maintained in the cerebral cells. The implication of the 
 medullary centres is well seen in the night sweats which so 
 frequently occur in these cases. 
 
 In children constipation gives rise to very marked disturb- 
 ance. During the day they are peevish, irritable, and easily 
 tired, suffer from colicky pains in the abdomen, which cause 
 them to cry, often to shriek with pain, this being associated 
 with flatulent distention. Periodic crying in children is in- 
 variably suggestive of intestinal derangement. The bowels, 
 in some cases, act daily, but the quantity passed is insufficient. 
 They eat fitfully and digest badly, look pale and sallow, and 
 lose flesh quickly. At night they sleep badly and may be 
 feverish ; they wake up screaming as if in pain, but they are 
 not confused as in night-terrors. They dream and are rest- 
 less, in the morning are tired and weary. 
 
 Treatment. Sleeplessness from this cause yields only to 
 the removal of the constipation; a purgative will, in a child, 
 often suffice to render sleep calm and healthful. 
 
 It is important to cultivate the habit of unloading the 
 bowel daily at a regular hour. All errors in the ingesta must 
 be remedied, and a regimen something like the following 
 adopted. Fruit should be eaten every morning when dressing. 
 Ripe fruit in season, oranges in winter, or French plums or 
 figs, soaked the evening before in a saucerful of cold water. 
 After the fruit, a claret glassful of hot water may be slowly 
 sipped. Whole flour bread should be preferred to white ; oat- 
 meal porridge with treacle or cream is useful at breakfast. 
 Green vegetables and fruit should be liberally used at luncheon
 
 Insomnia and its Therapeutics.. 185 
 
 and dinner. Red wines, beer, brandy, tea, milk, egg's, cheese, 
 nuts, pastry and farinacious milky puddings should be avoided. 
 A large glassful of hot water should be sipped at bedtime. 
 
 When the defect is due to enervation, hot compresses ap- 
 plied over the abdomen are often useful by exciting intestinal 
 movements. Electricity, either the galvanic or faradic cur- 
 rents should be tried when the muscular movements are weak. 
 Baths of various kind should be employed, followed by vigor- 
 ous flesh-brushing. Exercise in the open air short of fatigue 
 should be taken. Horse exercise is the best. 
 
 Until these hygienic measures have time to act, it is usu- 
 ally necessary to prescribe some laxative. Various mineral 
 waters taken in the morning fasting are useful, and may be 
 continued for some time. Probably the best are Friedrichs- 
 hall, Hun3 r adi Janos, JEsculap, and Rubinat-Condal. They 
 should be taken mixed with hot water, and sipped slowlj'. 
 
 What answers equally well, and in some cases better, being 
 less depressing in its action, is an infusion of senna pods. It 
 is one of the mildest and most reliable evacuants we possess. 
 It acts as a tonic, cleaning the tongue, promoting the appetite 
 and digestion, and increasing the muscular movements of the 
 whole alimentary tract. It does not cause griping, flatulence, 
 or congestion of the pelvic vessels like that made from senna 
 leaves. From six to twelve pods, or, more, should be infused 
 in a claret glassful of cold water for six hours, and the infusion 
 taken at bedtime. It is devoid of disagreeable smell and 
 taste. 
 
 The following mixture and pills have been found useful : 
 
 5 Tinct. nucis vom., 3 ij- 
 
 Acid. nit. dil., 3 ij. 
 
 Ext. cascar. sag., fl. 3 iij. 
 
 Infus. gentian., ad vi. 
 
 M. Sig. Take a tablespoonful in water after meals twice 
 or thrice daily. 
 
 5 Aloin., gr. i. 
 
 Ferri sulph., gr. i. 
 
 Ext. nucis vom., gr. ss. 
 
 Pulv. myrrh., gr. iss. 
 
 Ext. hyos., . gr. i. 
 
 Ft. pil. i. Sig. Take at dinner time.
 
 1 86 Insomnia and its Therapeutics. 
 
 Or, if iron be contra-indicated, 
 
 1J Ext. aloes soc., gr. iss. 
 
 Ext. nucis vom., ... . . . gr. ss. 
 
 Sulph. quin., . . ... . . gr. i. 
 
 Pulv. capsic., . ... . . . gr. i. 
 
 Ext. gentian., . . . . . q. s. 
 Ft. pil. i. Sig. Take one before dinner. 
 
 When the secretions are defective, one or other of the fol- 
 lowing will be found serviceable : 
 
 5 Res. podoph., ....... gr. \. 
 
 Ext. bell ad., . ..... . . gr. \. 
 
 Pulv. ipecac., . . . . . . . gr. ss. 
 
 Fei. bov. inspis., . , . . . . gr. ij. 
 Ft. pil. i. Sig. Take one in the evening. 
 Or, 
 
 5 Aloin., ........ gr. i. 
 
 Ext. nucis vom., gr. ss. 
 
 Pil. hydrarg., . * . , . . . gr. i. 
 
 Pulv. ipecac., . gr. ss. 
 
 Fel. bov. inspis., gr. ij. 
 
 Ft. pil. i. Sig. Take after dinner. 
 
 In all cases of disturbed sleep due to constipation, hyoscya- 
 mus is a most useful remedy, for besides acting as a hypnotic 
 in medium doses, it augments the peristaltic movements of 
 the intestines. 
 
 When there is any tendency to bleeding piles, this powder 
 is a reliable laxative. 
 
 R Sulphur, precip., 
 
 Pulv. cubeb., . . . ... . aa 3 i. 
 
 Pulv. guaiac., 3 ij. 
 
 Pulv. pip. nig., . . . . . . 3 i. 
 
 M. ft. pulv. Sig. A teaspconf ul in water, night and morning. 
 
 In cases in which the administration of purgatives appears 
 to still further disturb sleep, as in some neurasthenic and 
 hypochondriacal states, from two or six minims of the oil of 
 chamomile flowers alleviates the hyper-sensitivity. 
 
 In children, sodium phosphate in unsalted soup is a pleasant 
 if an old-fashioned laxative. Here also is a good and useful 
 prescription. Take of figs, as new and soft as they can be
 
 Insomnia and its Therapeutics, 187 
 
 got, 3 viij., powdered Alexandrian senna, 3 i., treacle 3 ij. Cut 
 the hard ends off the figs, then cut them into shreds, add the 
 senna and treacle, and beat the whole into a pulp. It is pleas- 
 ant to taste, and the dose is a piece about the size of a hazelnut. 
 Sleep may likewise be disturbed by catarrhal and inflam- 
 matory affections of the gastro-intestinal canal, as in diarrhoea 
 and dysentery, either acute or chronic. The treatment is ob- 
 viousty that of the disease. This remark is equally true of 
 the wakefulness of collapse, the result of perforation; as also 
 that which occasionally accompanies peritonitis; and the 
 wakefulness which is said to attend cholera morbus. 
 
 INTESTINAL WORMS. 
 (Ta?nia solium ; Ascaris lumbricoides ; Oxyuris vermicularis.) 
 
 Although these differ very greatly from one another, the 
 symptoms they instigate in the nervous and alimentary sys- 
 tems are so much alike that it is convenient to discuss them 
 together. 
 
 They may be present without giving rise to any symptoms 
 at all; or they may reflexly give rise to diseases of the ner- 
 vous system, such as chorea, etc. They invariably cause di- 
 gestive and nutritive derangements; frequently sleep disturb- 
 ance and dreams; and occasionally they may excite night- 
 mare, night terrors, and somnambulism. Grinding the teeth 
 is a common symptom, and if it be not due to gout, which is 
 rarely the case in children, it should always suggest worms. 
 This source of sleeplessness must not be overlooked, as an 
 anthelmintic is the only hypnotic. Worms occasionally 
 cause extreme irritability of the bladder. 
 
 The general symptoms are capricious or perverted appe- 
 tite, pain and uneasiness in the abdomen, itching of the nose 
 and anus, malaise associated with restlessness, headache, 
 mental depression, noises in the ears, etc. The amount of 
 sleeplessness and emaciation that threadworms sometimes 
 cause in adults is very great indeed. In children, the reflex 
 irritation which worms excite in the bladder is occasionally 
 so great as to suggest disease in the urinary organs. This 
 may disturb sleep. 
 
 Treatment. This consists, of course, in the expulsion of 
 the worms.
 
 CHAPTER X. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 
 LIVER. 
 
 FUNCTIONAL DISORDERS OF THE LIVER. 
 
 THE liver exerts an important influence upon the digestive 
 processes as well as upon nutrition. Its functions are mani- 
 fold. It forms bile in quantities bearing a distinct relation to 
 the ingesta ; a large quantity being secreted when the food is 
 highly nitrogenous, and a smaller amount when it is oleagin- 
 ous. The liver also is instrumental in the construction of 
 glycogen, and in its accumulation until its consumption is re- 
 quired in the economy. It is the organ which presides over 
 the transformation of a certain proportion of the nitrogenous 
 products into blood-corpuscles, and also of the disintegration 
 of effete blood-corpuscles; it is concerned also in the forma- 
 tion of urea. 
 
 Dr. Lauder Brunton credits the liver with the power of de- 
 stroying certain poisons, and of preventing their entrance into 
 the circulation in deleterious quantities. 
 
 In the course of the metamorphosis of the proteids into 
 peptones (especially in the later stages), in the small intes- 
 tines, leucin and tyrosin are formed as the result, probably, of 
 the ensuing decomposition. These, in passing through the 
 liver, are changed into uric acid and urea, and the latter, being 
 highly soluble, is excreted by the kidneys. It occasionally 
 happens, either from inherited inadequacy of the liver, or from 
 functional derangements induced by improper alimentation, 
 that these products are not transformed into urea, and the 
 process being perverted, uric acid is formed in excess. Uric 
 acid, being an exceedingly insoluble substance, is excreted by 
 the kidney with great difficulty. This incomplete metabol- 
 ism may lead to lithiasis and gout. 
 
 The liver being intimately concerned with the formation
 
 Insomnia and its Therapeutics. 189 
 
 and depuration of the blood, all interference with its functions 
 implies derangement of sanguinification, which necessarily 
 affects the digestive processes. 
 
 Functional derangements of the liver chiefly arise from the 
 secretion of bile being excessive or deficient in quantity, or 
 abnormal in quality ; or they may depend upon the imperfect 
 completion of the metabolic processes, producing lithsemia, a 
 condition invariably attended by sleeplessness. Attention 
 was called to this condition in 1874 by the late Dr. Murchison, 
 to whom we are indebted for a great part of our knowledge 
 of the subject. In discussing the symptoms he dilated at some 
 length upon the sleeplessness that invariably accompanies it, 
 and his words are so full of truth that they are here quoted. 
 "Sleeplessness may, of course, arise from many different 
 causes, but one of its causes is that derangement of the liver 
 which produces lithasmia. When this is the case, the patient 
 is often heavy and drowsy after a full meal, and he may fall 
 asleep at once on retiring to rest ; but, after one, two, three, 
 or four hours, he awakes, and then he either lies awake for 
 hours, or he is constantly falling asleep, dreaming or having 
 the nightmare and awaking four or five times or even oftener 
 in the course of one hour until the morning comes, when he 
 drops into a quiet sleep of an hour or more, or he is obliged to 
 get up tired and irritable. This sleeplessness, like the vertigo 
 we have already considered, is often induced by particular 
 articles of diet, or by some unwholesome combination of them. 
 What will excite headache, giddiness, or disorders of the cir- 
 culation in some patients, will in another cause sleeplessness. 
 Sometimes, however, this symptom will occur when the patient 
 is most careful as to diet. What is important also to note is, 
 that in most of these cases there are no obvious symptoms of 
 gastric dyspepsia; the appetite may be good too good, in 
 fact; the bowels may be regular; and there may be no pain, 
 flatulence, or other discomfort after meals; but there will be 
 found an unusual tendency to the deposit of lithates in the urine, 
 and very often other phenomena of a so-called gouty diathe- 
 sis. This form of sleeplessness was described a century ago 
 by Cullen, the distinguished nosologist, in these words : ' Per- 
 sons who labor under a weakness of the stomach, as I have 
 done for a great number of years past, know that certain 
 foods, without their being conscious of it, prevent sleeping.
 
 19' Insomnia and its Therapeutics. 
 
 So I have been awakened a hundred times at two o'clock in 
 the morning" when I did not feel any particular impression; 
 but I knew that I had been awaked by an irregular operation 
 in that organ, and I have then recollected what I took at 
 dinner, which was the cause of it. Dr. Haller is liable to the 
 same complaint; and in his larg-er work especially, he gives 
 the particulars of his own case/ " 
 
 The cause of this sleeplessness is irritabilitj" in the cerebral 
 cells more or less pronounced, brought about by imperfect 
 depuration of the blood. This excitability initiates sleepless- 
 ness in consequence of the perception of stimuli so slight as 
 not to be otherwise apparent. In this respect it resembles 
 that which pertains to intestinal dyspepsia. Sleeplessness is 
 due also to an increased blood-pressure. A minority of the 
 sufferers from lithaemia complain of no other discomfort, but 
 the origin of their insomnia can be recognized by two signs 
 which are invariably present : increased vascular tension, red 
 lithates in the urine. The majority of such patients present 
 many well-marked symptoms. The aspect is dull and jaded; 
 the complexion muddy, sallow, or slightly jaundiced; and the 
 conjunctivas tinged with bile pigment. The tongue may be 
 clean, but usually it is large, sodden, teeth-indented, and cov- 
 ered with a thick creamy fur; the mouth in the morning has 
 a bitter and disagreeable taste, which may disappear in the 
 course of the day. The breath is often heavy and offensive; 
 the appetite is variable, in some cases it is good, in others it 
 is capricious or bad, the want of appetite being often associ- 
 ated with -nausea and even vomiting. The bowels are slug- 
 gish and the motions pale; haemorrhoids are frequent. The 
 urine is scanty, high-colored, acid, of high specific gravity, and 
 deposits urates on cooling. Patients complain of pain in the 
 head, giddiness, and uncertainty in movements; noises in the 
 head; dimness of vision, or of motes floating before the eyes. 
 They suffer from palpitation and intermission of the heart; 
 breathlessness and a sickening sense of oppression which 
 awakes them during the night; pain and weight in the epi- 
 gastric and right hypochondriac regions, as also about the 
 right, or it may be the left, shoulder. They are often troubled 
 with flatulence and acidity; oppression, discomfort, and drow- 
 siness after meals, followed in an hour or two by feelings of 
 irritability, lassitude, and mental depression. Whether this
 
 Insomnia and its Therapeutics. 191 
 
 depression is due to the absorption of the products of diges- 
 tion, or to leucomaines which are formed in the processes of 
 digestion, is still a matter of doubt. Dr. Lauder Brunton, 
 who has studied the subject with great care, attributes it to 
 the depressing action of a poison upon the nervous system. 
 
 When these marked symptoms exist there is no difficulty 
 in accounting for the sleeplessness. 
 
 The subjects of these disorders are peculiarly liable to suffer 
 from acute hepatic dyspepsia or attacks of biliousness from 
 slight indiscretions in eating and drinking. These attacks are 
 usually accompanied by catarrhal conditions of the mucous 
 membrane of the stomach and duodenum, and characterized 
 by headache and vomiting. They resemble in some respects 
 attacks of migraine, for which they are occasionally mistaken. 
 
 Treatment, This obviously entails that the liver must be 
 relieved of work which it cannot overtake, or, in other words, 
 that its work should be proportioned to its strength. The 
 food should be poor in albuminoid elements, that the metabolic 
 processes can be completely effected, and the storage of effete 
 materials in the system prevented. This subject will be con- 
 sidered in detail under the heading of gout, to which disease 
 it is so closely related. 
 
 Alcohol must be interdicted to a very large extent, if not 
 altogether, tending as it does to embarrass the liver still 
 further. When it is allowed it should be in the form of brandy 
 or whiskey, well diluted with an alkaline effervescing water; 
 malt liquors and sweet wines being inadmissible. Exercise in 
 the open air is imperative, oxygen being required for the ade- 
 quate performance of the metabolic changes, and horse exer- 
 cise is the best of all. Turkish baths are also to be strongly 
 recommended. Sipping hot water night and morning is a 
 powerful stimulant of the hepatic functions. 
 
 Mercury in the form of calomel, blue pill, or gray powder 
 must be given until the tongue cleans. Mercury was long 
 ago advised by the late Dr. Graves, and it has gained the ap- 
 proval of many very able physicians in more recent years. 
 
 5 Subchlor. hydrarg., gr. ss. 
 
 Pulv. ipecac., . . . . . . gr. ss. 
 
 Ext. taraxac., gr. i. 
 
 Ft. pil. i. Sig. Take at night, and in the morning, while 
 yet fasting, a dose of one of the natural saline waters.
 
 192 Insomnia and its Therapeutics. 
 
 After the tongue has lost its coating, the activity of the 
 liver should be maintained by a pill containing- either leptan- 
 drin, iridin, euonymin, or podophyllin combined with aloin. 
 
 The increased vascular tension may be treated with the 
 following mixture : 
 
 B. lodid. potass., . . . . . . . . 3 i. 
 
 Bicarb, potass., 3 iij. 
 
 Tinct. aconit. (B. P.), TH, xxiv. 
 
 Tinct. hydrast., . 3 vi. 
 
 Aq. chlorof., ad 3 vi. 
 
 M. Sig. Take a tablespoonful three times a day, between 
 meals, in water. 
 
 Sodium salicylate in 10 to 30 gr. doses, ammonium chloride 
 in 20-grain doses, and sanguinarin in -grain doses, are useful 
 remedies. 
 
 External applications, as hot poultices at bedtime, or com- 
 presses of dilute nitro-muriatic acid, in the proportion of 3 i. to 
 ij. of tepid water, over the right hypochondriac region, for 
 eight or ten nights, are usually beneficial. 
 
 If sleeplessness is very pronounced an alkaline draught with 
 hops may be given at bedtime. The writer has got excellent 
 results from sulphonal in 20-grain doses two hours before bed- 
 time ; and also from methylal in doses ranging from tq, xv. to 
 TTI, xxx. When the patient awakes and becomes restless and 
 watchful, a teaspoonful of Carlsbad salts, taken with a tea- 
 spoonful of syrup of ginger in a good draught of water, has 
 the almost constant effect of inducing the speedy return of 
 quiet sleep. A like draught at bedtime frequently prevents 
 wakefulness. 
 
 Hyoscyamus is likewise useful. Equal parts of the tinc- 
 ture, and tincture of hops in teaspoonful doses is a good for- 
 mula. Opiates, chloral hydrate, etc., invariably do harm, 
 any sleep which they induce being followed by an aggravation 
 of the symptoms by deranging the secretions. Such remedies 
 are to be avoided. 
 
 JAUNDICE. 
 
 Drowsiness is the usual accompaniment of jaundice, but 
 every now and again the reverse condition is met with. The 
 late Dr. Graves, of Dublin, wrote that "in jaundice every-
 
 Insomnia and its Therapeutics. 193 
 
 thing- denoting- an unusual state of the nervous system, 
 whether it be too much sleep or too little, demands your at- 
 tention." He likewise pointed out that the sleeplessness which 
 sometimes occurred, manifested itself at the time that the 
 jaundice was declining- and the bile beginning- to reappear in 
 the stools. 
 
 Sleeplessness in this disease commonly depends upon dys- 
 peptic derangements, some of which we have already consid- 
 ered, and also upon general itching- of the skin, caused by the 
 circulation through it of blood laden with bile acids. In re- 
 g-ard to the latter, the Dublin physician called attention to 
 the fact, which has since been frequently confirmed by others, 
 that the itching- sometimes precedes the appearance of the 
 jaundice. 
 
 Treatment. When the insomnia is due to dyspeptic de- 
 rangements these must be treated upon the principles indi- 
 cated elsewhere. When it is due to itching-, the free use of 
 alkaline baths and the flesh-brush is useful. The following 
 lotion is serviceable : 
 
 IJ Bibor. sodii, . . . . . . . i. 
 
 Acid, carbol. pur., 3 ij. 
 
 Spt. vini rect., 1 ij. 
 
 Aquam, ad f xxiv. 
 
 M. Sig-. Sponge the body as often as required. 
 
 Amylene hydrate is said to be an efficacious remedy. The 
 subcutaneous injection of pilocarpkie, as recommended by Dr. 
 Goodhart and others, affords good results. 
 
 Where, in spite of these remedies, the sleeplessness persists, 
 the hypodermic injection of morphine combined with atropine 
 must be resorted to. 
 
 Sleeplessness occurs in connection with many other diseases 
 of the liver, such as congestion and cirrhosis, affections which 
 are most frequently induced by improper ingesta; the sleep 
 disturbance they inaugurate is therefore considered under 
 other headings. It is also occasioned by neuralgic ailments 
 and gall stones, in which it is obviously due to the pain they 
 cause. 
 
 It has long been noted in hepatitis. Dr. Johnston, writing 
 in 1818, remarks that "disturbed sleep and frightful dreams 
 accompany and precede this disease in almost every case."
 
 194 Insomnia and its Therapeutics. 
 
 Ziemssen says that in suppurative hepatitis sleep is disturbed 
 by dreams, and frequently there is more or less insomnia, and 
 that the latter " is considered by medical observers in hot cli- 
 mates to be a characteristic symptom of the disease not to be 
 accounted for by the physical suffering- or mental perturbation 
 of the invalid." 
 
 It may be that this persistent insomnia is due to the con- 
 tinuously maintained high temperature which characterizes 
 this disease. 
 
 The discussion of these diseases is obviously beyond the 
 scope of this work.
 
 CHAPTER XL 
 
 GOUT, ITS SYMPTOMS AND TREATMENT; WITH SPECIAL 
 REFERENCE TO INSOMNIA. 
 
 THIS disease is a fruitful, although not generally recognized, 
 source of insomnia. It seems convenient to consider it here. 
 
 No disease has been studied with more persistent care, and 
 yet its pathogeny is still subjudice. 
 
 That it depends upon the presence of uric acid in excess in 
 the blood is definitely known. Sir A. B. Garrod, who demon- 
 strated its presence by means of his widely-known thread ex- 
 periment, maintains that this excess is a constant accompani- 
 ment of acute and chronic gout. There are, however, many 
 contending opinions as to the causes of its retention and de- 
 fective excretion. It is impossible to attempt any discussion 
 of these moot points in these pages; the remarks concerning 
 them will be limited to those essential to the elucidation of 
 insomnia. 
 
 The late Dr. Murchison believed the presence of uric acid 
 to depend upon defective liver function, giving rise to disor- 
 dered metabolism. He averred that the normal processes by 
 which the nitrogenous elements of the food were converted 
 into urea, a soluble and easily excreted substance, became per- 
 verted so that uric acid was formed in excess; and that acid, 
 being highly insoluble and difficult to excrete, was retained in 
 the blood. To this theory it was always objected that gout 
 was not the same disease as lithaemia, and Dr. Bristowe put 
 it tersely when he wrote that Murchison "would naturally 
 consider gout to have some such relationship to the liver as 
 ureemic dropsy has to the kidney." 
 
 Garrod ascribes the retention of uric acid in the blood to 
 an inadequacy of the kidney to excrete it. He points out also 
 that in gout the sodium urate is deposited painlessly in the 
 joints. Acute gout follows the deposition, and does not cause
 
 196 Insomnia and its Therapeutics. 
 
 it. On the contrary, he believes an attack of acute gout is an 
 attempt to get rid of the uric acid. 
 
 Dr. Ord has given expression to a theory which must 
 always command thoughtful consideration. He considers that 
 the deposition of sodium urate can only take place in joints in 
 which the tissues have previously undergone alteration in 
 structure, and he credits the nervous system with part of the 
 faulty state. 
 
 Gout has been attributed to the nervous system by many 
 observers, and among them by Cullen. Sir Dyce Duckworth, 
 Dr. Ralfe, and others, believe that a special centre for gout 
 exists in the nervous system. 
 
 The excess of uric acid is therefore attributed to an exces- 
 sive formation in the liver; to a defective excretion by the 
 kidney, due either to the kidney itself or to a condition of the 
 blood unfavorable for its elimination ; and to some abnormal 
 state of the nervous structures. 
 
 A great impetus was given to the study of insomnia in 
 gout by the writings of Duckworth and Murchison in 1873 and 
 1874. The latter stated (p. 687) that the dyspeptic symptoms 
 which disturbed sleep were not associated with any obvious 
 digestive derangements. They both pointed out how prone 
 slight indiscretions in eating and drinking were to interrupt 
 sleep. The question naturally arises, Why should sleep be so 
 easily disturbed in the gouty ? The writer believes that it 
 depends primarily upon mal-nutrition of the cerebral cells, 
 which renders them irritable and impressionable. The clini- 
 cal study of gouty conditions goes far in the direction of sub- 
 stantiating this proposition. 
 
 The excess of uric acid in the blood varies from time to 
 time. It is greater, according to Garrod, previous to, and 
 during the early days of, an attack of acute gout, and it is 
 considerably less at its height and during defervescence. It 
 probably varies in like manner in the course of chronic gout. 
 Coincident with these varying quantities of uric acid in the 
 blood, the excretion is decreased and increased in like ratio. 
 It is decreased before the onset, and at the beginning, of the 
 acute seizure, and it is increased toward its termination. The 
 elimination of uric acid varies considerably at different parts 
 of the day. Dr. Haig has shown ("Wood's Med. and Surg. 
 Monographs," "Vol. V., No. 2) that it is increased after the in-
 
 Insomnia and its Therapeutics. 197 
 
 gestion of food, and he believes it to accumulate during- sleep. 
 The alkalinity of the blood is decreased in gout. Garrod has 
 recorded that it is almost neutral. 
 
 The products of cerebral activity or waste are acid. Dr. 
 Lauder Brunton has suggested that alkalinity of the blood is 
 an important factor in the removal of these acid products. It 
 seems to follow that blood, only slightly alkaline, is peculiarly 
 unsuitable for the depurative process. Cells imperfectly de- 
 prived of their detritus do not appear to take up oxygen 
 readily, and consequently they cannot be adequately nour- 
 ished. Hence, they grow excitable and hyper-perceptive, and 
 so responsive to faint impressions. Eventually they assume 
 a state allied to that met with in neurasthenia. It is before 
 the onset, and during the first days of, a paroxysm of acute 
 gout, that the symptoms of mal-nutrition of the nervous sys- 
 tem are most marked. They vary from time to time in the 
 course of chronic gout. They correspond to the periods when 
 the blood is known to be most surcharged with uric acid, and 
 to be least alkaline. 
 
 The evidence of malnutrition of the nervous system is 
 abundant. During the day it is evinced by the patient in 
 moodiness and depression of spirits, sometimes amounting 
 almost to hypochondriasis. At all times testy, he is apt to 
 lose his temper from trivial causes. He is restless and fidgety. 
 At night his sleep is liable to be disturbed and dream-laden. 
 He often grinds his teeth during his slumbers. When sleep is 
 interrupted his heart is usually palpitating indicative of per- 
 turbed cardiac centres. In the morning he has a headache, 
 indicating an altered cerebral condition. He suffers from 
 fugitive pains in various parts of the body. Sir James Paget 
 pointed out that gout mainly affects the sensory portions of 
 the nervous system. Eventually, it is not uncommon to find 
 the patient presenting all the symptoms described under the 
 head of neurasthenia. If such a patient comes under treat- 
 ment for the first time the gouty origin is very apt to be over- 
 looked. 
 
 It has been suggested that uric acid acts directly upon the 
 cerebral cells, and if this be the case the depuration of the 
 products of waste might be an equally difficult matter. The 
 writer believes the lessened alkalinity of the blood to be the 
 important cause. Some confirmation of this view was lately
 
 198 Insomnia and its Therapeutics. 
 
 gained from the observations of Ehrlich, to which Lauder 
 Brunton called attention. Brunton writes : 
 
 " You will remember that the gray substance of the brain 
 is possessed of a great power of reduction, as shown by the 
 readiness with which it reduces aniline colors after death; but 
 during life the necessity for oxygen is so great that it retains 
 within it a sufficient quantity of stored-up oxygen to prevent 
 such reduction taking place under ordinary circumstances. 
 But if its functional activity be augmented by stimulation, its 
 store of oxygen is used up, and thus it becomes ready at once 
 to reduce. Its very activity, however, gives rise to the forma- 
 tion of acid products, which lessen its reducing power, so that 
 the mere supply of fresh oxygen would not be sufficient to re- 
 store it to its previous condition unless the acid were neutral- 
 ized. Arterial blood supplies both these requirements, neu- 
 tralizing the acid and giving off oxygen to the brain cells/' 
 
 From these data we may conclude that the presence of 
 acid products in the cerebral cells alters in some respect their 
 constitution. We can also comprehend the explanation of 
 the persistence of gouty insomnia during months or years, in 
 spite of the use of hypnotics; and, on the other hand, why it 
 yields to the use of remedies which augment the excretion of 
 uric acid. 
 
 Insomnia may, however, depend to some extent upon an 
 increased arterial tension. In the early stages of the gouty 
 habit this is frequently increased, as it is in most cases of dis- 
 ordered metabolism. At first it is not constant, and it may 
 vary considerably, probably with the quantity of uric acid 
 retained in the system. This would well explain the different 
 qualities of sleep in the same persons at different times. In 
 the later stages arterial tension is dependent upon changes in 
 the blood-vessels of an organic nature, and this is associated 
 with sleeplessness of a more persistent and constant kind. 
 
 It seems to the writer that if centres for gout are eventu- 
 ally found to exist in the medulla oblongata, the frequency 
 with which circulatory derangements interfere with sleep will 
 be even more easily explained. In this connection it is worthy 
 of mention that glycosuria a symptom of gout can be in- 
 duced artificially by puncture of the vaso-motor centres. 
 Landois and Stirling write: "When the vaso-motor nerves, 
 which proceed from this centre to the liver, are cut or par-
 
 Insomnia and its Therapeutics. 199 
 
 atyzed in any part of their course, mellituria or glycosuria is 
 produced." 
 
 It may be asked why sleeplessness does not uniformly 
 affect all gouty persons, instead of some more than others. 
 Duckworth gives an excellent answer to such a question: 
 " Many sufferers have no troubles connected with the sleeping- 
 state, just as many have no urinary difficulties, no hemicrania, 
 and no tophi." A still further answer will probably be found 
 in this, that it is chiefly those possessing- cerebral cells con- 
 genitally defective in stamina who suffer most severely from 
 sleep disturbance. In gout, as in fevers, those sleep best who 
 have "strong" nervous systems. The rule, to which there 
 are few exceptions, must be remembered, that diseases expend 
 themselves for the most part upon the most vulnerable tex- 
 tures. Irregular gout is usually met with in the lean neurotic, 
 who from his temperament is peculiarly liable to sleeplessness. 
 Moreover, in such cases the true origin of the insomnia may 
 be unrecognized. 
 
 ACUTE GOUT. 
 
 Paroxysms of sthenic gout are met with most frequently 
 in males of sanguine temperament. Increased restlessness 
 and irritability by day and sleeplessness by night are common 
 premonitory symptoms. When the paroxysm supervenes, 
 sleep is prevented by pain and by febrile sj-mptoms. A quick- 
 ened pulse and an increased temperature are constantly pres- 
 ent. The onset usually takes place during sleep between 
 two and five in the morning; under favorable circumstances 
 the pain yields, and sleep returns toward morning. In the 
 evening the pain and febrile symptoms recur with such sever- 
 ity as to prevent sleep, and these nocturnal exacerbations dis- 
 turb sleep during several successive nights. 
 
 Treatment. The treatment of this form of insomnia is 
 that of gout itself. Colchicum is the remedy for gouty pain; 
 it should be given with sodium salicylate internally, in doses 
 suited to the individual patient. Opiates are best avoided. 
 Garrod remarks: " Cullen thus answers the question: 'Opi- 
 ates give the most certain relief from pain, yet when given in 
 the beginning of a gouty paroxysm they cause it to return 
 with greater violence.' . . . My own experience has led me to 
 form a very similar opinion, and in the majority of gouty
 
 2OO Insomnia and its Therapeutics. 
 
 cases, unless the pain be very excessive, or there be fear that 
 if not relieved the patient's nervous system will suffer, I always 
 feel disposed to withhold their administration, and trust to 
 other means, as opiates tend so powerfully to diminish the 
 secretions and to augment congestion of the portal system." 
 Chloral and like hypnotics are useless, as they do not influence 
 pain. 
 
 Externally, soothing applications afford some relief. Opium, 
 belladonna, and lithium citrate with morphine are all useful. 
 In some cases tincture of iodine alleviates the pain. 
 
 IRREGULAR GOUT. 
 
 It is chiefly to irregular gout that we wish to refer. This 
 'is most obscure in its nature. It seems quite certain that 
 uric acid can give rise to disease in almost every texture of 
 the body, without being deposited in them, or without giving 
 rise to any of the ordinary or usual manifestations of gout. 
 Indeed, the most extensive organic changes may supervene, 
 and proceed to a fatal termination, so insidiously and pain- 
 lessly that they may fail to attract the notice of the victim or 
 his friends. 
 
 The symptoms of irregular gout are obscure and ill-defined, 
 and they vary considerably with the textures they implicate. 
 There are two symptoms, however, which are seldom absent, 
 even in the most vague instances; these are, an increased 
 vascular tension and sleep disturbance. When these occur in 
 conjunction one with another they afford a valuable clue to 
 the line of investigation. 
 
 We must briefty survey the usual symptoms of chronic or 
 irregular gout as they affect the various systems. 
 
 . The Nervous System. This is variously affected. Head- 
 ache, vertigo, and migraine are by no means uncommon. 
 Noises in the head, often very pronounced and distressing; 
 troublesome throbbing of the arteries of the head, most no- 
 ticed when the head is placed upon the pillow; irritation of 
 the optic nerve, as evidenced by dimness of vision and scintilla- 
 tions; sleeplessness; restlessness, or fidgets, are generally 
 present. Neuralgia is of frequent occurrence, and usually 
 takes the form of facial or cervico-brachial neuralgia, lumbago 
 or sciatica. Such neuralgias, which often come on during
 
 Insomnia and its Therapeutics. 201 
 
 sleep, are associated with increased blood -pressure, and are 
 only relieved by anti-gouty remedies. Flitting pains, occur- 
 ring 1 in various fascia? pains which are often designated rheu- 
 matic are frequently of gouty origin. They are more likely 
 to be gouty when they follow the ingestion of wine or beer. 
 Cramps in the limbs are common symptoms. They usually 
 obcur during the state of transition from waking to sleeping. 
 If they come on during sleep they interrupt it. They most 
 frequently supervene before the onset of an acute paroxysm 
 at the time when the blood is surcharged with uric acid ; just 
 as the3 T are prone to follow excessive muscular fatigue, when 
 the blood is laden with the acid products of muscle waste. 
 They are not, however, of much diagnostic value, as they occur 
 in many persons suffering from anaemia, cachexia, neurasthe- 
 nia, and dyspepsia. 
 
 All gouty affections have a predisposition to make their 
 appearance during sleep. Apoplexy is sometimes the imme- 
 diate cause of death. Cerebral mischief always portends evil. 
 The throbbing blood-vessels, tinnitus, and painful affections, 
 are all inimical to sleep. 
 
 Alimentary System. Gout initiates many derangements; 
 amongst others, acidity, flatulence, heartburn, gastralgia, 
 nausea and vomiting, and irregularity and constipation of the 
 bowels, with a tendency to haemorrhoids. Gastric disorders, so 
 slight as to be characterized by no manifest symptoms, may 
 give rise to sleep disturbance. This- is specially true of those 
 arising from trivial indiscretions in eating and drinking, and 
 from the ingestion of food to which some gouty persons are 
 intolerant. The sleeplessness of gout resembles that of hepa- 
 tic dyspepsia in this respect, but it differs from it in not always 
 arising from such causes. Flatulent distention of the stomach 
 and intestines, by emb rrassing the respiratory and cardiac 
 movements, frequently causes terrifying dreams, nightmare, 
 and disturbed sleep. Tympanites in advanced cases is a dis- 
 tressing and occasionally fatal complication. 
 
 Spasmodic dysphagia may occur. In a case under ob- 
 servation for many years it alternated with gouty eczema. 
 Gouty conditions of the mucous membrane of the pharynx are 
 common. 
 
 The Liver. Derangements of the liver are necessarily fre- 
 quent, and enter into the causation of the affection. The
 
 2O2 Insomnia and its Therapeutics. 
 
 functional ailments which have already been discussed are apt 
 to cause eatarrhal and congestive affections of the liver and 
 its ducts, which eventually lead to indurated and cirrhotic 
 forms of disease. 
 
 Circulatory System. At first there are no organic changes. 
 Palpitation, breath lessness, irregularity of the pulse, increased 
 blood-pressure, and accentuation of the second cardiac sound 
 in the aortic area, alone exist. Changes, commencing in the 
 kidneys, etc., produce thickening of the muscular coats of the 
 arteries, which thickening increases until the vessels become 
 atheromatous and tortuous, when they pulsate visibty, and 
 feel like a cord under the finger. The heart, particularly the 
 left side, hypertrophies, and its impulse becomes forcible and 
 heaving. Eventually failing, hypertrophy interferes with the 
 compensation, and the coronary arteries degenerating, origin- 
 ate retrograde changes in the muscular structures of the 
 heart, the impulse grows feeble, and dyspnrea on exertion be- 
 comes very marked. The aorta, becoming atheromatous, may 
 give rise to aneurism. Attacks of angina pectoris are of fre- 
 quent occurrence. In the early stages, arterial tension pre- 
 vents the hardened cerebral arteries from contracting their 
 lumen to lessen the blood-supply when the hour for sleeping 
 comes round, and as cerebral activity is maintained, the night 
 is spent in watching. 
 
 In the later stages the lumen of the blood-vessels may be 
 so narrowed by degenerative changes that the cerebral sub- 
 stance is even more imperfectly nourished, and sleeplessness 
 in such cases may be due to cerebral anasmia. The nutrition 
 of the brain is still further interfered with by the quality of 
 the blood; the corpuscles, or oxygen-carriers, it contains being 
 greatly diminished. If the patient gets to sleep, the effects 
 of the circulation of deficiently-oxidized and imperfectly- 
 depurated blood through the cardiac, vaso-motor, and respira- 
 tory centres in the medulla must not be overlooked. These 
 centres are working at their lowest level, and are liable to be 
 affected by such conditions; hence the nocturnal attacks of 
 palpitation and dyspnoea which so often occur. The late Dr. 
 Milner Fothergill, referring to this point, wrote : " They may 
 be due to spasm of the pulmonary capillaries, or more proba- 
 bly, to the disturbing effect of the waste-laden blood upon the 
 respiratory centres. In sleep the respiratory centre acts less
 
 Insomnia and its Therapeutics. 203 
 
 energetical!} 7 than in the waking 1 state is to some extent de- 
 pressed, in other words; and the waste-laden blood probably 
 further depresses it, till an attack of dyspnoea is the result." 
 The miseiy endured by a patient suffering from an enlarged 
 heart, atheromatous vessels, and an abnormal blood-current, 
 is occasionally very great. In the evening he nods in his 
 chair, and is quite worn out with sleep ; whenever he lies down 
 in bed he becomes wide awake, and lies counting hour after 
 hour; if he dozes, it is to wake up in a start, arid toward 
 morning 1 , when quite exhausted, he may get two or three 
 hours' sleep. This morning sleep seems, in most cases, to 
 depend upon the lowering of the circulation which takes place 
 at that hour. 
 
 The veins are frequently the seat of inflammatory changes, 
 and the pain these affections cause interferes with sleep. 
 
 Respiratory System. The circulation of blood (possessing- 
 qualities just detailed) through the respiratory centres brings 
 in its train asthmatic attacks, and these are more frequent 
 during the night. It initiates catarrhal conditions of the 
 mucous membrane of the nose, throat, and bronchial tubes, 
 and it often gives rise to bronchitis. In the later stages the 
 lesions of the heart may secondarily cause pneumonic consoli- 
 dation as well as pleurisy and hydrothorax. 
 
 Urinary System. Reference has already been made to the 
 condition of the kidney. The constant circulation through it 
 of blood surcharged with uric acid leads to irritation of its 
 structures, and eventually to cirrhosis. In the early days of 
 the irritative stage the urine may be of high specific gravity, 
 of deep color, laden with pink urates which deposit on cooling, 
 or with crystals of uric acid. As the disease advances, inter- 
 stitial changes in the kidneys progress, until eventually the 
 cortical substance is practically destroyed, while concurrently 
 the heart and arteries are implicated and the vascular pressure 
 is. greatly augmented. The urine, as a consequence, is in- 
 creased in quantity, and may be quite clear and even pale. 
 The solids may not be diminished, for the urea per ounce, mul- 
 tiplied by the number of ounces passed, shows that an almost 
 normal amount is excreted in twenty-four hours. This is not 
 always the case. The writer, for example, has long had under 
 observation a patient who, during the past two years, has not 
 excreted more than two hundred and fifty grains of urea in
 
 204 Insomnia and its Therapeutics. 
 
 any twenty-four hours, and the amount has occasionally not 
 exceeded one hundred and fifty grains. Yet this patient lives 
 her life fairly well, suffering* almost no discomfort, and the 
 most pronounced complaint is of disturbed nights. It seems 
 probable from this and similar cases that many persons, the 
 subjects of gouty kidneys, can, on careful diet and regimen, 
 exist for long periods, excreting- urea in much smaller quanti- 
 ties than are supposed to be normal. Albumin in faint traces 
 may appear in the urine from time to time, and tube-casts 
 also, hyaline and granular. They require, however, to be 
 carefully searched for, and their detection is by no means es- 
 sential to the diagnosis. Dropsy is rare, usually not amount- 
 ing to more than oedema of the conjunct! vee, of the eyelids, or 
 to a fulness of the ankles toward night. Frequent micturi- 
 tion is usually present throughout the whole course of the 
 disease. Much light is thrown upon such cases by the oph- 
 thalmoscope, as albuminuric retinitis is present in many in- 
 stances. The habitual use of this instrument is not to be 
 omitted in connection with obstinate cases of insomnia. 
 
 Goutj*- glycosuria, depending upon impairment of the liver, 
 and upon an inability to store up glycogen, by setting up vul- 
 var pruritus, interferes with sleep. Pruritus vulvas and ec- 
 zema of the prepuce should always suggest sugar in the urine, 
 or, at least, gouty disease. 
 
 Integumentary. Uric acid in the blood appears to give 
 rise to marked irritation in the skin. Sir Charles Scudamore 
 wrote: "And a distressing itching, particularly affecting the 
 back and arms, is very much complained of by those who are 
 liable to gout. It not unusually occurs as one of the premoni- 
 tory S3 T mptoms. An erythematous rash, and urticaria, or 
 nettle-rash, also occur; and in one remarkable instance I saw 
 the latter irritation exist in a violent degree, during two days 
 before the paroxysm; to which, and the treatment adopted, 
 it immediate]}' 3 r ielded." Erythema intertrigo under the 
 breasts, in the groins, and round the genitals is, in some cases, 
 most troublesome, as the itching it causes always grows 
 worse at night, and prevents and disturbs sleep. Eczema, 
 too, is a common symptom. It is usually bilateral. The less 
 acute forms are often persistent, and difficult to cure. The 
 active varieties are intractable, and prone to interfere with 
 sleep. The violent paroxysms of itching to which they give
 
 Insomnia and its Therapeutics. 205 
 
 rise not only interrupt sleep, but they prevent its return. 
 The exhaustion which such seizures induce, combined with the 
 loss of sleep, may imperil life. They certainly aggravate the 
 affection. General itching- of the skin and pruritus ani are 
 frequently present, and interfere with sleep. 
 
 There is a class of gouty patients who, although not suffer- 
 ing from any of these pronounced abnormal cutaneous condi- 
 tions, have harsh and dry skins skins that do not easily per- 
 spire. These persons are unusually prone to sleep disturbance 
 and asthmatic seizures, and relief from these symptoms is sel- 
 dom obtained until the skin becomes softer, and assumes 
 healthier functions. 
 
 Tophi in the ear are the source of annoyance from the pain 
 they cause when the head is laid on the pillow. 
 
 Patients suffering from gout are almost constantly dis- 
 turbed with burning sensations in the palms of the hands and 
 the soles of the feet; the skin of the former being often very 
 red and tender. A patient observed upon one occasion that 
 he could sleep quite well if he had no hands or feet. 
 
 Swelling of the subcutaneous tissue is sometimes the source 
 of discomfort, and is chiefly seen in the back and haunches. 
 
 In cases where any or most of the foregoing symptoms 
 are pronounced, no difficulty in the diagnosis presents itself. 
 When, however, sleeplessness is the only symptom, care is re- 
 quired to trace it to its true source. The history of the sleep 
 habit is always helpful. It closely resembles that described 
 by Dr. Murchison, which is quoted under the heading of hepa- 
 tic dyspepsia (page 687). The patient usually gets to sleep 
 quickly after going to bed, to awake at two or three A.M., and 
 to remain wakeful for hours, usually falling- asleep again an 
 hour or two before the time for rising. He gets up worn out 
 and dejected, indeed more tired than when he went to bed. 
 Generally he suffers no discomfort during his wakefulness, 
 but at times he is afflicted with fidgets, and occasionally with 
 restlessness so considerable that he is compelled to rise and 
 wander about. The sleeplessness is increased by all indis- 
 cretions in eating and drinking. As a rule, such patients sleep 
 better in summer and in warm climates than in winter and in 
 cold regions, provided always that the heat is not excessive. 
 The warmth appears to promote sleep by relaxing the vascu- 
 lar tension.
 
 206 Insomnia and its TJierapeutics. 
 
 The diagnosis rests mainly upon the general symptoms of 
 gout, particularly upon the condition of the vascular tension 
 and of the urine. The teeth sometimes afford a clue, those 
 well-enamelled being frequently seen in the gouty, while in 
 some cases they are worn away by constant friction, from the 
 grinding of the teeth both by day and night that is so charac- 
 teristic of the disease. The liability to cramps in the limbs 
 and to flushings of the body, and to burnings of the palms of 
 the hands and the soles of the feet, are all indicative of gout. 
 The occurrence of gouty nodes on the fingers, or of nails 
 striated longitudinally, throws much light upon a case. The 
 physiognomy of gouty persons so ably depicted by Lay cock 
 is worthy of careful study. The origin of some very obscure 
 cases may be rendered clear if they quickly yield to anti-gouty 
 treatment. This, although an unsatisfactory line of diagnosis, 
 has the sanction of high authority. It is a clumsy method, 
 and one which a physician should avoid, as every surgeon does 
 the use of an exploring needle in the diagnosis of deep-seated 
 suppuration. With care it should be unnecessary. 
 
 Causes of Gout. These are so numerous that we can only 
 refer to a few of them. First must be placed the predisposing 
 cause of heredity. Garrod estimates it in hospital patients at 
 50 per cent, and in private cases at 75 per cent. Heredity 
 does not throw any light upon the source of gout, as an in- 
 adequate liver, inadequate kidneys, a tendency to degenera- 
 tion in certain structures, leading to the deposition of urate 
 salts, as well as disordered centres for gout, are each and all 
 capable of being transmitted hereditarily. They are likewise 
 capable of being originated anew, and of being transmitted to 
 the offspring. Males, probably on account of their habits and 
 mode of living, are more subject to it than females. In women 
 it seldom shows itself before the menopause, and its develop- 
 ment then is the source of much of the insomnia which attends 
 that epoch. 
 
 The absence of a distinct history must not be too much 
 relied upon. The symptoms and signs of gout must be inter- 
 preted without such a guide. The following will illustrate a 
 not infrequent experience. The writer, early in his career, 
 was consulted by a lady advanced in years, whose life was 
 rendered unbearable by sleeplessness, her only other symptom 
 being an occasional attack of migraine. Examination dis-
 
 Insomnia and its Therapeutics. 207 
 
 closed the fact that she was suffering 1 from high arterial ten- 
 sion, and the opinion given was, that she was the subject of 
 irregular gout. There was not, so far as could be discovered, 
 any history of gout, but that meant only that no ancestor 
 had been pronounced gouty. Abstemious and frugal in her 
 habits to the last degree, and active physically, she had lived 
 a life that was not calculated to have created the disease 
 anew. The diagnosis admitted of no uncertainty, and that 
 the gout was hereditary the writer never doubted. She died 
 eight years afterward of ursemic symptoms from cirrhotic 
 kidneys, and during these years the gradual diminution of 
 urea and uric acid excreted was noted, coincidently with grow- 
 ing changes in the heart and blood-vessels. At the same time 
 the manifestations of irregular gout were observed in her 
 grown-up family. Her eldest child died at the menopause 
 from cirrhotic kidneys with the usual complications; the 
 second is now, and has been for many years, the subject of 
 gouty glycosuria; the third maintains a moderate amount of 
 health by frequently visiting German spas; while the fourth 
 has tophi in his ear, and suffers from gouty irregularity of the 
 heart. 
 
 It may be caused de. novo by the use of foods, in quantity 
 or quality, such as throw an unusual tax upon the liver, or 
 which, by producing congestion in that organ, impair its func- 
 tional activity. These aliments may be summed up respec- 
 tively as large quantities of albuminoid, oleaginous, and sac- 
 charine substances; and excessive quantities of spirits, wines, 
 and malt liquors. Gout may be developed by a life of luxury 
 and ease, and by the daily neglect of an adequate amount of 
 exercise. It is also caused by deficient supply of oxygen, in- 
 terfering with the oxidizing processes of the liver. This may 
 be brought about by living and sleeping in badly-ventilated 
 apartments. It may arise from over-fatigue, depressing emo- 
 tions, great excitement, excesses of all kinds which debilitate 
 the system, as also from the ingestion of lead. It occurs more 
 commonly in damp cold weather. 
 
 It is met with in every part of the globe, but, according to 
 Hirsch, it is rare in the tropics. It has been well recognized 
 since the days of Hippocrates, and has always followed in the 
 train of luxury, affluence, and self-indulgence. Hirsch believes 
 it does not now prevail to the same extent that it once did.
 
 208 Insomnia and its Therapeutics. 
 
 It exists in greater proportion in England than in Scotland 
 and Ireland. Sir Charles Scudamore in 1817 wrote : " In Scot- 
 land, gout is much more rare than in England. In Edin- 
 burgh, where the habits of the people approach the nearest 
 to those of London, it is found most; but it is scarcely ever 
 known among the inferior classes." ... "In Glasgow, the 
 gout is very rare, even among the higher classes." He attri- 
 buted this to the people drinking whiskey and living chiefly 
 on farinaceous and other vegetable diet, which he believed 
 initiated diabetes and not gout. 
 
 The writer, however, is of opinion that gout is not a rare 
 disease in Scotland, and he believes that it has never been so 
 rare as some writers have supposed. The evidence is certainly 
 conflicting. When Sir Charles Scudamore recorded the rarity 
 of gout in Glasgow, he presented his work on that subject to 
 an eminent physician in that important centre, a work which 
 two years ago (through the kindness of the sole survivor of 
 that gentleman) came into the writer's possession. It is 
 somewhat curious that many of that physician's ancestors 
 had suffered from gout, and that his wife came from an old 
 and honorable family who could number many victims to the 
 same disease, perhaps exceeding in number the total cases 
 which Sir Charles believed to exist in Scotland. Scudamore 
 apparently forgot that Scotland had given London the illus- 
 trious Hunters, William and John, both of whom suffered 
 from gout. It is affirmed that they were abstemious men, 
 and therefore were not likely to develop the disease afresh. 
 So far from its occurring from the accident of residence in 
 London, we have the late Professor Laycock's assurance that 
 their father " had at least one of the diseases of the gouty 
 habit, namely, ( gravel.' " No one who has visited their birth- 
 place in the parish of East Kilbride can believe that luxury 
 ever abounded there. 
 
 Further, if gout has been such a rare disease in Scotland, 
 it seems inexplicable how Cullen, whose writings on gout are 
 still studied, though a century has elapsed since he penned 
 them, should have found cases for study, as he never practised 
 except in Edinburgh and Glasgow. Notwithstanding his 
 high position and brilliant fame, which must have attracted 
 to him many of the wealthier classes from distant parts, it 
 seems reasonable to suppose, that he must necessarily have 
 studied acute gout in the people among whom he lived.
 
 Insomnia and its Therapeutics. 209 
 
 Again, it is be\*ond question that Laycoek, than whom no 
 man ever left his personality more firmly impressed upon the 
 literature of gouty disease, must necessarily have studied the 
 malady during- the last twenty years of his life in Edinburgh. 
 
 Garrod, in discussing the influence of alcoholic drinks, 
 states, upon the authority of Dr. (afterward Sir Robert) 
 Christison, that cases of gout are seldom seen in Scotland. 
 Against that must be placed the opinion of Warburton Begbie, 
 who had the most ample opportunities in hospital and private, 
 as well as consulting practice, of accurately estimating its 
 prevalence, and he distinctly expressed his dissent by saying 
 he could not confirm the statement that gout occurred very 
 rarely. Still more recently Fothergill and Duckworth have 
 expressed their opinions that gout is rare north of the Tweed. 
 
 Professor Grainger Stewart of Edinburgh, in a letter to 
 the writer, states : " My experience satisfies me that gout and 
 gouty disorders are of very frequent occurrence among the 
 wealthier classes in Scotland, for I see its manifestations con- 
 stantly in my consulting room, and in cases to which I am 
 called. But it is rare among hospital patients." 
 
 The writer, who in Stirlingshire and Ayrshire had ample 
 opportunities of studying disease, is in concord with Stewart; 
 but he would add that gout is prevalent among the middle 
 classes, and that its manifestations are occasionally to be met 
 with among the working population. He is quite unable to 
 agree with the opinion that diabetes is unusually common in 
 Scotland, for he did not meet with that disease frequently; 
 upon the other hand, he had at one time, in his own practice, 
 as many as eight cases of gouty glycosuria under observation. 
 The suspicion, therefore, arises that some at least of the cases 
 referred to by Scudamore may have been glycosuric; hence 
 gouty. 
 
 These cases are interesting from a diagnostic point of 
 view, as four of the subjects came seeking advice for sleep- 
 lessness, three for pruritus vulvas, and one for eczema of the 
 prepuce; in each case the glycosuria was discovered in inves- 
 tigating the cause of the symptom. 
 
 This question of gout in Scotland has been raised for the 
 purpose, mainly, of expressing the opinion that the use of 
 whiskey is not so free from the risk of engendering gout as 
 some suppose.
 
 2io Insomnia and its Therapeutics. 
 
 Treatment. It goes without saying 1 that the treatment of 
 gouty insomnia is practically that of the disease itself. We 
 shall, therefore, briefly indicate it. 
 
 The first aim must be to remove from the blood the excess 
 of the uric acid which contaminates it; and second, to arrange 
 the patient's life and regimen so as to prevent its further ex- 
 cessive formation and reaccumulation. 
 
 One of the conditions responsible for the excess of uric acid 
 must be held clearly in view an impaired liver; for it is only 
 by regulating the work imposed upon that organ, in accord- 
 ance with its functional activity, that the abnormal formation 
 can be obviated. 
 
 There is an overwhelming accumulation of evidence to 
 show that in no disease is the life and health of an individual 
 so entirely in his own hands as in gout. He can, if he will, do 
 much to procure immunity from his enemy, and to enjoy a 
 healthy and active life. The supplies must be cut down to 
 the actual requirements of the body, so that waste-products 
 may not be allowed to accumulate. It is specially necessary 
 that nitrogenous substances should not be taken in larger- 
 quantity than is needed for tissue formation; while the amount 
 of starches, sugars, and fats consumed should be such as can 
 be quickly and easily digested and assimilated. 
 
 The meals should be fixed at regular hours, and mastica- 
 tion slowly and thoroughly performed. Late meals are un- 
 desirable, the best hour for dinner (which ought to be a light 
 repast) being 7 o'clock, and luncheon should constitute the 
 most substantial meal of the day. A few general indications 
 may be added as regards diet. 
 
 All meat should be well kept and plainly cooked, white 
 meat being preferred to brown. The best forms are, mutton 
 and lamb, lamb's head or calf's head, sweetbread (the throat 
 is the best), tripe, game, and poultry. Fat bacon is admissi- 
 ble at breakfast. Beef, pork, and veal are best avoided. 
 
 Soups (not too strong), such as clear, white, oyster, or 
 made with white fish, are all good. 
 
 Fish, as sole, turbot, brill, halibut, plaice, whiting, or raw 
 oysters, is very suitable. 
 
 Eggs must be eaten sparingly. 
 
 Milk and milky puddings (without eggs) and farinaceous 
 foods of all kinds.
 
 Insomnia and its Therapeutics. 21 1 
 
 All vegetables (excepting- rhubarb, tomatoes, sorrel, as- 
 paragus, broad-beans, and peas), provided they do not cause 
 flatulence. 
 
 Ripe fruits, either cooked or uncooked, when they agree, 
 are excellent. 
 
 Saccharine and oleaginous matters are to be eaten spar- 
 ingly, tending as they do to produce dyspeptic disturbance. 
 
 It is absolutely necessary that a quantity of fluid be taken 
 daily, as diluents promote the excretion of the solids. The 
 best of all is pure water, and a tumblerful (warm or cold) 
 should be sipped every morning during dressing, and another 
 of Apollinaris or seltzer-water before bedtime. Skim milk 
 and whey are good diluents. Tea and coffee are to be taken 
 sparingly, as they retard digestion and, like alcohol, hinder 
 tissue-metamorphosis. 
 
 If the patient is strong he should eschew alcohol in every 
 form, but when some stimulant is deemed advisable, the 
 quantity should be limited and taken with meals only. Malt 
 liquors and heavy wines, as burgund}^ port, or sherry, must 
 be forbidden. The best forms are light claret, hock, sauterne, 
 and well -matured dry champagne. Champagne disagrees 
 with many gout3 r persons, but it suits an equal number better 
 than any other wine, just as Amontillado agrees with a small 
 minority; and when experience dictates such a fact it is not 
 to be ignored. Sparkling hock is a light and agreeable stimu- 
 lant, which suits many patients well. Whiskey and unsweet- 
 ened gin freely diluted with an alkaline water are admissible. 
 Upon the ground that gout was unknown (?) in Scotland, a 
 country famous for the consumption of whiskey, that stimu- 
 lant has been largely prescribed in gouty cases. Time will 
 probably show that it is not so free from objection as is sup- 
 posed. 
 
 It remains to be added that though the great proportion 
 of gouty persons are best treated upon the lines just indicated, 
 there are some who do not get on well upon such a regimen. 
 Their idiosyncrasies rebel, and they are better in every way 
 upon food and stimulant restricted in quantity only. Some 
 of the most troublesome cases of irregular gout are met with 
 in the most abstemious and in tea drinkers. Many who look 
 strong and plethoric bear lowering treatment very badly. 
 
 The late Dr. Parkes, in his work on Practical Hygiene,
 
 212 Insomnia and its TJierapeutics. 
 
 states that the standard daily diet for an adult man should 
 consist of 
 
 Nitrogen, . 316.5 grains. 
 
 Carbon, 4862. 
 
 Salts, 461. 
 
 and he gives the following table, which indicates the constitu- 
 ents of ordinary food : 
 
 ONE OUNCE (=437.5 grs.) CONTAINS IN ITS 
 SUBSTANCE. NATURAL STATE IN GRAINS : 
 
 Water. Nitrogen. Carbon. Salts. 
 
 Uncooked meat (beef) 328 10.35 64 7 
 
 Uncooked fat meat (beef) 275.6 9.6 98.3 16 
 
 Cooked meat 236 19 117.7 13 
 
 Bread 175 5.5 119 5.6 
 
 Wheat flour 65.6 7.6 169 7.4 
 
 Biscuit 35 22.7 183 7.4 
 
 Rice 43.7 3.5 176 2.2 
 
 Oatmeal (Letheby's numbers) 65.6 8.7 172 13 
 
 Maize 59 7 176 6 
 
 Peas 65.6 15 161 10 
 
 Potatoes 324 1 49 4.4 
 
 Carrots 398 1.4 18 3 
 
 Butter 26 .2 315 11.8 
 
 Egg 321 9.3 71.5 4.4 
 
 Cheese 161 23 162 23.6 
 
 Milk 380 2.75 30.8 2.6 
 
 Sugar 13 .... 187 2 
 
 The clothing should be light and warm to promote the 
 free action of the skin, and to prevent the occurrence of chills. 
 Exercise is probably par excellence the best of all the means 
 of treatment^ Bodily activity must therefore be enjoined. 
 It is essential that it be taken in the open air, as a plentiful 
 supply of oxygen is needed. Horse exercise is the best of all, 
 as it increases the functional activity of the liver, and relieves 
 plethora of the abdominal viscera. Fatigue and all depress- 
 ing influences must be avoided. 4 
 
 A fair amount of mental work is beneficial to health, and 
 promotes sleep. Overwork, on the contrary, is detrimental. 
 
 The morning bath is best tepid, and soap should be freely 
 used, the soap being of suitable quality. The Turkish bath, 
 taken under medical advice, is of great service. The sham- 
 pooing is of special service. 
 
 A mild and dry climate suits the gouty best, and it con- 
 duces to improved sleep. 
 
 Mineral waters have long been sought after by the gouty,
 
 Insomnia and its Therapeutics. 213 
 
 and, conjoined with altered methods of living, such as early 
 hours, plain and simple feeding, with change of air and scene, 
 they are frequently highly beneficial. In this country the 
 waters of Bath, Cheltenham, Harrogate, Buxton, Droitvvich, 
 Leamington, Woodhall, Moffat and Strathpeffer are chiefly in 
 request. Abroad, the spas are without number, each possess- 
 ing certain climatic advantages, and the waters differing in 
 constituents and temperature. The resort in each case must 
 be selected with special reference to these factors. Among 
 them may be named Vichy, Horn burg, Carlsbad, Marienbad, 
 Contrexeville, Kissingen, Wiesbaden, and, when arthritic 
 troubles are present, Aix-les-Bains and Luchon. 
 
 General Medication. The emunctories must be kept in 
 an active state. The skin has been alluded to, and also the 
 kidneys in connection with the use of diluents. The bowels 
 should be moved daily. 
 
 To reduce arterial tension in the earlier stages of the affec- 
 tion, and to promote the excretion of uric acid, certain medi- 
 cines which act upon the liver and kidneys are useful. Dr. 
 Noel Paton recently ascertained from his experiments upon 
 dog's that "the formation of urea in the liver bears a very 
 direct relationship to the secretion of bile by that organ," 
 and also " that drugs which increase the quantity of bile in dogs 
 . . . also increase the urea in the urine " (Landois and Stirling). 
 This is exactly in accordance with clinical experience. An 
 occasional dose of calomel or blue pill at night, followed in 
 the morning by a dose of Friedrichshall, Piillna, or Hunyadi- 
 Janos water, or of sodium sulphate, is always beneficial. If, 
 for any reason, it is desired to avoid mercury, then podophyl- 
 lin, euonymin, leptandrin, and iridin with coloc3 r nth or colchi- 
 cum may be employed separately or in combination. Colchi- 
 cum has a very decided influence on the excretion of urea and 
 uric acid, and no reliable evidence has yet been forthcoming 
 that its use is attended by any bad effects, as has been so fre- 
 quently and popularly alleged ; on the other hand, there is a 
 large consensus of opinion as to its utility. The following is 
 a useful pill in persons who are robust: 
 
 3 Pil. hydrarg., gr. i. 
 
 Pil. coloc. co., gr. iij. 
 
 Ext. colchic. acet., gr. i. 
 
 Ft. pil. i. Sig. Take at bedtime.
 
 214 Insomnia and its Therapeutics. 
 
 Sulphur is in many cases a valuable remedy : 
 
 $ Pulv. guaiac., 3 v. 
 
 Sulphur, lact., 3 iij. 
 
 Mel. dep., 3 vi. 
 
 Pulv. glycyrr., gr. xx. 
 
 Ft. elect. Take a piece the size of a hazelnut at bedtime. 
 
 The alkalies, such as the salts of potassium and lithium, 
 by entering- into combination with the uric acid, and forming- 
 soluble salts, promote the excretion of the acid The sodium 
 salts forming urate of soda, which is highly insoluble, are to 
 be avoided. Potassium iodide, and bicarbonate, and sodium 
 salicylate are useful remedies, their action being promoted by 
 free dilution. Sal ammoniac is likewise a reliable drug, pro- 
 moting the excretion of solids. In dyspeptic conditions, alka- 
 lies should be given after meals, and the use of alkaline waters 
 during meals avoided, as likely to increase the acidity. The 
 following powder is serviceable : 
 
 fy Bicarb, potass., 
 
 Garb, magnes. pond., 
 
 Garb, bismuth., aa 3 iij. 
 
 Pulv. aromat. co., 3 i. 
 
 M. Sig. Take a teaspoonful in water after meals when 
 required. 
 
 When flatulence is troublesome some charcoal or sulpho- 
 carbolate of sodium may be added to it. The following pill 
 is useful : 
 
 $ Terebinth. Chiae, . . . . . gr. iiss. 
 
 Gum. galban., gr. iss. 
 
 Pulv. ipecac., gr. f . 
 
 Ft. pil. i. Sig. Take one night and morning. 
 
 Should tympanites be pronounced, electricity (the continu- 
 ous current) will often enable the bowel to pass the flatus on- 
 ward. Quinine or Warburg's tincture, injected into the bowel, 
 are also reliable agents. An enema of the infusion of rue is an 
 efficacious remedy. 
 
 The cardiac symptoms require attention. In the early 
 stages of the disease tincture of aconite controls excitement 
 and palpitation, and relaxes vascular tension. In angina 
 pectoris the nitrites are called for; they also relieve the mi-
 
 Insomnia and its Therapeutics. 215 
 
 graine and headache which occasionally prove troublesome. 
 In the stage of failing 1 compensation of the heart digitalis and 
 ferruginous tonics may be required, and it is advantageous to 
 mix them with sal ammoniac. 
 
 IJ Hydrochlor. ammon., 3 iv. 
 
 Tinct. ferri. mur. (Ed. Ph.), . . . . 3 iv. 
 
 Tinct. digital., 3 i. 
 
 Glycerin., i. 
 
 Aq. chlorof ., ad vi. 
 
 M. Big-. Take a tablespoonful in water thrice daily after 
 meals. 
 
 Digitalis must be given cautiously, as it may precipitate 
 an apoplectic seizure by raising- still further the blood-pressure. 
 Asthmatic and bronchitic attacks yield to ordinary treatment 
 for gout. Nocturnal dyspnoea, depending- upon undue irrita- 
 bility or impressionability of the respiratory centres, is at 
 times relieved by the following- : 
 
 IJ Tinct. belladon., 3 ij. 
 
 Liq. strychn., 3 i. 
 
 Spt. ammon. arom., . . . . . 3 vi. 
 
 Spt. chlorof., . 3 vi. 
 
 Aquam, ad vi. 
 
 M. Sig-. Take a tablespoonful in water at five P.M., at bed- 
 time, and during- the nig-ht if required. 
 
 Irritability of the bladder is alleviated by potassium bro- 
 mide and henbane. 
 
 Neuralgia needs special as well as g-eneral treatment; 
 local applications of camphor-chloral or menthol, with the 
 internal administration of sal ammoniac, afford good results 
 (p. 637). Antipyrine likewise acts well, but it has the objec- 
 tion of raising the blood-pressure. Many cases of gouty lum- 
 bago yield to acupuncture, and also to dry cupping, as sciatica 
 does to blistering 1 , and muscular pains to deep massage. Mor- 
 phine, however, has to be resorted to when the pain is urgent 
 and severe. 
 
 When cramps in the limbs tend to recur at night, the 
 avoidance of excessive muscular fatigue must be enjoined. If 
 that cannot be dispensed with, a warm bath at bedtime and 
 a draught of lithium citrate, or potassium bicarbonate, with a
 
 2i6 Insomnia and its Therapeutics. 
 
 full dose of sumbul or camphor, will probably avert the seiz- 
 ure. Amylene hydrate has been greatly lauded in this trou- 
 blesome ailment. It is averred that cramps do not occur so 
 frequently in persons who sleep with the head of the bed well 
 raised. A high pillow is not sufficient. For immediate relief 
 when the cramps come on, nothing- answers so well and quickly 
 a^s turning out to stand upon a piece of cold wax-cloth at the 
 side of the bed. 
 
 Affections of the skin must be sedulously attended to, as 
 they always disturb sleep. General pruritus may be relieved 
 by warm alkaline baths, or by lotions, as boracic acid, potas- 
 sium bromide, or carbolic acid. A solution of menthol has 
 been recommended, but it not rarely hinders sleep by the cold 
 sensation it produces, as well as by its smell (p. 633). 
 
 In acute eczema every effort must be made to allay the 
 paroxysmal itching, and to promote sleep. The nightly ad- 
 ministration of cannabis indica, hyoscyamus, camphor mono- 
 bromide, or belladonna, either given alone or in combination, 
 will insure this. In urgent cases morphine may be required. 
 Diuretics and mild mercurials must be given, and if arsenic 
 be prescribed, its effects should be carefully observed, as it 
 occasionally increases the distress. Localty, the exposure of 
 the surfaces to the air and frequent washings must be avoided. 
 Dusting the parts with boracic acid, lycopodium, or oxide of 
 zinc, and protecting them with starch poultices, are suitable 
 remedies. In the subacute cases, ointments spread on linen 
 should be carefully laid over the parts to exclude the air. The 
 following have been found useful : Bismuth subnitrate, 6 parts; 
 zinc oxide, 1 part; cerat. Galeni, q.s. to make a soft ointment; 
 zinc carbonate, 6 parts; salicylic acid, 1 part; cerat. Galeni, a 
 sufficiency to make an ointment; or boracic acid ointment. 
 In chronic cases zinc ointment, containing either carbolic acid, 
 tar or ichthyol, are suitable. In dry and chronic cases the itch- 
 ing is quickly relieved by sulphurous acid. 
 
 Pruritus ani must be treated locally as well as generally; 
 sponging the parts with hot water at bedtime and then ap- 
 plying one or other of the following remedies usually affords 
 relief. Dusting with equal parts of powdered sulphur and 
 oxide of zinc, or applying calomel ointment ( 3 i. to 3 i.), co- 
 caine ointment (10 to 20 per cent), black wash, carbolic acid 
 lotion (1 to 100).
 
 Insomnia and its Therapeutics. 217 
 
 5 Acid, hydrocy. (Scheele's), . . . 3ij. 
 
 Sulph. zinc., . . . . . . . 3 ss. 
 
 Oxid. zinc., ' . . . { . . . 3 ij. 
 
 Glycerin., ... . . . . . . i. 
 
 Aq., . . . . . . . . ad | vi. 
 
 M. Sig. Apply at bedtime. 
 
 When there are small cracks or fissures in the skin round 
 the anus, verdigris ointment often answers admirably. Mild 
 mercurials with small doses of sulphur, as in the above formulae, 
 are useful remedies. 
 
 If the sensation of burning- in the soles of the feet hinder 
 sleep, it may, in some instances, be relieved by an india-rubber 
 bag- filled with cool or cold water, which can be used or dis- 
 carded at pleasure. 
 
 Sleeplessness will frequently yield to the foregoing regi- 
 men, and require no special treatment. If it does not, attention 
 must be paid to the temperature of the sleeping- apartment, 
 for if it is a few degrees higher or lower than the sitting-room 
 it may cause wakefulness. 
 
 Douching 1 the head with luke-warm water, a hot foot-bath, 
 a wet pack, or friction of the body at bedtime, are all useful 
 aids to sleep. Dr. Broadbent has suggested lying- with the 
 back of the neck on a hot bottle. It has, however, always 
 seemed doubtful to the writer whether such an aid as this did 
 not frequently act as a disturbant. The following has been 
 found a useful remedy in the early stages. 
 
 # Tinct. aconit. (B. P.), m iij. 
 
 Tinct. belladon., ""I x. 
 
 Bicarb, potass., gr. xx. 
 
 Aqua* menth. pip., i ij. 
 
 M. Sig. Take at bedtime. 
 
 It is also efficacious taken a few minutes after awaking. 
 A whiff of nitrite of amyl, or a dose of Carlsbad salts, are 
 both useful on awaking. 
 
 In severe cases it is well to apply leeches to the temples, 
 and repeat them as often as it is necessary. Chloral hydrate 
 and paraldehyde are the best hypnotics. Opiates and mor- 
 phine are always hurtful. 
 
 In the later stages the nitrites are the best hypnotics : two
 
 218 Insomnia and its Therapeutics. 
 
 grains of sodium nitrite thrice daily, with an occasional sniff 
 of amyl nitrite during- the night, seldom fails to do good. The 
 \vriter has seen two minims of a one-per-cent solution of nitro- 
 g-lycerin given at bedtime induce sleep which lasted nine 
 hours.
 
 OHAPTEE XII. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 CIRCULATORY SYSTEM. 
 
 IN every case of insomnia, the causation of which cannot 
 be traced to some disorder of the nervous or digestive sys- 
 tems, or to derangement of the metabolic processes, it is nec- 
 essary to inquire most narrowly into the state of the heart 
 and blood-vessels ; for participating-, as they do, with the nerv- 
 ous system in the daily-increasing wear and tear of life, they 
 not infrequently become impaired by the strain they are called 
 upon to bear. Many of the diseases that so arise become the 
 sources of insomnia. 
 
 Organic changes in the heart and blood-vessels may orig- 
 inate, and insidiously increase, until they develop into positive 
 and alarming lesions, without exciting the attention of the 
 victim; and it is not until some secondary affection, such as 
 dyspepsia or insomnia, attracts his notice, that he seeks ad- 
 vice. Indeed, he comes on account of symptoms which he 
 does not attribute to his heart, and among which perturba- 
 tion of sleep is one of the most common and significant. 
 
 It has been often and truly said, that a patient suffering 
 from heart disease seldom seeks aid for it. On the other 
 hand, those who ask counsel for symptoms which they deem 
 due to cardiac disease, are either the subjects of neurosal affec- 
 tions or do not suffer from any disease of the heart at all. It 
 is indeed rare that a patient connects his want of sleep with 
 his heart, unless he is suffering from that very apparent and 
 distressing symptom, palpitation. Yet, there is scarcely a 
 derangement of the heart, either functional or organic, which 
 does not modify the distribution of blood in the brain and 
 nervous system to some extent. This altered blood-supply is 
 almost invariably attended by disturbed sleep, nightmare, or 
 dreaming, and, in some instances, by persistent insomnia.
 
 220 Insomnia and its Therapeutics. 
 
 Alterations in the cerebral circulation arise from causes 
 interfering" with the normal rhythmic action of the heart, such 
 as occurs in cardiac excitement ; from alterations in the tone 
 and lumen of the arteries, capillaries, and veins, leading- to 
 modifications of blood-pressure and to venous stasis; and 
 from variation in the quantity or quality of the blood trans- 
 mitted. Such vascularization is inimical to sleep, for among 
 the conditions essential for good sleep are, a heart beating- 
 quietly and slowly, and a lowered arterial tension. It is only 
 by scrutinizing all these points closely, and searching for 
 sig-ns of heart disease, that this source of sleeplessness can be 
 disclosed, and its relief effected. 
 
 It is proposed, first, to briefly allude to the most usual 
 symptoms of heart disease which prevent sleep, namely, pal- 
 pitation, dyspnoea, Cheyne-Stokes' respiration, cardialgia, and 
 angina pectoris; and then, in a few words, to refer to sleep- 
 lessness as it occurs in some valvular diseases, in fatty degen- 
 eration of the heart, and in aneurism. 
 
 Palpitation. Among- the numerous symptoms of func- 
 tional and organic affections of the heart, which interfere with 
 sleep, palpitation holds the first place. It may present itself 
 at any hour during- the day or night, either in trivial degree 
 or in the most urg-ent form ; in the latter, the heart beats vig- 
 orously and tumultuously, causing the walls of the chest to 
 heave and the larger blood-vessels of the body to throb and 
 pulsate visibly. 
 
 Palpitation may be a symptom of organic disease of the 
 heart, the structural changes being commonly those of degen- 
 eration, or hypertrophy of the muscular walls, or dilatation 
 of the cavities; or it may be caused by aneurism. It appears 
 chiefly after exertion when the heart is coping with defective 
 conditions and quickened movements, struggling, in short, in 
 its weakened state, to discharge, temporarily, work more 
 laborious than usual. 
 
 ' Functional palpitation is met with usually in younger per- 
 sons, and is either associated with hremic changes, neurosal 
 derang-ements, or toxic causes. Frequently it is more severe 
 in character than the organic. 
 
 Palpitation from haemic disorder depends upon two causes, 
 blood faultily formed and imperfectly depurated. 
 
 Examples of the former are to be found in those suffering
 
 Insomnia and its Therapeutics. 221 
 
 from anaemia, chlorosis, and from debility, however brought 
 about ; in which states the quality of the blood is impaired, 
 and the blood pressure modified, the cardiac centres perceiv- 
 ing- and resenting- quickly an imperfectly oxyg-enated blood 
 circulating- through them. Examples of the latter are to be 
 found in those suffering from defective metabolism, as in 
 gout, etc. 
 
 The neurosal cases can usually be traced to overwork, 
 worry, excesses, over-excitement of the passions or affections, 
 hysteria, or to sources of reflex irritation, e.g., dyspepsia and 
 other derang-ements of the gastro-intestinal canal, worms, 
 ovarian or uterine disorder, and spinal irritation. 
 
 The toxic causes embrace the indiscreet use of tobacco, tea, 
 and alcohol. 
 
 It occurs invariably in exophthalmic g-oitre. That which 
 supervenes in hysterical patients (male or female) is associ- 
 ated with heightened blood tension constriction of the arteri- 
 oles as evidenced by the copious secretion of colorless urine. 
 
 The diagnosis between palpitation depending- upon organic 
 disease, and functional disorder, must rest largely upon the 
 presence or absence of physical signs of org-anic heart disease. 
 It is more probably organic when the pulse is irregular; when 
 murmurs indicative of valvular lesions are heard; or when the 
 heart is enlarged. We may conclude it is organic if we find 
 any of the common secondary effects of heart disease, such 
 as dropsy, are present; or that the palpitation and the ac- 
 companying dyspnrea are set up and further aggravated by 
 exertion; or when we find the attack is not severe, and occurs 
 only as an exacerbation of a more permanent disorder. 
 
 On the other hand, it is more likely to be functional when 
 the pulse is intermittent; when murmurs are absent, or if 
 present, most distinctly heard at the base and in the large 
 vessels of the neck, their intensity being increased by the erect 
 posture; when the heart is of small size; when the attacks 
 are severe and paroxysmal in character, and when they come 
 on during rest, and are benefited by exercise. 
 
 Palpitation, whether of organic or functional origin, is 
 liable to prevent the onset of sleep, and to interrupt it when 
 it has ensued. In the latter case severe attacks, occurring at 
 distant intervals and traceable to some exciting cause, are 
 invariably functional; while attacks less severe, recurring fre-
 
 222 Insomnia and its Therapeutics. 
 
 quentty without apparent reason, are generally organic in 
 their genesis. 
 
 The late Sir Thomas Watson wrote : " I must caution you, 
 however, against the mistake which is often made, of infer- 
 ring that the heart is free from organic change because its 
 irregular movements are accompanied by dyspeptic symp- 
 toms. Structural disease of that organ is very apt to derange 
 the digestive functions. You will commonly find that patients 
 who labor under such disease are exceedingly liable to flatu- 
 lence of the stomach, and free eructation of the gas which 
 plagued them mitigates wonderfully the cardiac distress. It 
 does so, no doubt, by relieving the diaphragm from that up- 
 ward pressure which embarrassed the motions of the heart." 
 ..." The age, and frequently the sex, of the patient form 
 leading points in the' diagnosis. Nervous palpitations are 
 apt to come on when the patient is quite at rest : palpitations 
 that result from organic disease are, on the contrar} 7 , miti- 
 gated, usually, by repose. The occurrence of palpitations in 
 the night, however, is but an equivocal circumstance, for nerv- 
 ous persons who dream, awake often with palpitation; and 
 the recumbent posture is apt to excite or to aggravate the 
 palpitations that are organic/' 
 
 Palpitation may be excited during sleep by tying on the 
 left side, by large accumulations of flatus in the stomach, and 
 by all perturbing impressions arising in the economy. These 
 impressions being transmitted to the cardiac centres in the 
 medulla, and then reflected through the sympathetic to the 
 heart, instigate disorderly and excited movements, which 
 arouse the sleeper; and the throbbing of the heart, and pulsa- 
 tions of the vessels, dyspnoea, and feelings of oppression, com- 
 bined with mental agitation, prevent the recurrence of sleep 
 for some hours. 
 
 The distress which palpitation causes is occasional^ so 
 great as to make the patient afraid to fall asleep again, lest it 
 should return. In the majority of cases, it is the hypersemia 
 of the brain that interferes with sleep, hyperaemia being in- 
 separable from an accelerated action of the heart, and an in- 
 creased blood-pressure. 
 
 Treatment. In each and every case the exciting cause 
 must be obviated. When it depends upon weakness of the 
 muscular walls, or upon dilatation of the cavities of the heart,
 
 Insomnia and its Therapeutics. 223 
 
 patients should be counselled to avoid exertion or strain, and 
 not to lie on the left side. The food should be highly nutritious, 
 and as concentrated as possible; stimulant being 1 allowed up 
 to the limit of promoting the digestive processes. 
 
 Digitalis and convallaria majalis are the remedies most 
 called for. 
 
 I Tinct. digital., 3 ij. 
 
 Tinct. nucis vom., 3 iss. 
 
 Spt. ammon. arom., 3 vi. 
 
 Aq. chlorof., ad | vi. 
 
 M. Sig. Take a tablespoonful every three or four hours 
 in water. 
 
 Or, 
 
 $ Ext. convall. maj., 3 i. 
 
 Tinct. scill., 3 ij. 
 
 Syr. prun. virg., . . . . . . f iss. 
 
 Aquam, . ad vi. 
 
 M. Sig. Take a tablespoonful very three or four hours in 
 water. 
 
 The digitalis must not be pushed to the point of nauseat- 
 ing, nor the convallaria to that of relaxing the bowels. In 
 some very pronounced cases where these measures failed, the 
 writer has got excellent results from 2-grain doses of citrate 
 of caffeine thrice daily, with cold-water compresses applied 
 over the cardiac region, as recommended by Schrotter. Some 
 able physicians caution against the use of these cold applica- 
 tions, but the writer, who has employed them in a large num- 
 ber of selected cases of palpitation, arising both from organic 
 and functional diseases of the heart, has never met with any 
 untoward result from their judicious employment. 
 
 During the attack the patient should be propped up in bed; 
 and bromide of potassium may be cautiously given, along 
 with a stimulant, such as brandy and water. Morphine in 
 small stimulating doses of gr. -f g to gr. T V administered hypo- 
 dermicalry, is of great service, often giving instantaneous 
 relief. In palpitation, occurring at the close of a long and ex- 
 hausting illness and causing much distress and sleeplessness, 
 morphine, evon in minute doses, is not free from risk, as it oc- 
 casionally induces the sleep that knows no waking, and that
 
 224 Insomnia and its Therapeutics. 
 
 without producing- any of the symptoms of morphine poison- 
 ing. In such cases the induction of perspiration is the most 
 suitable remed3 7 , for in them, as in almost all forms of palpita- 
 tion, sweating- seldom fails to give more speedy relief than 
 any sedative medicine. 
 
 In the aged, no remedy seems to relieve palpitation and 
 promote sleep so well as a teaspoonful of sal volatile and 
 chloric ether; in equal parts, in water, frequentty repeated. 
 
 In palpitation in connection with hypertrophy of the heart, 
 as in the gouty, the diet must be attended to, nitrogenous 
 food being- limited, and stimulants forbidden. 
 
 5, lod. potass., . . . . . . . 3 ij. 
 
 Bicarb, potass., . . . . . . 3 iij. 
 
 Tinct. cimicifug-., . , . . . . 3 vi. 
 
 Infus. serpent. . . . . ad vi. 
 
 M. Sig. Take a tablespoonful thrice daily in water. 
 
 If the arterial tension be pronounced, TT[ ij. of tincture of 
 aconite (B. P.) may be added to each dose. During- the attack, 
 20 grains of chloral hydrate, or from 2 to 8 grains of the tan- 
 nate of cannabin, or 45 minims of paraldehyde, may be given. 
 
 The treatment of palpitation due to functional causes may 
 be considered under the following heads : 
 
 Hcemic. The diet and regimen must be reg-ulated in ac- 
 cordance with the sug-g-estions already given under the head 
 of cerebral anaemia. Cardiac tonics are required, while the 
 manufacture of blood-corpuscles is encouraged. 
 
 ]J Pulv. digital., g-r. ss. 
 
 Arsen. sodii, gr. -fo. 
 
 Ferri redact., gr. iv. 
 
 Ext. calumb., q. s. 
 
 Ft. pil. i. Sig. Take one pill after meals thrice daily. 
 
 For immediate relief the following is useful : 
 
 ^ Brom. potass., 3 iij. 
 
 Spt. chlorof., 3 vi. 
 
 Mist, camph., ad vi. 
 
 M. Sig. Take a tablespoonful every hour or two. 
 
 When it is due to the effects of disordered metabolism, 
 without any hypertrophy of the heart, the diet and regimen 
 must be arrang-ed suitably; while mercurial purg-atives and
 
 Insomnia and its Therapeutics. 225 
 
 aconite with alkalies are indicated. For immediate relief the 
 following- will be found useful: 
 
 # Tinct. hyoscy., . . . . . . 3 ss. 
 
 Tinct. cannab. ind., . . . . . . ill x. 
 
 Mucil. acac., 3 ij. 
 
 Aq. camph., ... . . . ad 3 ij. 
 
 M. f. h. Sig. Take at once. 
 
 The skin in such cases demands unusual attention, an occa- 
 sional perspiration being- invaluable. Soap should be freely 
 used. 
 
 Neurosal palpitation, such as arises from conditions which 
 induce neurasthenia, requires the diet and regimen to be ad- 
 justed on the lines laid down when writing on the latter sub- 
 ject. Exercise is important, and gymnastics are to be pre- 
 ferred to walking. In those in whom it depends primarily 
 upon ungratified desires, nymphomania, etc., the mental ener- 
 gies must be directed into new and healthy channels, and all 
 exciting literature and day-dreaming avoided. Cold or tepid 
 baths are daily required. Turkish baths are also beneficial. 
 Tonics, as quinine, phosphorus, and strychnine, are useful. 
 For the attack, the patient should have cold applications over 
 the heart, and if it has disturbed sleep, he may wander about 
 the bedroom taking an air bath, and sipping occasionally 
 some cold water. The valerianates, with ammonia, camphor, 
 and chloric ether, may be given freely. Monobromide of cam- 
 phor is also a reliable remedy. When palpitation is due to 
 reflex irritation, as disorders of the gastro-intestinal canal, or 
 of the uterus, ovaries, etc., these causes must be remedied, ere 
 improvement can be obtained. 
 
 Toxic palpitation requires the abandonment of the poison- 
 ing agent, e.gr., tea or tobacco. 
 
 Dyspnoea. This is a symptom of almost every form of 
 heart disease and aneurism. It is distinct from the breath- 
 lessness which characterizes pulmonary and other complaints, 
 and which will not be discussed here. In the graver cardiac 
 lesions it is often associated with palpitation, Cheyne-Stokes' 
 respiration, cardiac pain, and angina pectoris, although it 
 may alone be present. It may exist in very varying degrees, 
 in some instances being so slight as to be perceived only after 
 exertion, or when breathing a close atmosphere. Some pa-
 
 226 Insomnia and its Therapeutics. 
 
 tients experience it only when sleeping- in a badly-ventilated 
 bedroom, and obtain relief simply by opening the door or win- 
 dow. In other cases it comes on paroxysinally, usually during- 
 sleep, and when that is deepest, at a time when the respira- 
 tory centres are working 1 at their lowest possible level, and 
 consequently more liable to be affected by an altered vascular 
 supply. The implication of the medullary centres is further 
 evidenced by the sickness and vomiting, which occasionally 
 terminate these nocturnal attacks. Irritability of these cen- 
 tres once initiated may cause breathlessness from the most 
 trifling excitations, or perpetuate it for a time after they are 
 removed. Lastly, dyspnoea may be constant and distressing, 
 amounting 1 to orthopncea, and in such cases the symptom is 
 greatly aggravated if any attempt be made to resume the 
 recumbent posture. This severe breathlessness is usually 
 associated with mitral or other org-anic disease in an advanced 
 stage, in which dropsy is general, and has supervened in the 
 larger cavities of the body, as also in aortic aneurism. 
 
 Dyspnoea depends chiefly upon poisoning of the respiratory 
 centres with inadequately oxyg-enated blood, and this may 
 arise from an excess of carbonic acid in the blood, the result 
 of impeded circulation in the lung's ; or it may be due to a 
 want of oxyg-en, as in anaemia, in which there is a scarcity of 
 oxygen-carrying corpuscles. It is excited by blood imperfectly 
 depurated, as in lithiasis, and especially is this the case, when 
 the arterial tension is increased. 
 
 In patients predisposed to its invasion, it may be inaugu- 
 rated in several ways, e.g., by sleeping- in an atmosphere defi- 
 cient in oxygen. The respirations during sleep, being 1 fewer 
 and shallower, the want of oxygen is more quickly felt than 
 when the respirations are more frequent and deeper. By im- 
 pressions transmitted to the respiratory centres. In health, 
 such sensations modify the character of the breathing during- 
 sleep ; it is not, therefore, surprising that in diseased condi- 
 tions they should initiate dyspnoea. They may arise in any 
 part of the economy, and they frequently do so in the gastro- 
 intestinal canal. By causes which embarrass the free move- 
 ments of the heart and lungs, as occurs when the diaphragm is 
 pushed up by a distended stomach, an incident most likely to 
 happen in the recumbent posture during sleep. 
 
 Treatment. It is impossible to discuss the treatment of
 
 Insomnia and its Therapeutics. 227 
 
 dyspnoea satisfactorily, apart from the conditions upon which 
 it depends. We may, however, indicate generally its main 
 lines. 
 
 Posture is of the first importance. The patient should 
 either be well propped up in bed, or sit in a chair, so that the 
 capacity of the chest may be increased as much as possible. 
 
 The air of the room should be pure, while an equable tem- 
 perature is maintained, and draughts avoided. 
 
 The digestive processes must be attended to, and all de- 
 rangements rectified. 
 
 In those grave cases of advanced disease, associated with 
 relaxed vascular tension, digitalis, convallaria majalis, or 
 strophanthus, with stimulants, such as ammonia, chloric ether, 
 etc., must be pushed freely. If the attack terminates sleep, 
 a minute dose of morphine (gr. T ^) should be injected hypoder- 
 mically. 
 
 When the tension is increased, as in lithiasis, nitrite of 
 sodium, nitrite of amyl, or nitro-glycerin, must be resorted 
 to. Anaemia must be treated in the usual way, arsenic being 
 preferred to iron. A dose of chloral hydrate, with potassium 
 bromide, is suitable for combating the seizure. Belladonna, 
 given every two, three, or four hours, will be found very effica- 
 cious. It is alleged that its alkaloid, atropine, acts upon the 
 constrictor fibres of the vagus, paralyzing them. 
 
 Cheyne-Stokes' Respiration. This peculiar form of res- 
 piration, first recognized by Hippocrates, has been variously 
 designated rhythmical dyspncea, ascending and descending 
 respiration, etc. It was so carefully studied by Dr. Cheyne 
 and Dr. Stokes that their names are now commonly asso- 
 ciated with it. 
 
 It is met with chiefly in diseases of the heart and head ; 
 but it has also been observed in febrile affections, as typhoid 
 fever, diphtheria, and erysipelas; and in morphine and chloral 
 poisoning. 
 
 It is usually a symptom of the graver forms of heart dis- 
 ease, such as fatty degeneration, dilatations of the cavities and 
 aortic lesions, and sometimes occurs in the process of dying. 
 The causation of this symptom is obscure; certainly it is not 
 definitely known. Tizzoni discovered " histological alterations 
 in the bulb and pneumogastric nerves." The late Dr. War- 
 burton Begbie, in discussing the historical case of Philiscus,
 
 228 Insomnia and its TJierapeutics. 
 
 detailed by Hippocrates, said : " Sleeplessness was a notable 
 feature; and although the febrile condition under which the 
 patient labored ma} 7 be the explanation of this symptom, it is 
 at least as reasonable to suppose that the neurosis of the 
 vagus on which the peculiarity of his breathing- depended was 
 its cause." 
 
 Such respiration prevents the onset of sleep. The abject 
 misery which a patient, thoroughly worn out, suffers in strug- 
 gling to get to sleep is very great indeed, and can only be 
 realized by those who have experienced its terrors. If sleep 
 be not obtained, the downward progress is greatly accelerated. 
 
 Treatment. Besides the treatment of the disease upon 
 which it depends, morphine and atrophine, hypodermically in- 
 jected, are the two remedies worthy of confidence. The doses 
 should be as small as is consistent with the production of sleep. 
 
 Pain and Angina Pectoris. These are by no means rare 
 concomitants of heart disease, indeed pain, more or less intense, 
 is a frequent symptom of cardiac and aneurismal affections. 
 Cardialgia, or what may be designated pseudo-angina, varies 
 in its severity and duration; it may be slight and fleeting, or 
 severe and lasting.. It usually radiates through the chest 
 and back, but it may affect the neck and jaws; it is neuralgic 
 in character, and is apt to be mistaken for that ailment, espe- 
 cially when it occurs in those whose nutrition is defective. It 
 may awaken a patient from his sleep, and sometimes in a 
 terrifying dream, which causes him great distress. A patient 
 lately told the writer that she was only conscious of dreaming 
 thrice in her life, and upon each occasion (at intervals of sev- 
 eral years) she was the subject of cardiac pain. Occasionally 
 it seems to be excited by indigestion and by indiscretions in 
 eating and drinking, as well as by over-fatigue; also by anas- 
 mic conditions. 
 
 Closely allied to this, but of far more grave and terrible 
 import, is angina pectoris, or breast-pang. It is characterized 
 by paroxysmal, agonizing pain, radiating through the chest, 
 back, and arms, and accompanied by an overwhelming sensa- 
 tion of suffocation and impending death; this combination of 
 symptoms never failing to appall the sufferer. 
 
 Its pathogeny is by no means definitely ascertained. 
 Whether it affects primarily the cardiac muscle (spasm), or 
 the cardiac plexus (neurosis), is unknown. The diseases with
 
 Insomnia and its Therapeutics. 229 
 
 which it is most commonly associated are well recognized. It 
 occurs most frequently as a symptom of fatty degeneration 
 of the heart; and in diseases occasioning- a sudden constric- 
 tion in the arterioles throughout the body, causing a painful 
 distention of the cavities of the heart; in diseases of the coro- 
 nary arteries, in aortic lesions, and in aneurism; although it may 
 occur in almost every form of heart disease. That it is asso- 
 ciated with heightened tension seems undoubted. Here is 
 Dr. Balfour's view of its causation : 
 
 " I believe nwself to be justified in saying that in all proba- 
 bility the predisposing cause is anaemia of the cardiac plexus 
 of general or local origin, and that the exciting cause is some- 
 thing which directly or reflexly still further cuts off the sup- 
 ply, or in some other mode injuriously influences the cardiac 
 nerves. These exciting causes may be very various; in some 
 it may be some trifling exertion, in others the depressing in- 
 fluence of tea, tobacco, the malarious poison, or an} 7 form of 
 gastric irritation, and when the cardiac nerves are in a state 
 of great irritability the most trifling cause may give rise to a 
 severe paroxysm/' 
 
 Angina pectoris usually comes on as a consequence of 
 mental perturbation; or physical exertion; or of gastric de- 
 rangements, such as distention. It may occur at any hour 
 of the day or night. Sleep is the common time for such seiz- 
 ures, and death has not infrequently taken place during the 
 night from this cause. The writer has found in his own prac- 
 tice that the favorite times for this occurrence at night are 
 immediately after going to bed, which he ascribes to a chill 
 in undressing raising the blood tension; about two hours after 
 falling asleep, when sleep is deepest; and about four or five 
 in the morning, when the circulation of the blood is most de- 
 pressed. 
 
 The attack may be of very short duration, or it may last 
 for a considerable time. 
 
 Treatment. It is important that the bedroom and the bed 
 should be comfortably warmed in the case of patients who 
 have suffered, or who are likely to suffer from angina pectoris, 
 so that all risk of chill may be avoided. Great attention 
 should be paid to the digestive and excretory organs, so that 
 derangements may be forestalled. Smoking and tea drinking 
 must be discountenanced. Rest of body and peace of mind
 
 230 Insomnia and its Therapeutics. 
 
 are essentially necessary; the patient should be enjoined to 
 live rather than to work. In short, the general regimen, diet, 
 and medication should be regulated in accordance with the 
 requirements of each individual case. The iodides are useful 
 in relieving pain. 
 
 $ lod. potass., ... . . .3 ij.-iv. 
 
 Liq. arsen. sodii, ... . . . 3ij.-3i. 
 
 Tinct. digital., v 3 i. 
 
 Aq. chlorof., ad 3 vi. 
 
 M. Sig. Take a tablespoonful in water three times a day. 
 
 The dose of the digitalis must be smaller than that which 
 will raise the blood-pressure unduly. 
 
 The nitrites are efficacious in allaying pain and averting 
 angina; nitro-glycerin may be given in doses of from two to 
 four minims, of a one-per-cent solution; and in the nitrite of 
 sodium in 2-grain doses three times a day. Both of these 
 medicines are more slow in their action than the nitrite of 
 amyl, but their effects are more lasting. When an attack 
 supervenes, nitrite of amyl is the best remedy; from two to 
 five minims should be inhaled quickly. Stimulants are like- 
 wise called for. Morphine is an invaluable remedy, speedily 
 alleviating the distress, and promoting sleep. 
 
 Liegeois counsels against the use of antipyrine in angina 
 pectoris, pointing out that as it is a vaso-motor constrictor it 
 may aggravate the attack. (Phila. " Medical Times," 1888.) 
 
 The careful and judicious inhalation of chloroform or ether 
 is sometimes serviceable. External applications of mustard 
 plasters, or turpentine stupes, and a hot mustard foot bath, 
 are useful adjuncts. 
 
 Mitral Insufficiency. The symptoms are well marked. 
 They depend mainly upon the engorgement of the venous and 
 capillary systems with blood, while the arterial system is 
 greatly impoverished. This leads to the overloading of all 
 the organs of the body with blood. The lungs, liver, kidneys, 
 etc., all suffer, and dropsical effusion into the cavities and sub- 
 cutaneous tissue follows. There is usually gastric catarrh; 
 and the digestive derangements which it and the hepatic dis- 
 orders cause are detrimental to sleep. Palpitation is common. 
 The pulmonary troubles being attended by breathlessness, 
 frequently demand the sitting posture for the maintenance
 
 Insomnia and its Therapeutics. 23 1| 
 
 of respiration. The pulse is small, soft, frequent, and irreg- 
 ular. 
 
 Sleeplessness is mainly due to passive congestion of the 
 brain, which leads to mal-nutrition of the cerebral cells; and 
 it is probable that sleep is still further disturbed by the ir- 
 regularity of the blood-supply. 
 
 Such patients are often unable to fall asleep; they are 
 breathless, and may suffer from Cheyne-Stokes' respiration. 
 Exhausted to the last degree, they sit propped up in a chair 
 or in bed, with heavy drooping- eyelids, gazing languidly 
 around in despair. Upon attempting to sleep they nod for a 
 moment and then awake with a start as if being suffocated, 
 and with a terrified aspect. After a short time the process is 
 repeated. If eventually they sleep, it is to start, twitch, and 
 dream, and the dreams being of a horrible description, they 
 awake in fright. In less pronounced cases, patients are apt 
 to be aroused after an hour or two, when sleep is deepest, by 
 attacks of palpitation and d3'spnoea, which prevent the return 
 of sleep for some hours. 
 
 Treatment. The first indication is to secure rest for such 
 a patient; he should be well propped up in bed to allow the 
 heart as much room to beat as possible, and to favor the 
 return of blood from the head ; indeed, in bad cases the re- 
 cumbent posture cannot be assumed. Everything likely to 
 put a strain upon the heart or to enervate the nervous system 
 must be avoided. The food should be light, nutritious, and 
 as concentrated as possible. Alcohol may be given up to the 
 point of improving digestion. The bowels must be kept active; 
 for that purpose salines, as sodium sulphate or Carlsbad salts, 
 with an occasional dose of calomel or blue pill, suit best. 
 When dropsy is present, hydragogue cathartics, as elaterium, 
 gamboge, or jalap, are required. 
 
 The best hypnotics are cardiac tonics. 
 
 # Tinct. digital., 3 ij.- 3 iij. 
 
 Liq. arsen., 3 ss. 
 
 Acet. potass., 3 vi. 
 
 Infus. scopar., ad xij. 
 
 M. Sig. Take two tablespoonfuls thrice daily between 
 meals. 
 
 In some cases the following answers well :
 
 232 Insomnia and its Therapeutics. 
 
 # Tinct. ferri raur. (Ed. Ph.), . . . 3 iv. 
 
 Hydrochlor. ammon., . . . . 3 iv. 
 
 Tinct. digital., . . , . . .3 ij.-iij. 
 
 Tinct. scill, . ... . . .3 iij. 
 
 Aq. chlorof., . . . . ad f vi. 
 
 M. Sig. Take a tablespoonful in water thrice daily. 
 
 Should the digitalis cause increased nausea or vomiting, 
 strophanthus" can be submitted for it. Convallaria, when it 
 does not purge, frequently acts well. 
 
 IJ Ext. convall. maj., fl. 3 ij. 
 
 Tinct. nucis vom., 3 ij. 
 
 Tinct. scill., 3 iij. 
 
 Syr. prun. virg., . , ' . . .3 xij. 
 
 Aq. chlorof., . . . . . . ad 3 vi. 
 
 M. Sig. Take a tablespoonful in water every six hours. 
 
 The citrate of caffeine, in doses of 2 to 4 grains three times 
 a day, is beneficial in some instances, particularly if it does 
 not produce any increase of headache. It certainly tends to 
 promote and improve sleep. 
 
 Occasionally these tonic remedies fail completely, so long 
 as the dropsical effusion persists. For its removal mercurials 
 and pilocarpine are useful, although draining the fluid off by 
 means of incisions or Southey's tubes offers advantages. 
 
 Till the improvement sets in, when sleep naturally returns, 
 hypnotics may be required. Morphine is the most reliable 
 remedy. Dr. Clifford Allbutt called attention, some years ago, 
 to the great value of hypodermic injections of morphine in 
 these cases, allowing the patient to sleep by relieving the feel- 
 ing of suffocation. Experience has confirmed his suggestion. 
 The writer believes that in small doses it acts as a tonic to 
 the heart, and therefore is a curative agent. , The best dose 
 to begin with is ^ of a grain. 
 
 Chloral hydrate should be avoided as too depressing. 
 
 Paraldehyde and urethane are good and reliable remedies 
 when morphine is contra-indicated. 
 
 The hypnotic properties of alcohol, and of diffusible stimu- 
 lants, such as chloric ether and sal volatile, must not be over- 
 looked. 
 
 Aortic Incompetence. There is usually from the first 
 some dilatation of the left ventricle, caused by the reflux of
 
 Insomnia and its Therapeutics. 233 
 
 blood, but a hypertrophic condition soon arises to compensate 
 the defective arrangement. So long as the hypertrophy over- 
 comes the incompetence things go on comfortably, but when 
 it begins to fail^ the left auricle is implicated, which in its turn 
 dilates and hypertrophies, and pulmonary embarrassment 
 ensues with all the characteristic symptoms of mitral regurgi- 
 tation. 
 
 Sleep disturbance in the early stages is inconstant; when 
 it does occur it is due to cerebral anaemia and to relaxed vas- 
 cular tension. In the later stages, when the right side of the 
 heart becomes involved, there is passive congestion super- 
 added. Many such sufferers doze and sleep in their chair 
 during the day. In the evening, quite overcome with sleep, 
 they go to bed, but immediately on assuming the recumbent 
 posture they become wakeful, and spend the night in watch- 
 ing. The other disturbing symptoms are palpitation, dyspnoea, 
 cough, pain, angina pectoris, and gastralgia. They are of fre- 
 quent occurence, and are peculiarly liable to come on during 
 the night. 
 
 Treatment. It is, in the main, similar to that of mitral in- 
 sufficiency, but it demands even more care. The patient must 
 be encouraged to live a quiet, regular, and uneventful life, all 
 sudden and violent exertion being interdicted. Digitalis must 
 be given more carefully than in mitral disease; the dose must 
 be limited to that which will tone the cardiac muscle, to pro- 
 mote hypertrophy without slowing the heart's action. Iron 
 and arsenic may be pushed,, and everything done to improve 
 the quality of the blood and the nutrition of the body. 
 
 For the promotion of sleep, morphine combined with atro- 
 pine is most generally applicable. Urethane, paraldehyde, 
 and sulphonal, in the order mentioned, are excellent remedies; 
 it is, however, well to combine their use with some diffusible 
 stimulant, as chloric ether, ammonia, camphor, or brandy. 
 
 In cases where the S3 r mptoms are not very pronounced, 
 the administration of nitrite of amyl, or sodium nitrite, aids 
 sleep. It is judicious to follow Dr. Lauder Brunton's advice, 
 and direct that they should be taken only in the lying posture. 
 
 Fatty Degeneration of the Heart. Sleeplessness may 
 also depend upon fatty degeneration of the heart, which is 
 not an unusual disease in the gouty, although it occurs under 
 many other conditions, notably in diseases interfering with 
 the coronary arteries, as well as in dilatations of the heart.
 
 234 Insomnia and its Therapeutics. 
 
 There may be no symptom of it at all, except dreaming 
 and disturbed sleep, and its presence may remain unsuspected 
 until death closes the scene. It is, however, more usual to 
 have evidence upon which to hinge a provisional diagnosis of 
 fattjr degeneration of the heart. The aspect changes; the 
 face becomes pale and anxious; the pupils exhibit the arcus 
 senilis; the skin, pale and glossy, assumes perhaps even an 
 unctuous appearance; the extremities are prone to become 
 cold, especially at night; the temper changes, becoming vari- 
 able and unreasonable, with feelings of weakness, and a ten- 
 dency to giddiness and fainting on making any exertion. The 
 heart's sounds are feeble; the first sound loses its distinctness, 
 the impulse becoming diffused and less powerful; sensations 
 of discomfort, which in some cases amount to pain in the car- 
 diac region, are felt ; the pulse, weak and irregular, is easily 
 quickened Toy exertion, but, at rest, it may be exceedingly 
 slow 30 to 40 per minute. Dyspnoea on exertion, with some 
 lividity, readily occurs, and this may come on from sitting in 
 a close atmosphere, so sensitive are these patients to the want 
 of air; it may be excited even by indigestion. They sleep 
 badly, dream, awake often, at times with well-marked dysp- 
 noea, or with the feeling of want of air. They ascribe their 
 awaking and asthma to the quality of the air in the room. 
 They sleep with the door ajar. 
 
 Treatment. As cardiac asthma is liable to be induced by 
 digestive derangements, the food must be carefully regulated. 
 Dry concentrated foods usually suit best; the last meal should 
 be easy of digestion. Alcohol is beneficial in this form of 
 sleeplessness, as it is in nocturnal asthma. There is truth in 
 the old saying, that a man with a weak heart should be 
 always near the brandy bottle, if seldom at it. The air of the 
 sleeping apartment should be frequently changed, and main- 
 tained at an equable temperature. Repose of mind and body 
 must be enjoined. The medicines worthy of the most confi- 
 dence are arsenic, iron, digitalis, and strychnine. The bowels 
 should be regularly moved. Sleep is promoted by the following : 
 
 ]J Spt. chloroform., 3 vij. 
 
 Spt. ammon. arom., . . . ... 3 vij. 
 
 Tinct. bellad., . . . . . . 3 ij. 
 
 M. Sig. Take a teaspoonful in water every three hours.
 
 Insomnia and its Therapeutics. 235 
 
 Also by, 
 
 1^ Bicarb, sodii, 3 ij. 
 
 Tinct. lupul., . . . ' .. . . . 3 xij. 
 Tinct. sumbul., . . . . .3 xij. 
 
 Infus. serpentar., . . . . . ad vi. 
 M. Sig. Take a tablespoonful in water at bedtime, and 
 repeat if necessary. 
 
 Morphine in small doses is admissible, but chloral hydrate 
 is best avoided. 
 
 Aortic Aneurism. There is, perhaps, no disease which is 
 attended by symptoms so diverse in their character and sever- 
 ity as aortic aneurism; there is no one in which sleep is more 
 curiously influenced; nor any in which the want of sleep is 
 more keenly felt. 
 
 So long- as a patient with an aneurism of his aorta can sleep 
 soundly, and remains free from pain, he maintains his appear- 
 ance of health and his flesh and strength; but so soon as he 
 becomes sleepless he grows worn and wan, he emaciates and 
 loses his vigor, and the fatal termination is accelerated. 
 
 It may be that a patient so affected sleeps soundly during 
 the whole course of the disease, for cases have occurred in 
 which the patient's attention was first attracted to his condi- 
 tion by noticing- a bulging- and pulsating- tumor under the skin 
 of his chest wall. 
 
 In another group of cases, sleep is more (but not gravely) 
 interfered with, where the aneurism is just above the aortic 
 valves at the sinus of Valsalva. 
 
 In the majority of cases there is much suffering and sleep- 
 lessness, and these depend upon cardiac implication leading 
 to circulatory derangements, pulmonary and bronchial impli- 
 cations, pain, and gastric and hepatic derangements. Aneur- 
 ism is usually met with in those of sanguine temperament, 
 and who have a hereditary tendency to disease of the heart 
 and blood-vessels; and at the time when active and violent 
 work is usually undertaken, from twenty to fifty years. It is 
 much more frequently seen in males than in females. 
 
 The symptoms are due to pressure of the aneurismal tumor 
 upon adjacent structures, and to changes in the heart itself. 
 Pain is seldom absent; it ranges from mere discomfort within 
 the thorax to constant and severe pain, which is either neural-
 
 236 Insomnia and its Therapeutics. 
 
 gic or anginal in character, its direction being determined by 
 the nerves it affects directly or reflexly. It is increased by 
 everything 1 (as excitement) which tends to augment the size 
 of the tumor. 
 
 Dyspnoea may be trivial and only noticeable on exertion, 
 or it may amount to persistent orthopnrea, with violent par- 
 oxysmal exacerbations. It is caused by the condition of the 
 heart, by pressure on nerves, or by mechanical interference 
 with the respiratory tract. Nocturnal seizures interrupt sleep. 
 
 Treatment. It must be held in recollection that many of 
 these symptoms that disturb sleep, as pain, dyspnoea, etc., 
 are instigated and aggravated by increased arterial pressure 
 within the aneurism; it is therefore important that the iritra- 
 arterial tension should be reduced to, and kept at, the mini- 
 mum. To accomplish this every effort must be made to se- 
 cure absolute repose of both mind and body. Best is the best 
 remedy we possess. Reference was made to the fact (p. 595) 
 that in one of Mr. TufnelPs cases the pulse fell, from this cause 
 alone, fifty thousand beats in twenty-four hours. Paroxysmal 
 attacks being influenced by position, it is necessary to give 
 this point special attention, particularly when sleep is termin- 
 ated by nocturnal seizures. 
 
 In the majority of cases the diet must be restricted. Mr. 
 Tufnell's plan was to allow four ounces of liquid and six ounces 
 of solid food at noon, and two ounces of liquids and four ounces 
 of solids night and morning. This being a rigorous diet, it is 
 seldom possible even in hospital practice to prevail upon 
 patients to adopt it in its entirety. It affords, however, a 
 good guide to the essential element of treatment. 
 
 In cases in which anaemia is pronounced, and in which the 
 anaemia does not depend upon syphilis, when every texture of 
 the body is calling loudly for oxygen, it must ever be a matter 
 for anxious consideration, whether daily driving in the open 
 air, generous diet, and a small quantity of red wine, does not 
 tend to prolong life, more than rest and restricted diet. 
 
 As a rule, stimulants should be dispensed with ; the bowels 
 kept active that all straining at stool may be avoided. Iodide 
 of potassium, besides being curative, possesses sedative prop- 
 erties of a very high order, soothing pain, relieving breathless- 
 ness, and frequently promoting sleep. Most patients bear 
 thirty grains three times a day.
 
 Insomnia and its Therapeutics. 237 
 
 Antipyrine has lately been recommended by Professor 
 Germain See, as possessing 1 the power of quieting- the heart, 
 and so favoring- coagulation, as well as alleviating distressing- 
 thoracic pain and cardiac oppression resembling angina pec- 
 toris. The writer's experience of its use in a recent case was 
 not encouraging ; it appeared to increase the distress by aug- 
 menting the arterial tension. Dr. Dujardin-Beaumetz concurs 
 with Professor See, but prefers phenacetin, which he says acts 
 as an analgesic in half the doses of antipyrine, and he adds 
 that it is not poisonous. 
 
 Individual symptoms require in many cases special treat- 
 ment. Pain is occasionally relieved by cold to the chest; at 
 other times by moderate bleedings; and also by anodyne lini- 
 ments. Dyspnoea yields to the inhalation of chloroform or 
 more quickly, perhaps, to the hypodermic injection of mor- 
 phine. When a special hypnotic is required morphine is the 
 drug.
 
 CHAPTER XIII. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 RESPIRATORY SYSTEM. 
 
 INSOMNIA is a symptom of many diseases of the respiratory 
 system, in some cases entailing merely increased discomfort, 
 in others, particularly when pronounced, undoubtedly exer- 
 cising- a prejudicial influence over the course and termination 
 of the illness. 
 
 It is a matter of common clinical experience that many 
 cases of pneumonia and bronchitis, in which sleeplessness is a 
 prominent sj^mptom, do not improve until sleep takes place, 
 either naturally or as the result of the administration of 
 drugs. During- sleep the movements of the lung-s are curtailed, 
 the amount of inspired air is diminished, the blood-supply is 
 lessened, and recuperation takes place in the heart and nerv- 
 ous system, all of which tend to promote recovery. The em- 
 barrassed lung-s and bronchial tubes improve under the influ- 
 ence of the repose in a very remarkable way. 
 
 Sleep can often be secured by relieving- the conditions upon 
 which the insomnia primarily depends, but it must be borne 
 in mind that in every case the cerebral circulation is modified 
 secondarily in some degree, and that the selection of remedial 
 ag-ents should be g-uided by the nature of these modifications. 
 Successful treatment demands that these side issues be con- 
 sidered with the same care as that bestowed upon the disease 
 itself. 
 
 Sleeplessness, although one of the symptoms of the dis- 
 eases under consideration, is in reality in many cases a precau- 
 tionary arrangement for the preservation of life. It enables the 
 patient to bring to the aid of the respiratory muscles all the 
 voluntary help he possesses to assist in carrying on the work 
 of respiration. It is therefore apparent that it must not be 
 interfered with recklessly, for in such instances as those just 
 referred to, the induction of sleep would speedily end in that
 
 Insomnia and its Therapeutics. 239 
 
 from which there is no waking 1 . In no class of diseases is it 
 more needful to remember the advice of the father of physic 
 to " do no harm." 
 
 It is proposed to review some of the causes which disturb 
 sleep in respiratory diseases; to refer to the abnormal condi- 
 tions in the nervous system which these instigate and perpetu- 
 ate; and to suggest treatment which has been found reliable 
 in practice. 
 
 Causes which disturb sleep. Among- these must be enumer- 
 ated cough, dyspnoea, pain, and increased temperature. 
 
 Regarding- cough we may premise that it depends upon 
 impressions conveyed by afferent nerves to the centres in the 
 medulla oblong-ata which preside over coughing-. These may 
 originate in the terminal ending's of the nerves in almost any 
 organ, or in the cutaneous or mucous surface of the body. 
 We know, for example, that diseases of the teeth, ear, or nose 
 are all provocative of cough, not to speak of the latter being 
 fruitful sources of asthmatic seizures. Similar causes, acting 
 in other parts of the body, may reflexly excite cough. 
 
 The characteristics of irritative cough are, that it is ex- 
 tremely frequent, spasmodic, and paroxysmal, and not accom- 
 panied (for obvious reasons) by expectoration. It is peculiarly 
 liable to disturb sleep. When the terminal endings of the 
 nerves in the respiratory tract are unduly sensitive, this de- 
 scription of cough is often excited by cold and dust-laden air; 
 these excitants are also the source of asthmatic attacks. 
 
 We are here concerned only with cough as it is excited by 
 abnormal conditions in the respiratory system. In ordinary 
 circumstances it is designed for the expulsion, from the respira- 
 tory tract, of foreign materials, or of secretions when these are 
 formed in abnormal quantity. During sleep, when the cen- 
 tres for coughing are in a state of repose, they fail to respond 
 to sensations which in waking moments would induce the 
 reflex act. 
 
 It requires a more powerful stimulus, or, in other words, a 
 larger accumulation of mucus in the tubes, to excite cough, 
 although when this does occur coughing may be unusually 
 severe on account of the greater quantity of material to be 
 got rid of. 
 
 When the mucous membrane of the bronchial tract is un- 
 duly sensitive nnd irritable, the most trifling provocations
 
 240 Insomnia and its TJicrapeutics. 
 
 initiate sensations which are transmitted in an exaggerated 
 way, giving- rise to a dry, irritating cough, which accomplishes 
 no useful purpose. This often occurs in the first stages of 
 bronchitis and whooping cough when the tubes are h3 T pera> 
 mic, in the early stages of pneumonia and phthisis pulmonalis, 
 and in laryngeal phthisis when the nerves are implicated. 
 
 Superfluous cough of this kind is a frequent source of sleep- 
 lessness, and it may most safely and advantageously be sub- 
 dued. 
 
 It is different, however, when cough is perpetuated by 
 abundant secretion, as in the advanced stages of bronchitis 
 and phthisis pulmonalis. Here the accumulation may excite 
 so much coughing as to prevent the onset of sleep, or if sleep 
 has supervened it may interrupt it temporarily, in order, if 
 possible, to clear the bronchi. When cough is out of propor- 
 tion to the work done, the excess, as it were, may be cautiously 
 curtailed, so that its frequency and severity may bear some 
 relation to the amount of expectoration. 
 
 In cases in which secretion is profuse, and where the pa- 
 tient's whole energies are required for breathing and expec- 
 torating, to induce sleep would be to ran the risk of bringing 
 about fatal asphyxia. 
 
 Severe paroxysmal coughing is occasionally due to exhaus- 
 tion and undue irritability of the medullary centres, for al- 
 though instigated by peripheral irritation the excitability 
 persists, and the reflex act continues long after the necessity 
 for it has passed away. Under certain circumstances, as, e.g., 
 in some cases of whooping cough and pulmonary phthisis, this 
 abnormal excitability exists, and the slightest stimuli, such as 
 those caused by draughts or by changes of temperature, are 
 sufficient to set up paroxysms of coughing. 
 
 Irritability of the nervous centre which governs the act of 
 coughing is exceedingly apt to spread to those in its immedi- 
 ate neighborhood, namely, the centres for vomiting and sweat- 
 ing, and the vaso-motor and cardiac centres. This explains 
 the vomiting which in pertussis and phthisis pulmonalis so 
 frequently terminates a fit of coughing; and, to a certain 
 extent, the perspiration which is such a prominent symptom 
 in the latter disease. The vaso-motor centres implicated in 
 this way, initiate hypersemic conditions of the brain, that the 
 patient may be kept awake to cough. When cough is very
 
 Insomnia and its Therapeutics 241 
 
 severe, as in pertussis, passive cerebral congestion occurs, 
 which is unfavorable both to sleep and to the proper nourish- 
 ment of the brain. The lividity of the face during- severe fits 
 of coughing in this disease testifies to the extent of the venous 
 congestion present. 
 
 Dyspnoea in diseases of the respiratory apparatus depends 
 upon many causes, and it may be slight and constant, or 
 severe and paroxysmal. It is sometimes due to constriction 
 of the lumen of the respiratory tract, as in croup, in which 
 the inspirations are prolonged and stridulous, and the urgency 
 so distressing as to be almost incompatible with sleep. As a 
 rule, the difficulty of breathing in such instances bears some 
 relation to the obstruction to be overcome. 
 
 Dyspnoea from obstruction may also be paroxysmal, and 
 if so, is almost always neurosal, and therefore specialty liable 
 to develop during sleep, and to interrupt it. This is the case 
 in the sudden seizures of laryngismus, where the spasm nar- 
 rows the larynx, impedes respiration, and causes the breath- 
 ing to be stridulous and crowing; likewise, in false croup, 
 which closely simulates genuine croup in its dyspnoea! symp- 
 toms; and also in asthma. In this last disease, the spasm 
 contracting the lumen of the bronchial tubes occasions labori- 
 ous breathing and wheezing, accompanying both expiration 
 and inspiration. The expirations are so unduly prolonged, 
 and the distress so great altogether, as to necessitate the sit- 
 ting posture, during which sleep is generally impossible. 
 Dyspnoea is less pronounced in emphysema, in which it may 
 amount merely to a prolongation of the expiration, with 
 shortness of breath, increased upon exertion; but it is more 
 marked in bronchitis, in which there is a sense of constriction, 
 oppression, and suffocation, with labored breathing. 
 
 Dyspnoea is increased by the venosity of the blood circulat- 
 ing through the respiratory centres. This depends primarity 
 upon defective aeration of the blood, as in emphysema, in 
 which duskiness of the lips and face is seldom absent. It is 
 not unusual in severe bronchitis with profuse secretion, and 
 although not often met with in phthisis pulmonalis, except as 
 the result of some complication, it is sometimes seen toward 
 the termination of the disease, when it may be so exaggerated 
 as to cause the patient to struggle for breath. Increased 
 temperature of the body invariably quickens the pulse and
 
 242 Insomnia and its Therapeutics. 
 
 respirations, and, when present, helps to increase the rapidity 
 of the breathing- due to other causes. Implication of the lung 
 tissue, as in phthisis pulmonalis and pneumonia, always occa- 
 sions an increased frequency of the respirations, in order to 
 compensate for the deficient aeration of the blood. It must 
 not be forgotten, however, as Cohnheim pointed out, that after 
 the crisis in pneumonia, when the temperature falls, all the 
 symptoms are alleviated, and the respirations become normal, 
 while the lung 1 is still hepatized to the same extent as before 
 the defervescence took place. Of equal importance are those 
 cases depending on interference with the expansion of the 
 lung, as in pleuritic effusions, etc., and those associated with 
 pain, such as pleurisy and pleuro-pneumonia, where the res- 
 pirations are voluntarily diminished in depth, and consequently 
 increased in frequency. 
 
 Pain is another of the symptoms in connection with res- 
 piratory disease which often exercises a disturbing influence 
 on sleep. It quickens the pulse and induces hypercemia of the 
 brain. The pain is usually increased Toy coughing, deep in- 
 spiration and movements, explaining the instinctive desire 
 patients have to inhibit the centres for coughing, and so sup- 
 press cough voluntarily. It varies in character from the sub- 
 sternal pain of bronchitis to the sharp and piercing pain of 
 pleurisy, and to the severe pain of a central pneumonia, in 
 which the portion of lung inflamed gives rise to considerable 
 tension on the neighboring parts, impressing the nervous sys- 
 tem unfavorably. Such cases are difficult of diagnosis, per- 
 cussion failing to elicit a dull note, or auscultation to detect 
 any abnormal sounds, until the inflammation makes its way 
 to the surface. Sleeplessness in such cases is very pronounced. 
 
 Increased body temperature, as a rule, disturbs sleep, 
 mainly in proportion to its height ; it is thus more frequently 
 a source of sleeplessness in pneumonia and acute phthisis pul- 
 monalis than in other cases, for in the former it ranges from 
 103 to 105 Fahr., and in the latter it reaches 105 Fahr. or 
 more ; and these patients often do not sleep until four, five, or 
 six A.M., when the fever remits. In bronchitis, even capillary, 
 it seldom exceeds 101 to 103 Fahr., the pulse being rapid in 
 proportion to the fever. And it is equally true of pleurisy 
 that the temperature is not high in ratio to the other symp- 
 toms.
 
 Insomnia and its Therapeutics. 243 
 
 It might here be added that the night sweats of phthisis 
 are most apt to come on during sound sleep, whether by day 
 or by night, thus accounting for their frequent occurrence 
 toward morning, when the remission of the fever admits of 
 sleep. They are always more common and more profuse 
 when coughing is unusually severe, and they tend to shorten 
 sleep, and prevent its recurrence when it has been once dis- 
 turbed. Dr. Graves wrote: "It is between three and five 
 o'clock in the morning that the inclination to sleep is strong- 
 est; it is about this time that sentinels are most apt to slum- 
 ber at their posts, and consequently attacks upon camps or 
 cities, made with the intention of effecting a surprise, are 
 usually undertaken about this period of the morning. How 
 well marked is the periodic tendency to sleep at this hour, in 
 all patients laboring under hectic fever, produced \)y what- 
 ever cause ! How often do we hear the poor sufferer complain 
 of restlessly tossing about in his bed until three or four o'clock 
 in the morning, when at last sleep, welcome although uneasy, 
 for a few hours separates the patient from his pains ! " This 
 sleep is amply accounted for by the remission of the fever and 
 the lowering of the circulation, which usually happen at that 
 hour. 
 
 The abnormal modifications of the nervous system which 
 are induced by respiratory diseases, and upon which disturbed 
 sleep really depends, will be best noted under the heading of 
 the various diseases, and treatment will also be thus consid- 
 ered. 
 
 Whooping Cough. In the first stage, that of invasion, 
 when the symptoms resemble those of an ordinary catarrh or 
 bronchitis according to their severity, disturbed sleep and 
 dreams are due to byperagmia of the brain. In the second 
 stage, when the characteristic cough becomes the marked 
 feature of the disease, there is passive congestion of the brain, 
 which, besides causing sleeplessness, accounts for the number 
 of cerebral affections which complicate the complaint. In the 
 last stage, when the paroxysms become less frequent and 
 severe, and when the patient often exhibits symptoms of ex- 
 haustion, impaired sleep is due to anaemia of the brain, and 
 night-terrors not infrequently ensue. 
 
 Treatment. The first thing is to secure satisfactory con- 
 ditions of sleep. We have seen that irritable nerves transmit
 
 244 Insomnia and its Therapeutics. 
 
 impressions very readily; hence the necessity for avoiding" 
 draughts of cold air and all impurities of atmosphere. The 
 room should be thoroughly ventilated, the temperature main- 
 tained at 65 Fahr., and the air laden with a certain amount 
 of moisture from a steam kettle. This applies to all acute 
 diseases of the bronchial tubes. In whooping- cough it is spe- 
 cially important to avoid all draughts. Dr. Eustace Smith 
 writes': " The paroxysms are often most frequent and severe 
 at night when the child is asleep. The slightest movement of 
 air across the face, such as is produced by a person walking 
 near the cot, will often excite an attack. These night seizures 
 can usually be greatly reduced in number by an expedient 
 suggested, I believe, originally by Dr. Marshall Hall. It con- 
 sists in throwing a fine rnuslin curtain over the cot at night- 
 time. The simplest plan is to have a couple of hoops arranged 
 at the ends of the cot, like the ' tilts ' of a wagon, so as to 
 support the curtain at a sufficient height. This arrangement, 
 which corresponds to the mosquito curtain used in hot cli- 
 mates, does not interfere with a free supply of oxygen, while 
 it effectually stops all wandering currents of air. So pro- 
 tected, a child will often sleep the night through without an 
 attack." 
 
 In the first stage the general treatment must be derivative 
 and depressant; expectorants with salines, and counter-irri- 
 tants, as mustard and linseed meal poultices, being useful. 
 Sleep is best induced by potassium bromide and chloral hy- 
 drate. 
 
 In the second stage, when the quantity of secretion is not 
 abundant, the centres for cough require to be soothed. The 
 bromides and belladonna are here specially called for. It is 
 curious to notice that the best remedy varies with the epi- 
 demic; what suits well in one, fails in another; while the 
 remedy that answers well in any given epidemic often does 
 so in all the cases. To get good from medicines they must be 
 pushed. In the case of belladonna, it is often marvellous to 
 note the improvement which follows the production of noisy 
 and hilarious delirium and dilatation of the pupils the physio- 
 logical effects of the drug. Grindelia is also a useful drug. 
 When there is much secretion, the nightly administration of 
 an emetic, such as sulphate of zinc or sulphate of copper, acts 
 as ah excellent hypnotic. The passive congestion of the brain
 
 Insomnia and its Therapeutics. 245 
 
 is best treated by carbonate of ammonia and digitalis, and 
 stimulants, as alcohol and musk. For a child a year old : 
 
 5 Tinct. digital., 3i. to 3ss. 
 
 Garb, ammon., gr. x. 
 
 Spt. chlorof., 3 ss. 
 
 Syr. tolu., ' 3 i. 
 
 Aquam, ad ij. 
 
 M. Sig. Give a teaspoonful three or four times a day, in 
 a little water. 
 
 Two or three drops of tincture of musk (U.S.P.) may be 
 added to each dose when there is much depression. Anti- 
 P3 r rine is said to answer well in such patients; it may be by 
 raising the blood-pressure. Paroxysmal attacks of cough 
 may be alleviated by the inhalation of chloroform. So ad- 
 vantageous is this that children, after experiencing its bene- 
 fits, will not leave one room for another until they ascertain 
 that the nurse has with her the bottle containing it. A few 
 drops sprinkled upon a handkerchief should be held to the 
 nostrils. It must be borne in mind that the fewer the fits of 
 coughing the less is the passive cerebral congestion, and the 
 better the sleep. If any hypnotic is required, chloral hydrate 
 and paraldehyde are suitable, the difficulty with the latter 
 being its taste. 
 
 In the last stage, when the paroxysmal cough is subsiding, 
 and anaemia of the brain replaces passive congestion, iron, qui- 
 nine, and alcohol are the best hypnotics. Steel wine and the gly- 
 cerin of dialyzed iron answer well, while change of air acts 
 beneficially. Moiiobromide of camphor and belladonna are 
 occasionally valuable agents. 
 
 Bronchitis. Disturbed sleep depends largely upon the 
 severity of the disease, or, in other words, upon the extent to 
 which the smaller tubes are implicated; and it is due in the 
 earlier stages to hyperaamia, and in the more advanced stages 
 to passive congestion of the brain. 
 
 Treatment. This at first must be derivative and depress- 
 ing in the majority of cases. Hot poultices of linseed meal, 
 sprinkled with cayenne pepper or mixed with mustard, or 
 turpentine stupes, should be applied to the chest and back for 
 a short time, at least twice in twenty -four hours; the chest
 
 246 Insomnia and its Therapetitics. 
 
 being- protected in the interval with a swansdown, or extra 
 flannel, jacket. Flying- blisters applied to the limbs are use- 
 ful auxiliaries. They are decided aids to sleep. It should be 
 remembered that, in some animals whose skulls had been 
 trephined, Schiller saw the arteries of the pia mater contract 
 subsequent to the application of mustard to the abdomen. 
 
 Dry cupping 1 the back and chest and a saline purgative are 
 useful expedients for depleting the brain and bronchial tubes 
 simultaneously. Tartar emetic or ipecacuanha, with nitrate 
 of potash in Mindererus' spirit, should be given every three or 
 four hours. In the gouty the following answers well: 
 
 IJ, Vini antim., * 3 ij. 
 
 Vini colch., . * . . . . 3 ij. 
 
 Liq. potass., 3 ij. 
 
 Tinct. camph. co., . . . . . . f i. 
 
 Aq. menth. pip., ad vi. 
 
 M. Sig. Take a tablespoonful every three or four hours, in 
 water. 
 
 In the early stages, when cough is not required for the 
 purpose of expelling- phleg-m, it should be curtailed. An occa- 
 sional dose of codeine effects this, and it is often sufficient to 
 induce sleep. 
 
 * 
 
 IJ Syr. codeinae, 1 i ss - 
 
 Acid, hydrocy. dil., TT[ xxiv. 
 
 Spt. chlorof., 3 ss. 
 
 M. Sig-. Take a teaspoonful in water every two hours 
 when required for the cough. 
 
 If sleep be not induced, two teaspoonfuls of the syrup of 
 chloral hydrate can be given at bedtime, and repeated in two 
 hours if necessary. Urethane is also admissible in doses of 
 from 20 to 30 grains, or 10 grains of Dover's powder; the dis- 
 advantage of the latter being its tendency to derange the 
 secretions and to constipate the bowels. 
 
 When the bronchial secretion becomes abundant, cough, 
 being a conservative measure, must not be allayed; on the 
 contrary, its expelling power should be improved, if possible, 
 by the administration of stimulants. Carbonate of ammonia 
 and nux vomica are useful remedies.
 
 Insomnia and its Therapeutics. 247 
 
 $, lodid. potass., 3 i. 
 
 Carb. ammon., 3 i. 
 
 Tinct. nucis vomic., 3 i. 
 
 Syr. prun. virg., = iss. 
 
 Aq. chlorof., ad 3 vi. 
 
 M. Sig. Take a tablespoonful every three hours. 
 
 To procure sleep at the cost of checking cough would obvi- 
 ously be highly improper. 
 
 If the secretion be very profuse, an emetic at bedtime is 
 the only admissible hypnotic. For the adult the most suitable 
 emetic is sulphate of zinc or of copper; for the child subsul- 
 phate of mercury. If sleep does not ensue, it is generally safe 
 to give a dose of paraldehyde or urethane immediately after 
 the tubes have been emptied. Opiates are contra-indicated, 
 particularly in the 3 r oung and aged. 
 
 Should the disease linger on, efforts must be made to check 
 the formation of the secretion, to sustain the strength of the 
 patient, and to increase the efficiency of the cough. The min- 
 eral acids, terebene, quebracho, tar, the benzoates, sal am- 
 moniac, ammoniacum, yerba-santa, quillaya saponaria, are all 
 useful turpentine especially so. The late Dr. Warburton 
 Begbie, describing a case of severe bronchitis, attended by 
 excessive accumulation of secretion in the bronchial tubes, 
 wrote: "An emetic suggests itself as a likety means of af- 
 fording relief, but the frequent feeble pulse, and the clammy 
 surface of the body, with features almost collapsed, and livid 
 lips, forbid its employment. Turpentine is then an alternative 
 remedy, and it is a safe one; given internally and diligently 
 applied externally, it will not unfrequently reward the confi- 
 dence which has been placed in it." 
 
 In like cases, sulphuric ether injected hypodermically in 
 3 ss. doses frequently affords good result, strengthening the 
 heart, augmenting the expelling powers of the cough, and 
 eventually inducing restorative sleep. Alcohol in its various 
 forms may be given freely in this condition. 
 
 Chronic bronchitis is benefited and sleep improved by 
 Turkish baths, and by change of residence to a suitable climate. 
 
 Asthma. Sleep in this neurosal affection is prevented by 
 the extreme difficulty in breathing, and by the passive con- 
 gestion of the brain to which it conduces. The following re-
 
 248 Insomnia and its Therapeutics. 
 
 marks do not refer to cardiac or anaemic asthma, or that which 
 pertains to gout. 
 
 Treatment. At the onset of the attack the best remedies 
 are morphine, gr. to gr. , with atropine, gr. yf^ by hypoder- 
 mic injection, and an inhalation of nitrite of an^l (TIL iij.), or 
 of chloroform. Next in order are chloral hydrate 3 ss., and 
 potassium bromide 3 ss., taken in the form of a draught, and 
 the inhalation of the fumes of Himrod's cure, or of Martin- 
 dale's pulvis lobeliae compositus. The extractum grindeliae 
 liquidum, B.P.C., in doses ranging from TH, x. to fT[ xxx., or the 
 tincture of lobelia in doses from "fT[ x. to m, xxx., may both be 
 advantageously employed. The depressing effects of the lat- 
 ter are such as to require that its action should be watched. 
 
 Massage of the spine sometimes shortens and alleviates 
 the attacks, and deserves more attention than it has hitherto 
 received. 
 
 In the intervals between the attacks, when the sleep habit 
 is poor, the treatment to be recommended requires considera- 
 tion. When the malady is reflexly occasioned by bronchitic 
 or catarrhal affections of the respiratory tract ; by gastric or 
 intestinal derangements; lay conditions arising out of a dis- 
 ordered metabolism; or by abnormal states of the nasal cavi- 
 ties, attention must be directed to the relief of these exciting 
 causes. When it results from an inherent proclivity (idio- 
 pathic ?) to the disease, either inherited or otherwise, e.g., in- 
 duced by malarial poison, the climatic conditions under which 
 the patient lives demand careful investigation. 
 
 Some patients sleep best in densely-crowded cities, others 
 in the country; many sleep badly at the seaside. Their ex- 
 perience in this respect is of the first importance in determin- 
 ing a suitable residence, for no climate, however salubrious, 
 will afford benefit unless sleep be sound and undisturbed. 
 
 Many weakly subjects improve by sojourning for some 
 months at the Cape, in Egypt, and in the Riviera, not too 
 near the coast. Others, who have a tendency to obesity, are 
 benefited by periodic visits to one or other of the spas, either 
 at home or abroad. Electricity has rendered good service in 
 some cases, particularly in those of purely neurosal origin. 
 
 In all cases attention must be paid to the digestive func- 
 tions, and Turkish baths advised, in selected cases, with a 
 view to improve the sleeping habit.
 
 Insomnia and its Therapeutics. 249 
 
 The prolonged use of iodide of potassium with arsenic, or 
 of small doses of sodium nitrite or nitre-glycerin, improves 
 sleep, and acts as a prophylactic. Paraldehyde and urethane 
 are eligible hypnotics for temporary relief. 
 
 Hay Fever. In this affection sleep is much disturbed by 
 asthmatic attacks, arising- from the irritant action which the 
 pollen of grasses sets up in the mucous membrane of the eyes, 
 nose, and respiratory tract. It must not be forgotten that 
 those afflicted with this affection are often gouty and neurotic. 
 
 Treatment. Those who are liable to this complaint should 
 at all times live carefully, but especially so in spring. This is 
 desirable for the purpose of maintaining their general health 
 at the highest possible point, so that their bodies may be as 
 little vulnerable as possible. The weakly often benefit from a 
 course of arsenic or quinine; the plethoric from ammonium 
 chloride or potassium iodide. The diathesis must be nar- 
 rowly studied. 
 
 When the season for an attack is due, a residence at die 
 seaside or in a large city is desirable; although in a very dry 
 hot summer the quantity of fine dust constantly floating 
 about in the atmosphere of a city is provocative of asthmatic 
 seizures. 
 
 When the attack supervenes the fluid extract of grindelia 
 robusta and chloral hydrate are the best remedies. Locally, 
 swabbing the nostrils with a solution of cocaine, menthol and 
 iodine in vaseline oil, carbolic douching, and the use of car- 
 bolized smelling salts, are probably the drugs which afford 
 the most relief. 
 
 Emphysema. This frequently follows in the train of re- 
 peated attacks of bronchitis and asthma, as well as whooping 
 cough, and old standing tubercular disease, and is often com- 
 plicated by sleeplessness, depending upon slight passive con- 
 gestion of the brain, which becomes more pronounced when 
 the heart gets involved. 
 
 Treatment. In the early stages, careful feeding, avoidance 
 of cold, the administration of arsenic, strychine, and cod-liver 
 oil, with discreetly regulated Turkish baths at stated inter- 
 vals, will improve sleep, and indeed the patient's whole tone. 
 In the later stages, where the heart is affected, mercurials, 
 combined with salines and diuretics, to deplete the circula- 
 tion, occasionally afford relief. Tonics, such as digitalis and
 
 250 Insomnia and its TJierapeiitics. 
 
 strychnine or nux vomica, together with a stimulant, are the 
 safest and most efficacious hypnotics. 
 
 1 Tinct. digital., 3 ij. 
 
 Liq. strychnin., 3 i. 
 
 Tinct. serpentar., 3 xij. 
 
 Aq. chlorof., ad 3 vi. 
 
 M. Sig. Take a tablespoonful thrice daily in water. 
 
 Alcohol may be allowed at bedtime, and the patient should 
 be advised to sleep with a high pillow, to facilitate the return 
 of the venous blood from the head. Paraldehyde is probably 
 the best hypnotic we possess at present for this malady. 
 
 Pneumonia. Croupous or lobar. Insomnia, in this disease, 
 depends at the onset upon increased vascular tension in the 
 cerebral circulation; during- its course, upon passive conges- 
 tion; and toward the termination, upon anaemia of the brain 
 with decreased vascular pressure. 
 
 Treatment. The observation of Cohnheim (page 740) af- 
 fords a good indication for the treatment of this insomnia. 
 As a clinical fact sleep is best secured Toy lowering the tem- 
 perature. The application of cold also acts on the cerebral 
 circulation. Schiller observed that cold compresses and the 
 cold pack produced, at first, dilatation of the arteries of the 
 pia mater, but afterward, contraction of these vessels a con- 
 dition favorable for sleep. 
 
 In the young and strong, the application of cold iced cloths 
 to the chest, frequently changed, fulfils these conditions, par- 
 ticularly if quinine and aconite be administered concurrently. 
 Aconite possesses the power of lessening the conductivity of 
 the sensory nerves, and this, by relieving pain, conduces to sleep. 
 
 $ Sulph. quinin., gr. xx. 
 
 Ext. aconit., gr. i. 
 
 Ft. pil. iv. Sig. Take two at four and six P.M. 
 
 At the onset, opium with antimony is a suitable and useful 
 combination. However, when there is much secretion, and 
 when the respirations are irregular and shallow, opiates must 
 be cautiously used. Antipyrine, given in 15-grain doses every 
 hour for four or six hours, serves a similar purpose, although 
 it acts less satisfactorily when the arterial tension is very 
 marked.
 
 Insomnia and its Therapeutics. 251 
 
 In the debilitated and aged, hot poultices may be applied 
 to the affected side, and a mixture something- like the follow- 
 ing given : 
 
 $ Garb, ammon., 3 i. 
 
 Tinct. belladon., . . . . 3 i. vel 3 iss. 
 
 Liq. strychn., 3 i. 
 
 Infus. serpentar., ad vi. 
 
 M. Sig. Take a tablespoonful every four hours in water. 
 
 When special remedies are required to promote sleep, 
 chloral hydrate with potassium bromide, or paraldehyde alone, 
 may be prescribed during the first few days; and in the later 
 stages, morphine, gr. J- to \, with atropine, gr. T ^, an hour 
 before bedtime. Sponging the body with tepid water, and a 
 timely dose of alcohol with a light meal, are often followed 
 by refreshing sleep. 
 
 In grave cases, occurring particularly among the aged, 
 and in those who have lived freely, cardiac exhaustion endan- 
 gers life. The symptoms are a running, irregular, and inter- 
 mitting pulse, 140 to 180, quickened respirations, 50 to 60, and 
 sometimes a temperature of 105 to 106 Fahr. The sufferer 
 being anxious and distressed, if he sleeps it is to mutter and 
 talk for a few moments, and then to waken with a start. Opi- 
 ates are out of the question. Such cases are too weak to sleep. 
 Sulphuric ether injected hypodermically will often, in these 
 cases, slow and steady the pulse, strengthen the heart, lower 
 the temperature, moderate the respirations, increase the power 
 to expectorate, and bring about peaceful sleep. The writer 
 has repeatedly seen apparently hopeless cases recover under 
 this treatment. In very urgent cases it must be injected every 
 hour. Alcohol and musk may be given at the same time by 
 the mouth. 
 
 Phthisis Pulmonalis. Dreams of a terrifying nature and 
 disturbed sleep are among the many premonitory symptoms 
 of this disease. So substantially true is this, that the writer 
 has been able frequently to rightly predict, from their occur- 
 rence, the onset of the disease, while as yet no other symptom 
 appeared to justify the diagnosis. They depend largely upon 
 the anaemia and digestive derangements which so frequently 
 prelude it, and initiate irritability in the cerebral cells. 
 
 Treatment. Besides attending to digestion, nutrition, and
 
 252 Insomnia and its Therapeutics, 
 
 decubitus (which latter should be that instinctively chosen by 
 the patient) the cough must be curtailed to the point of use- 
 fulness. Codeine answers well and does not derange the di- 
 gestive processes like opium or morphine a most essential 
 attribute in a debilitating disease. 
 
 IJ Codeinae, . . . . . gr. iij. vel gr. iv. 
 
 Acid, hydrocyan. dil., TTJ, xxiv. 
 
 Acid, phosphor, dil., 3 i. 
 
 Glycerin., 3 vi. 
 
 Aq. chlorof., ad vi. 
 
 M. Sig. Take a tablespoonful when the cough is trouble- 
 some, and repeat if required every two or three hours. 
 
 For a time this seldom fails to soothe and admit of sleep. 
 Where it is insufficient, ten grains of chloral hydrate, or one 
 of the following, may be given at bedtime : ten to fifteen min- 
 ims of chlorodyne; 3 ss. of the ammoniated tincture of opium 
 (Scotch paregoric elixir); 3 ss. to 3 i. of compound tincture of 
 camphor (English paregoric); each separately acts in differ- 
 ent cases satisfactorily. Occasionally it may answer the pur- 
 pose to give a morphine or cocaine lozenge, or better still a 
 few whiffs of chloroform. Alcohol at bedtime, with a flying 
 blister of mustard or turpentine, is worthy of a trial. When 
 the expectoration is copious, care must be taken not to inter- 
 fere further than to allay the superfluous coughing. Much 
 may be done by controlling the bulk of the sputum and by 
 strengthening the powers of expulsion. The acids with squills 
 and strychnine, or cubebs with wild cherry and terebene, are 
 both suitable combinations. When a direct hypnotic .is called 
 for to obtain sleep, either paraldehyde or urethane may be 
 given. 
 
 When fever runs high it must be controlled. Quinine acts 
 as a hypnotic. 
 
 IJ Sulph. quinin., gr. viij. 
 
 Pulv. digital., gr. i. 
 
 Ext. opii, gr. \. 
 
 Ft. pil. ij. Sig. Take at four P.M. and repeat at 6 P.M. 
 
 The application of cold-water cloths for an hour or two 
 before bedtime answers the same end. 
 
 In chronic cases the administration of six grains of anti-
 
 Insomnia and its Therapeutics. 253 
 
 febrine, about four and six P.M., with free sponging- with tepid 
 water at bedtime, is conducive to sleep. The inunction of 
 cocoa-nut oil is useful, the friction appearing- to promote sleep. 
 Dyspnoea in this disease is most speedily relieved by the hypo- 
 dermic injection of sulphuric ether. 
 
 Haemoptysis very frequently supervenes during sleep. 
 
 Pleuritis. Insomnia is due chiefly to cerebral hyperaemia 
 in the early stages, and to anaemia in the later. It is some- 
 times one of the few symptoms of latent pleurisy, and may 
 even be the only one. 
 
 Treatment. Attention to decubitus. At first, relief from 
 pain (by restricting movement) is gained by lying- upon the 
 affected side, an end which may also be attained by the appli- 
 cation of a firm bandage. In the more advanced stages prop- 
 ping up the patient in bed often promotes sleep. The treat- 
 ment must be decidedly antiphlogistic. Morphine, with or 
 without atropine, is the only reliable hypnotic, and effusion is 
 no bar to its use ; the dose oug-ht to be as small as is corn- 
 pa tible with the end to be attained. Paracentesis is invari- 
 ably followed by improved sleep. 
 
 Laryngismus Stridulus. This neurosal affection fre- 
 quently interrupts sleep at its deepest. It occurs in those pos- 
 sessing unstable nervous systems, whether inherited or induced 
 by mal-nutrition, such as arises from improper feeding-, e.g., poor 
 milk, or an excess of starchy food; and unhealthy surround- 
 ings. In this debilitated state there is a tendency to explosive 
 attacks when the respiratory centres are slumbering- deeply, 
 and these are easily excited by reflex irritations, such as teeth- 
 ing, gastric derang-ements, worms, etc. The inherent weak- 
 ness in the cerebral textures renders these infants at all times 
 restless and fitful sleepers, awaking- often and crying. The 
 affection is most frequently met with in rickety children, and 
 also in the victims of hereditary syphilis. 
 
 Treatment. This naturally divides itself under three heads. 
 The first includes the removal of the exciting- cause, and atten- 
 tion to the tone of the nervous system, by means of hygiene, 
 proper food, tonics, etc.; the second embraces the adoption of 
 prophylactic measures, such as the cold bath, spong-ing- the 
 throat several times a day with cold water, administering- a 
 nightly dose of potassium bromide and chloral hydrate, which 
 children bear well, attending to the ventilation of the bed-
 
 254 Insomnia and its Therapeutics. 
 
 room and to the bed-clothing 1 , etc.; the third deals with the 
 attack itself. The writer has been accustomed to advise that 
 the nurse should always have at hand a basin containing cold 
 water and a sponge, and a phial of one part of chloroform 
 mixed with three parts of spirits of wine, that the former may 
 be immediately dashed over the face and chest, and a few 
 drops of the latter sprinkled on a handkerchief and held to 
 the nostrils. Nitrite of amyl may also be used. In very 
 young- children smelling salts may be substituted for the 
 chloroform. In severe cases musk and ammonia are excellent 
 remedies. Opiates are usually injurious. Cod-liver oil usually 
 affords good results when given between the seizures. 
 
 Spurious Croup. This malady occurs in the same class of 
 patients, and by many is considered to be one and the same 
 disease; it attacks those of older years, from one to seven. 
 It invariably comes on at night, during the first two hours of 
 sleep, when it is deepest. The child suddenly awakes gasping 
 for breath, flushed, distressed, and alarmed; tosses about as 
 if looking for relief, and not finding it, cries. The attack does 
 not usually last more than half an hour, though it may recur 
 the same night when sleep again becomes sound, and it almost 
 always does so on the succeeding nights. At times it is pre- 
 ceded by eatarrhal conditions of the nostrils and throat. This 
 is a eatarrhal affection with a neurosal element superadded. 
 
 Treatment. This consists in affording relief at the time, 
 and subsequently attending to the general condition of the 
 patient. Two or more grains of the subsulphate of mercury 
 in a teaspoonful of water induces emesis rapidly, and the ap- 
 plication of hot poultices, or a hot sponge to the throat for 
 half an hour, often suffices to relieve the cough and distress, 
 and to render the breathing easy and comfortable. If it does 
 not, the cautious administration of minute doses of aconite is 
 desirable. The after-treatment consists in the use of tepid 
 salt-water baths and suitable tonics.
 
 CHAPTER XIV. 
 
 INSOMNIA DEPENDING UPON FEBRILE AND GENERAL 
 
 DISEASES. 
 
 THE constitutional disturbance which arises from the vari- 
 ous specific fevers invariably affects the nervous system. In 
 a large percentage of cases this is apparent in the stage of 
 invasion, by depression, headache, and sleeplessness; through- 
 out the course of the fever, by disturbed sleep and delirium, 
 more rarely by convulsions and coma; and occasional^', in 
 convalescence (e.g., in enteric fever), by mental enfeeblement, 
 and in some instances by well-marked insomnia. 
 
 Sleeplessness usually depends in the earliest stage upon 
 circulatory derangements; and subsequently, upon an enfee- 
 bled state of the cerebral cells, brought about by defective 
 nutrition. 
 
 At the onset of the fever there is, in most cases, anaemia of 
 the brain with increased vascular tension, the blood-vessels 
 being tonically contracted and the pulse hard and incom- 
 pressible. Cerebral irritation thus induced gives rise to head- 
 ache, sensory derangements, restlessness and sleeplessness, 
 followed or accompanied by profound malaise, and muscular 
 and articular pain. In children, convulsions may occur, par- 
 ticularly in measles, without any serious after-effects. The 
 anaemia of the cutaneous surface, rendering it unduly sensitive 
 to all impressions, occasions the sensations of chilliness and 
 shivering. 
 
 This state is replaced after a time, longer or shorter, by a 
 reversed condition of things, in which the blood reaches the 
 brain and surface through relaxed blood-vessels (and with 
 lowered tension). The temperature of the body, increasing 
 from the beginning up to its maximum, causes much heat to 
 be given off by the skin, which feels dry and pungent. The 
 pulse becomes quicker, fuller, and softer. In this stage the 
 brain and nervous system are practically starved. A rapid
 
 256 Insomnia and its Therapeutics. 
 
 circulation being at all times badly adapted for the removal 
 of the waste products from, and for the supply of healthy 
 pabulum to, the tissues, it is still more embarrassed in the 
 discharge of its functions by being surcharged with morbid 
 materials, inseparable from an enormously increased tissue 
 metamorphosis; and, it may be, with those elementary and 
 poisonous substances which initiate the disorder. 
 
 The effects of this starvation are displayed in prostration, 
 mild delirium, restlessness, and sleeplessness; and in grave 
 cases, by convulsions arid coma. 
 
 Toward the termination of the fever the heart becomes 
 feeble, the pulse quicker and dicrotic, and, coincidently, the 
 nervous system is more profoundly exhausted. 
 
 In no class of cases is sleep of more importance, the want 
 of it influencing the course and termination of the diseases 
 most unfavorably. The late Dr. Murchison wrote: "The 
 practitioner cannot be too forcibly 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." On the 
 other hand, sleep, even of limited duration, never fails to act 
 beneficially; to secure it for a patient is in many instances 
 tantamount to insuring his recovery. Sleeplessness may be 
 taken as an indication of the gravity of the disease, particu- 
 larly if it resist treatment. It must, of course, be borne in 
 mind that the greatest differences exist in the ability of pa- 
 tients to sleep under feverish conditions; those possessing 
 excitable and impressionable nervous systems sleeping very 
 badlr. It is therefore doubly important to promote sleep in 
 their case. 
 
 To illustrate the management of insomnia in febrile condi- 
 tions it is proposed to discuss the symptoms of typhus and 
 enteric fevers at some length, those of measles and scarlet 
 fever being alluded to very briefly. 
 
 Typhus Fever. As the full brunt of typhus fever is borne 
 by the nervous system, sleep disturbance of a severe nature is 
 of frequent occurrence. The invasion is usually sudden, oblig- 
 ing the patient to relinquish his occupation and betake him- 
 self to bed. He complains of headache, great depression, and 
 of articular and muscular pain. Sleeplessness is present more 
 or less throughout the illness. Among the other symptoms 
 are, a pulse full at first (less hard than an ordinary febrile
 
 Insomnia and its TJierapeutics. 257 
 
 pulse), afterward full and soft; a high temperature; and a 
 scant}' flow of urine, containing a greatly increased quantity of 
 urea. When the vascular tension relaxes, the headache dis- 
 appears and gives place, in a well-marked case, to muttering 
 delirium, the patient lying in an apathetic state, with his in- 
 tellect clouded and confused, answering questions slowly, if at 
 all; or his delirium maj r be excited, though it is usually less 
 so than that of delirium tremens; or he may gravitate into 
 the condition known as coma vigil, and lie with his eyes wide 
 open, apparently unconscious of all that is going on, and pick- 
 ing at the bed clothes, etc. 
 
 It will be useful to inquire into the condition of the brain 
 and nervous system in this disease with reference to sleep. 
 After death the brain has been found atrophied, and the sub- 
 arachnoidal fluid increased. In a small proportion of the cases 
 there was an " increased vascularity of the meninges." Dr. 
 Murchison wrote : " The increased vascularity of the cerebral 
 membranes in typhus must not be regarded as a sign of in- 
 flammation, and does not account for the cerebral symptoms 
 observed during life. The vascularity is not greater, or more 
 common, than when death results from disease of the lungs; 
 and in most cases where it is increased, some impediment will 
 be found in the pulmonary circulation, or there has been evi- 
 dence of greatly impaired cardiac action. ... I have repeat- 
 edly known the most severe cerebral symptoms during life, 
 without abnormal vascularity of the cerebral membranes after 
 death." This indicates, with tolerable conclusiveness, that the 
 nervous symptoms in typhus are not the result of inflamma- 
 tory changes in the brain or its membranes. On the contrary, 
 they are due to mal-nutrition. It is evident that the poison- 
 laden blood, which perverts the secretions, destroys the appe- 
 tite and deranges all the digestive processes, and subsequently 
 modifies the nutrition of the mucous membranes and skin, 
 must be inadequate for the nourishment of the delicate and 
 sensitive textures of the nervous system. Not only are they 
 deprived of recuperative pabulum, but they are poisoned by 
 the toxic constituents of the blood. If further proof of their 
 mal-nutrition be required, it is found in the exaggerated knee- 
 reflex and ankle-clonus, which can be elicited in the majority 
 of cases of severe and prolonged fevers. 
 
 Treatment. A thoroughly comprehensive knowledge of
 
 258 Insomnia and its Therapeutics, 
 
 the whole treatment of typhus fever is essential, if one would 
 successfully grapple with its insomnia. Some points in gen- 
 eral treatment must therefore be first referred to, as demand- 
 ing careful study. 
 
 It must be directed to the conservation of strength, and to 
 the prevention of complications, until the natural crisis of the 
 disease is reached. It may be considered under three head- 
 ings: The maintenance of the patient's strength; the promo- 
 tion of the excretion of the poison; the alleviation of symp- 
 toms. 
 
 1. The Maintenance of the Patient's Strength. This en- 
 tails that the surroundings should be comfortable. It is 
 important that the bed mattress should be firm, and at the 
 same time yielding, and the bed clothes light and cool ; the 
 bedroom quiet, moderately lighted, and free from all external 
 disturbances. It must be thoroughly ventilated and free 
 from draughts, which occasionally cause bronchitis and like 
 complications. 
 
 An efficient nurse is indispensable for typhus fever, and 
 under no circumstances can she display her abilities more con- 
 spicuously. Thinking and acting, it may be absolutely for the 
 patient himself, she notes all things things that in them- 
 selves are the veriest trifles. His wants she not alone notes, 
 tut she anticipates them. 
 
 With regard to sleep she notices its absence, presence, and 
 duration; if it is restless or disturbed by dreams or sleep- 
 talking; or if there is delirium, she observes what its charac- 
 teristics are. 
 
 Food. While this is of the first importance independent^', 
 it is a far more frequent source of sleeplessness than is sup- 
 posed. All overfeeding must be avoided. Milk, for example, 
 should not, in the early days when thirst is still urgent, be 
 given to assuage it. Food, in short, should be managed judi- 
 ciously, and with direct reference to the digestive powers. 
 
 Stimulant. it is seldom required by the young. Admin- 
 istered in limited quantity in severe cases, and in those occur- 
 ring in patients beyond middle life, it promotes appetite, and 
 improves digestion and assimilation, controls muttering de- 
 lirium, and induces sleep. That it always influences delirium 
 favorably is doubtful. It must be given prudently, and the 
 quantity determined in each individual case; for in typhus as
 
 Insomnia and its Therapeutics. 259 
 
 in health, the effects of alcohol upon the system vary very 
 remarkably. Its administration must be guided by the state 
 of the pulse, heart, temperature, and tongue, as well as by the 
 amount of sleep. It must be cautiously prescribed when the 
 kidneys are not excreting well. 
 
 2. Excretion of the Poison. The solution and elimination 
 of the excessive quantity of urea is accomplished by diluents, 
 the best of which is plain water without stint. Among others 
 suitable may be mentioned, ice, soda or potash water, lemon- 
 ade, barley, rice, or toast water; whey; lemon or orange juice 
 and water; all of which may be iced if the patient prefer it. 
 A sharp distinction must be drawn between diluent and food. 
 
 3. Alleviation of Symptoms. Many symptoms may arise 
 in the course of the disease which, of themselves, may cause 
 sleeplessness. Their palliation is therefore highly desirable. 
 For instance, an unusually high temperature may disturb 
 sleep unduly. This calls for the administration of antipj r re- 
 tics, for although these are unable to shorten in the slightest 
 degree the duration of the fever, they are occasionally capa- 
 ble of controlling in some measure the excessive metamorpho- 
 sis, and in that way permitting of sleep. Many antipyretics 
 possess decided hypnotic properties. Again, symptoms like 
 cough may act in an equally perturbing manner, and these 
 require suitable treatment for their relief. 
 
 Sleeplessness in the early days of typhus frequently de- 
 pends upon, or is associated with, headache, and remedies 
 which relieve the latter alleviate the former. It is not infre- 
 quently relieved by fomenting the head with water, as hot as 
 it can be borne, as recommended by the late Dr. Graves of 
 Dublin. Douching the head with warm water while the pa- 
 tient leans over the side of the bed suits well. In some cases 
 more comfort is experienced from the use of tepid or cold ap- 
 plications, and in a few instances leeches to the temples are 
 required. 
 
 If the headache does not yield and sleep return, chloral hy- 
 drate should be given in 20-grain doses, as recommended by 
 Dr. Russell, of Glasgow, and repeated in three hours if required. 
 Dr. Russell urged in its favor that the patient could be readily 
 roused to clear his bronchial tubes, or to take food, and then 
 fall asleep again. Sound sleep relieves headache; on the con- 
 trary, sleeplessness aggravates it.
 
 260 Insomnia and its Therapeutics. 
 
 Chloral hydrate is suitable in the early part of the disease 
 when there is suffusion of the eyes and high arterial tension. 
 When headache and sleeplessness are replaced by delirium 
 and disturbed sleep, chloral hydrate is still the best hpynotic 
 so long, as the patient's strength remains good; but when the 
 heart grows feeble, and perhaps irregular, its use is contra- 
 indicated. Opium, or its alkaloid morphine, is then the better 
 medicant. An injection of morphine with atropine about 8 or 
 9 P.M. suits well. 
 
 Dr. Graves was in the habit of giving tartar emetic with 
 the opium when the delirium was unduly violent, and when 
 the fever was unusually high, the amount being increased or 
 decreased as these complications seemed to require. His or- 
 dinary prescription was as follows : 
 
 3 Tinct. opii, 3 i. 
 
 Antim. tart., gr. iv. 
 
 Mist, camphor., 3 viij. 
 
 Sig. Take a tablespoonful every two hours until sleep is 
 induced. 
 
 Dr. Murchison recommended digitalis in place of antimony 
 as a vascular sedative, and as an aid to elimination through 
 the kidneys instead of through the skin. 
 
 ]J Liq. opii sed., 3 i. 
 
 Tinct. digital., 3 i. 
 
 Spt. eth. nit., . . . . . . 3 ij. 
 
 Aq. camph., ad 3 vi. 
 
 M. Sig. Take two tablespoonfuls at once, and a table- 
 spoonful every two hours until sleep is induced. 
 
 In delirium resembling that of delirium tremens Dr. Mur- 
 chison advocated the addition of IT], xx. of sulphuric ether to 
 each dose of the digitalis mixture, or a pill containing half a 
 grain of opium with three grains of camphor. 
 
 It is occasionally a very difficult task to decide whether or 
 not to prescribe an opiate; from the knowledge, on the one 
 hand, that the patient will die unless he get sleep, and on the 
 other, that his suffused eyes and pin-hole pupils render it pos- 
 sible that fatal coma may follow the administration of the 
 narcotic. In the majority of cases it is wisest to undertake
 
 Insomnia and its Therapeutics. 261 
 
 the risk. Dr. Murchison thought that opium was much more 
 dreaded than it ought to be. 
 
 The use of opium is contra-indicated when there is vaso- 
 motor paralysis, extreme contraction of the pupils, bronchial 
 or pulmonary affections, or any tendency to coma, or to sup- 
 pression of urine. Belladonna, cannabis indica, and henbane 
 have all been tried, and have found many warm advocates. 
 Camphor, musk, sulphuric. ether, and turpentine, are all useful 
 remedies in weakened states. 
 
 In the insomnia of convalescence quinine and strychnine 
 hold the first places. Careful diet, and the judicious use of 
 malt liquors and change of air, are powerful adjuncts to treat- 
 ment. Opium should be avoided, tending as it does to de- 
 range the secretions. 
 
 Enteric Fever. This fever comes on insidiously and the 
 patient may not be compelled to take to bed until six or eight 
 days have elapsed. Its incursion is evidenced by chilliness 
 and shivering, muscular and articular pain, malaise, headache, 
 depression, and sleeplessness. 
 
 Toward the end of the first week the headache subsides, 
 and the sleeplessness is associated with restlessness and mild 
 delirium, or with hallucinations or violent delirium. If the 
 patient does sleep he is disturbed by dreams. Still later, 
 there may be somnolence, the sufferer lying for days without 
 taking any notice of his surroundings or asking for food, and 
 often neglecting even the calls of nature. 
 
 The chief features of the disease are, a somewhat quick- 
 ened pulse, at first of increased tension but subsequently soft 
 and compressible, and as the heart gets weakened, dicrotic ; 
 an increased temperature; scanty urine containing a large 
 excess of urea; diarrhoea of a characteristic kind. 
 
 In enteric fever there is even less vascularity of the brain 
 and membranes found after death than in typhus. Dr. Mur- 
 chison summed up thus : " It was clearly shown by Louis and 
 Chomel that the morbid appearances found in the brain and 
 its membranes in enteric fever were equally common after 
 death from other acute diseases, especially pneumonia, and 
 that no relation existed between them and the intensity of 
 the cerebral symptoms." Here again we must attribute the 
 sleeplessness and other nervous symptoms to mal-nutrition of 
 the nervous textures.
 
 262 Insomnia and its Therapeutics. 
 
 Treatment. The remarks made upon the maintenance of 
 the general strength and the excretion of the poison in connec- 
 tion with typhus fever, apply with equal force here. It may, 
 however, be emphasised that the food must be free from solid 
 particles of all kinds, and that all indiscretions in diet are 
 apt to cause sleeplessness. The mitigation of all unfavorable 
 symptoms is usually conducive to sleep. Diarrhoea, distention 
 of the bowels with gas, cough, and other symptoms must be 
 treated, and abnormally high temperature controlled. 
 
 For many years the writer has treated all his cases, with 
 a few exceptions, from the start to the termination, with the 
 following pills. 
 
 5 Pulv. digital., . . . . . . gr. ss. 
 
 Sulph. quinin., gr. ij. 
 
 Ext. opii, . gr. . 
 
 Pulv. ipecac., gr. \. 
 
 Ft. pil. i. Sig. One every four hours. 
 
 He increases or decreases the dose of the opium and digi- 
 talis, the former in reference to diarrhoea and sleep, and the 
 latter to the state of the pulse and heart. He has had little 
 trouble wi f h sleeplessness. When the temperature rose to 
 an abnormal height decisive measures were adopted for its 
 control. 
 
 Sleeplessness should be treated upon the same lines as that 
 of typhus. The writer has seldom required to resort to the 
 use of special remedies, alcohol being usually sufficient to in- 
 duce sleep. When a hypnotic is needed, he gives chloral in 
 the early stages and opium in the later, combining potassium 
 bromide with the former and antimony with the latter if the 
 delirium be violent. He is satisfied that the injurious effects 
 which are supposed to attend the administration of opium in 
 this disease are over-rated ; although when great prostration 
 of the heart is present both opium and chloral are best avoided, 
 and camphor and sulphuric ether used instead. He has got 
 good results from the use of paraldehyde in 45-minim and 
 urethane in 25-grain doses. In some instances, where death 
 seemed to be imminent, sulphuric ether, subcutaneously in- 
 jected, induced sleep and saved life. 
 
 It does not seem needful to pursue this subject further, as
 
 Insomnia and its Therapeutics. 263 
 
 the sleeplessness which accompanies influenza and relapsing 1 
 fever, puerperal septicaemia and erysipelas, etc., requires to 
 be treated upon the same principles. 
 
 Measles. This is a febrile disease ushered in somewhat 
 gradually with rigors, frontal headache, malaise, vomiting, 
 and severe catarrh of the eyes and nostrils, with intolerance 
 of light. In children convulsions may announce the invasion. 
 Sleeplessness is present from the first, and may be accom- 
 panied by mild delirium. The fever quickly rises till it reaches 
 103 or perhaps 104 Fahr., very rarely higher; a high tem- 
 perature indicating a severe attack, or the occurrence of com- 
 plications. It usualty subsides somewhat suddenly. The pulse 
 is quick; in children, very rapid. The complications met with 
 are chiefly bronchitis, pneumonia, pleurisy, pericarditis, diar- 
 rhoea, and ophthalmia. 
 
 Treatment. Attention must be paid to the patient's sur- 
 roundings and feeding, and to the alleviation of symptoms, 
 etc. Sleeplessness, headache, and increased body-temperature 
 are best treated by warm or tepid water douching- to the head, 
 and by the blanket bath, which is simply a pack in which a 
 blanket wrung out of hot water is substituted for a cold wet 
 sheet. A warm bath at night and a tepid one in the morning 
 conduce to sleep, and to the comfort of the patient. A mixture 
 of aconite, ipecacuanha, and Mindererus' spirit, mitigates the 
 catarrhal symptoms, and moderates the temperature. Should 
 a hypnotic be required, chloral hydrate may be given in doses 
 of one grain for each year of age up till ten or twelve years. 
 Opium is best avoided. 
 
 The sleeplessness of rotheln and of varicella may be simi- 
 larly managed. 
 
 Scarlet Fever. A few words will suffice, in addition to 
 what has already been written, to indicate the treatment of 
 sleeplessness in connection with scarlet fever; the shortest of 
 the exanthemata, as it is the most variable. It is character- 
 ized mainly by high temperature (104 or 105 Fahr.) and an 
 excessively rapid pulse, with redness, soreness, and occasion- 
 ally ulceration of the throat. The temperature usually sub- 
 sides gradually. 
 
 The complications which mostly disturb sleep are, vomit- 
 ing, which is best treated with an emetic, and afterward with 
 hydrocyanic acid in an effervescing saline; coryza, which
 
 1264 Insomnia and its Therapeutics. 
 
 yields to the injection of a weak solution of nitrate of silver 
 (gr. iv. to i.) into the nasal cavities; soreness and ulceration 
 of the throat, which must be actively attended to, as also 
 the earliest symptoms of inflammation of the middle ear. Ice 
 applied externally and frequently swallowed is a useful remedy 
 in those circumstances. 
 
 Salivation is sometimes a troublesome symptom, and the 
 greatest care must be taken to remove the tenacious secretion 
 as often as possible. No hypnotic is admissible under such 
 conditions. 
 
 Treatment. Headache yields to douching- with either warm 
 or tepid water; rheumatic pains require opium, and the best 
 form is Dover's powder, but it must be carefully prescribed in 
 the case of children. The temperature must be controlled, 
 this being" often accomplished by means of the wet pack re- 
 peated twice a day, which also conduces to sleep. When rest- 
 lessness is pronounced, tincture of aconite may be given at 
 hourly intervals, in minute doses, its effects being- closely 
 watched. Quinine is likewise serviceable in doses of one grain 
 for each year of age up till ten years, and may be given either 
 alone or with a small dose of digitalis. Antipyrine answers 
 well in similar doses given every three or four hours. The 
 writer thinks that antipyrine answers better in the course of 
 the disease than at its onset. 
 
 Restlessness during- the night, when the skin is hot and 
 pung-ent, may be alleviated by the free inunction of cocoa-nut 
 oil. Sleeplessness is likewise modified by anointing- the head 
 freely with oil, and this should be tried whenever the hair is 
 not too abundant. These remedies will usually serA r e to pro- 
 mote sleep, but when they fail chloral hydrate must be cau- 
 tiously given. Alcoholic stimulant and carbonate of ammonia 
 are sometimes useful in advanced stages. 
 
 In very enfeebled states, both in scarlet fever and in diph- 
 theria, the patient may lapse into a drowsj^ condition. When 
 this occurs he should be roused frequently to take nourish- 
 ment. 
 
 In the sleeplessness of diphtheria chloral hydrate and 
 opium must be dispensed with. 
 
 In small-pox insomnia is frequently a persistent symptom; 
 chloral hydrate and opium are then called for. Salivation 
 requires careful watching. The free inunction of oil, impreg-
 
 Insomnia and its TJierapeutics. 265 
 
 nated with camphor or carbolic acid, is always soothing" to the 
 skin, and sometimes induces sleep. 
 
 Acute Rheumatism. Whatever may be the real pathol- 
 ogy of acute rheumatism, it resembles the continued fevers in 
 many important respects. After a premonitory stage, in 
 which sleeplessness is a characteristic symptom, it is ushered 
 in by chill, followed by rise of temperature, quickened pulse, 
 and the usual symptoms of fever. Its main features are pro- 
 fuse sweats, not critical, having- the odor of sour milk; pain 
 in the joints, greatly aggravated by movement and pressure, 
 and accompanied by swelling-. It may affect most of the 
 joints simultaneously or in succession, often progressing- by 
 metastasis, and frequently attacking- the fibrous textures of 
 the cardiac valves or endocardial or pericardial membranes. 
 It impresses the nervous system, causing- restlessness and 
 sleeplessness throughout all its stages, and occasionallj' in 
 convalescence. Sometimes' slight delirium is observed, and 
 also hyperpyrexia. 
 
 There are many complications, such as embolism of the 
 brain, spleen, lungs, and kidnej'S, as well as pneumonia, pleu- 
 risy, etc. 
 
 Treatment. This must be conducted upon the general 
 principles laid down in discussing that of t3'phus fever. The 
 diet, however, must be, as far as possible, free from meat 
 soups. Alkaline effervescing water should be drunk copiously. 
 The patient should be clothed in a flannel night-dress, and lie 
 between blankets. Purgatives must be avoided as much as 
 possible, as movements aggravate the distress. The salicyl- 
 ates are curative beyond the relief they give to pain/and they 
 promote sleep out of proportion to the reduction of tempera- 
 ture that they effect. Salicin or the salicylate of soda in 20- 
 grain doses should be given every afternoon at hourly inter- 
 vals, for four or six times. The joints must be wrapped up 
 in cotton wool, and supported so as to be maintained at rest. 
 Anodynes, such as menthol liniment, chloroform and bella- 
 donna liniments in equal parts, or alkaline lotions (e.g., 1J 
 loci id. potass., 3 ij., Bicarb, sodii, 3 vi., Liq. morph. acet., 3 i., 
 Aq., ad 3 xij.), are useful ; or fomentations with a saturated solu- 
 tion of washing soda. 
 
 Antipyrine affords excellent results, relieving pain, lower- 
 ing temperature, inducing sleep, and apparently curing the
 
 266 Insomnia and its Therapeutics. 
 
 disease. When hyperpyrexia occurs it must be treated actively 
 by baths rapidly cooled. 
 
 If sleeplessness persist either as an individual symptom 
 or as the result of pain, opium must be resorted to in the 
 form of Dover's powder, or the subcutaneous injection of mor- 
 phine, at bedtime. In convalescence, before the cerebral cells 
 have recovered their tone, sleeplessness is best combated by 
 quinine in IQrgrain doses at bedtime, followed by whiskey or 
 brandy in hot water. Warburg's tincture in 3 ss. doses serves 
 the same purpose. Endocarditis and pericarditis occurring 1 
 in the course of this disease require the same treatment as 
 the disease itself. 
 
 In sleeplessness which occasionally attends chronic rheu- 
 matism ten minims of the oil of wintergreen three times a 
 day, the last dose at bedtime, is sometimes very efficacious. 
 The use of sulphur in such cases should not be forgotten. 
 
 Rickets. It is a common occurrence to be consulted about 
 a child who is said to be restless and sleepless at night, and 
 who spends a considerable portion of every twenty-four hours 
 in crying, deriving" no solace from its nurse's efforts to soothe 
 and amuse it, and this when it is believed to be in good health. 
 
 Such S3 r mptoms very often depend upon rickets, although 
 they by no means enter into the history of ever3 r example of 
 the disease. On the contrary, many children who suffer se- 
 verely from it present no such noisy symptoms, but sit quietly 
 and peacefully throughout the whole day if they be left un- 
 disturbed. Inquiry discloses a history of slight fever, disor- 
 dered evacuations, variable appetite, and loss of flesh ; and that 
 the child from being- good-tempered and happy has become 
 peevish and fretful, crying 1 upon the least provocation or with- 
 out it. Pushing 1 the examination further, evidence of the dis- 
 ease is abundantly obtained. 
 
 During sleep three characteristic symptoms are noticed: 
 that the child is restless and uneasy, and tosses off the bed- 
 clothes, preferring to lie naked even in cold weather; that it 
 sweats profusely about the head, neck, and chest; and that 
 its decubitus may be altered, the forehead being buried in the 
 pillow, and the body supported on the elbows and knees. 
 During sleep the veins of the head and neck are seen to be 
 distended, while the carotid arteries throb and heave in a very 
 marked way. Sleeplessness depends upon irritability of the
 
 Insomnia and its Therapeutics. 267 
 
 cerebral cells, and upon an enfeebled state of the nervous sys- 
 tem from defective nourishment. This impaired nutrition is 
 further evidenced in emaciation, late dentition, and backward- 
 ness in talking- and walking. 
 
 The subjects of rickets are liable to suffer from night ter- 
 rors, laryngismus stridulus, and spurious croup, and are apt 
 to have their slumbers further disturbed by these causes. 
 
 Treatment. The dwelling- and surroundings are impor- 
 tant. The drainage and ventilation of the house ought to be 
 as perfect as possible. The day room should preferably have 
 a southern aspect; the bedroom a temperature maintained at 
 about 60 Fahr., and the mattress and pillow made of firm 
 hair. Dr. West suggested that the latter should have a hole 
 in the centre to relieve the occiput from pressure, which he 
 stated greatly improved sleep. In many cases this is a com- 
 fort, as rickety children rub all the hair off the back of the 
 head through rolling it uneasily from side to side. The clothes 
 may be tied to the corners of the bed to prevent them being 
 tossed off, as these children are very liable to catarrhal affec- 
 tions. A morning salt bath, cold or tepid, followed by gentle 
 rubbing, a considerable portion of every day spent in the open 
 air, and a change to the country or seaside, are all most de- 
 sirable adjuncts to treatment. During the first six months 
 of age the food should be restricted solely to milk, and if re- 
 course be had to cows' milk, that of the Alderney is to be pre- 
 ferred. It should be boiled for a minute, and mixed with a 
 fourth part of lime water. Between eight and fourteen 
 months, oatmeal gruel or other farinaceous food may be 
 added to the milk. After that time very weak meat soup, 
 made of beef, mutton, or chicken, with a little cream, is allow- 
 able. Thin bread and butter sprinkled with brown sugar often 
 agrees well. Raw meat pounded and eaten as a sandwich, 
 gravy and potatoes, the yolk of a boiled egg, are all suitable. 
 Digestion may be aided by malt extracts, which agree also 
 when they are mixed with small quantities of cod-liver oil. 
 Diarrhoea yields to the administration of the salicylates of bis- 
 muth or magnesia, in doses of from gr. ij. to v., after the tract 
 has been cleared with rhubarb and soda. Tonics are usually 
 required; steel wine, Parrish's syrup, small doses of quinine, 
 strychnine with an acid, are all useful. The writer has got 
 very good results from the syrup of lactophosphate of lime 
 and iron.
 
 268 Insomnia and its Therapeutics. 
 
 Sleeplessness is generally remedied by sponging the pa- 
 tient's bod} 7 at bedtime with warm vinegar and water, or with 
 equal parts of olive oil and whiskey, and by a dose of quinine, 
 varying from one to three grains. It is best given in milk. 
 Opiates are extremely injurious. 
 
 It ma} 7 not be out of place here to advert to a good rule in 
 medical practice, to strip completely every child that cries 
 without apparent cause, for the explanation will frequently 
 be found in some obnoxious article torturing it. 
 
 Syphilis. Inherited. This disease presents in the infant 
 some symptoms analogous to those met with in rickets, e.g., 
 violent and persistent fits of crying by day, and restlessness 
 and sleeplessness at night. It is to be similarly explained 
 the cerebral cells are starved. 
 
 If the child has been born free from the usual characteris- 
 tic appearances of the disease, these will manifest themselves 
 during the first six weeks. The chief are, congestion of the 
 mucous membrane of the eyes and nasal cavities, causing 
 well-marked coryza and snuffles, the latter interfering with 
 the respiration. The appearance alters greatly. They be- 
 come puny and aged-looking, with a muddy unhealthy com- 
 plexion. A coppery rash appears on the hands, feet, genitals, 
 perineum, and abdomen; ecthymatous eruptions are found 
 here and there over the body ; and mucous tubercles round 
 the anus, and fissures at the angles of the mouth and nostrils. 
 Loss of hair, hoarseness and huskiness of the voice, are noticed, 
 and if the thymus gland be enlarged, there may be attacks of 
 laryngismus stridulus. Further, there is loss of flesh; and 
 when the teeth appear they are pegged. 
 
 Treatment. This involves the treatment of the disease, no 
 hypnotic being of any service. Equal parts of mercurial oint- 
 ment and lanolin may be applied to the abdomen, and covered 
 up with a flannel bandage, or small doses of gray powder 
 given several times a day. Considerable relief is often af- 
 forded by local applications to the nostrils. The diet and 
 regimen must be carefully attended to. 
 
 Syphilis. Acquired. In the early history of secondary 
 syphilis sleeplessness may depend upon the general febrile 
 symptoms, and upon pain in different parts of the body. It 
 is not to this form of insomnia that we wish to refer, as its 
 association is perfectly evident.
 
 Insomnia and its Therapeutics. 269 
 
 There is a second class of cases associated with syphilis, 
 which depend chiefly upon severe headache and obscure pains 
 in the bones (particularly the clavicles), and also in the joints, 
 resembling- rheumatic pains, which tend to grow worse at 
 night and to disappear during- the day. Such cases will obvi- 
 ously be traced to their proper origin. 
 
 There is yet a third group of cases, which are much more 
 obscure, and are characterized by insomnia, nightly recurring 
 at a certain hour, when without pain or discomfort, or any 
 apparent reason to account for it, the patient practically re- 
 mains wide awake till the morning. The usual time for awak- 
 ing is about two or three A.M. These cases present difficulties, 
 for they are sometimes associated with dyspeptic derange- 
 ments, and symptoms of anaemia and neurasthenia. The 
 sleeplessness is never by any chance connected by the patient 
 with the malady from which he has suffered, consequently he 
 does not mention the circumstance at all; and as it sometimes 
 happens in private practice that reasons exist for concealing 
 the truth, the suggestion of syphilis by the practitioner may 
 be repudiated. 
 
 This symptom may occur in either sex, and in any tempera- 
 ment, but it seems probable that it is more frequently met 
 with in those of neurotic temperament, and particularly in the 
 neurasthenics just mentioned. It is peculiar in this respect, 
 that it 3'ields only to constitutional treatment. There is no 
 reason to doubt that sleeplessness is due to a cachectic condi- 
 tion, inducing an irritable and unstable state of the cerebral 
 cells. Frequently the sole guide one has in these cases is the 
 evidence to be obtained from old scars or lesions which tell 
 their own tale. Some time agp the writer was consulted by a 
 gentleman for loss of sleep, who presented the appearance of 
 one who had long suffered from bad health, though he as- 
 serted it was not so. Upon looking at his tongue a small 
 lump the size of a small hazel-nut was observed toward its 
 centre, and no remark being made he was put upon specific 
 remedies, when the tumor and the insomnia disappeared 
 simultaneously. These patients have a cachectic appearance, 
 with muddy and earthy complexions; symptoms which should 
 always arouse the suspicion of the disease. 
 
 Treatment. Mercury in one or other of its various forms 
 is to be prescribed, such as a calomel vapor bath, the inunc-
 
 270 Insomnia and its Therapeutics. 
 
 tion of the oleate with lanolin into the groins or armpits, or 
 the green iodide by the mouth. One of these combined with 
 the free use of the iodide of potassium will speedily relieve the 
 insomnia. As a rule, the iodide alone is not sufficient; mer- 
 cury is the remedy. Tonics, such as iron and arsenic, and 
 cod-liver oil, with increased nourishment, will probably be 
 called tor; while Turkish baths, wet packs, and change of air 
 will expedite" the cure. 
 
 Cachexice. Insomnia due to this cause is closely allied to 
 that depending upon syphilitic poison. The altered condition 
 of blood leads to a perverted nutrition of the nervous centres, 
 peculiarly favorable to insomnia. It is met with in those who 
 have either suffered from well-marked malarious fevers, or in 
 those who have lived in malarious districts without having 
 had fever. It comes on at two or three in the morning with 
 provoking punctuality, and persists until almost the hour for 
 rising, leading to great mental and physical exhaustion. Dur- 
 ing the day patients complain of this exhaustion, and give 
 evidence of it in increased irritability and depression; but if we 
 except a h3 T persensitiveness to cold, they exhibit no symptom 
 pointing to malaria, and certainly they do not attribute their 
 sleeplessness to that cause. Some present a cachectic appear- 
 ance, which affords a clue to the source. The writer has met 
 with this form of insomnia more frequently in children than 
 in adults. They have usually presented a pasty and un- 
 healthy physiognomy. 
 
 Treatment. This consists in the nightly administration of 
 quinine, a grain for every year of age up to twenty years. 
 Warburg's tincture in f ss. doses for adults is also efficacious. 
 During the day arsenic should be given after meals. Massage, 
 change of air to the seaside, and nourishing and stimulating 
 diet, are all beneficial auxiliaries. Opiates are very unsuitable.
 
 CHAPTER XV. 
 
 INSOMNIA DEPENDING UPON AFFECTIONS OF THE 
 URINARY SYSTEM. 
 
 MANY diseases of the urinary organs give rise to disturbed 
 sleep, and the want of sleep frequently becomes a troublesome 
 and aggravating symptom. We cannot attempt in this work 
 to discuss these diseases or their therapeutics. A few words 
 must suffice to indicate the importance of the subject. 
 
 Sleeplessness in these ailments is mainly due to irritability 
 of the bladder, which arises from many and diverse causes. 
 
 The irritability may depend upon an increased secretion 
 of urine at night as well as during the day. Such a flow 
 should always excite suspicion, particularly if no considerable 
 amount of liquid is imbibed before going to bed. For it must 
 be remembered that the quantity of urine secreted during 
 sleep is greatly diminished, and there is therefore so much 
 the less occasion to expel the amount which has accumulated. 
 
 Irritability of the bladder, dependent upon an abundant 
 increase in the quantity of urine secreted, is met with in the 
 following diseases. 
 
 Diabetes Mellitus. Sleep is apt to be broken by frequent 
 calls to urinate, and to appease hunger and assuage thirst. 
 It is also disturbed by eczematous and pruriginous eruptions 
 dependent on the sugar in the blood. These irritations, like 
 all excitations of sensor}' nerves, are attended by a corre- 
 sponding rise in the arterial tension, which disturbs sleep. 
 Such patients are sometimes kept awake by pains in the ex- 
 tremities, neuralgic in character, which grow worse at night 
 in bed. Dr. Pavy, who (with others) has called attention to 
 these pains, believes they are due to peripheral neuritis. The 
 writer has seen deep ulceration of the heel with excruciating 
 pain occur in diabetes. Twice he has witnessed most agoniz- 
 ing pain in the shoulder prelude a fatal termination. In some 
 respects the symptoms approximate to those of locomotor
 
 272 Insomnia and its Therapeutics. 
 
 ataxy, for there is often some awkwardness of gait, and the 
 knee-jerk is usually lessened. Sciatica is frequently com- 
 plained of. Affections of the skin, such as boils, carbuncles, 
 erysipelas, etc., may perturb sleep. 
 
 Treatment. Diet is of the first importance. Opium and 
 codeine tend in the direction of curing' the disease and pro- 
 ducing sleep. Antipyrine and antifebrine have a decided influ- 
 ence over the pain which occurs in this affection. 
 
 Diabetes Insipidus. In this affection sleep is chiefly dis- 
 turbed by frequent calls to urinate. 
 
 Azoturia. The writer has met with this ailment mostly 
 in young men who were suffering from mental emotion. They 
 complain of constant and teasing inclination to pass water, 
 depending apparently upon a spasmodic irritability of the 
 neck of the bladder. This is usually accompanied by a train 
 of dyspeptic symptoms, and a marked feeling of prostration 
 and inability for exertion. Their days are filled with mental 
 weariness, and their nights with restlessness. The urine is 
 generally copious (80 to 100 ounces), having a specific gravity 
 ranging from 1.030 to 1.040, due to an excessive excretion of 
 urea, and being quite free from sugar. 
 
 Treatment. This consists in removal of the source of 
 worry when that is possible, together with change of air and 
 scene; nutritious diet, chiefry composed of non-nitrogenous 
 foods, and the alleviation of dj^speptic derangements. Quinine 
 and strychnine are the drugs that have afforded the best re- 
 sults. Minim doses of tincture of cantharides have on one or 
 two occasions relieved the feelings Of strangury. 
 
 Chronic Diseases of the Kidney. In the later stages of 
 these diseases there is irritability of the bladder, which in- 
 variably grows worse at night, and is associated with rest- 
 lessness. The attendant symptoms naturally lead to the cor- 
 rect diagnosis and treatment of these affections. 
 
 Irritability may depend upon inflammatory changes in 
 the prostate gland, bladder, and ureters, as well as upon or- 
 ganic diseases in these parts. 
 
 Acute Prostatitis. This is mostly met with in young sub- 
 jects, particularly of gouty habit, as the result of gonorrhoeal 
 and other inflammations. Among the symptoms, the urgent 
 and constant desire to pass water is probably the most dis- 
 tressing. Relief is not obtained by emptying the bladder, and
 
 Insomnia and its Therapeutics. 273 
 
 a trace of blood not infrequently follows urination. Digital 
 examination is sometimes necessary to clear up the diagnosis. 
 
 Treatment. This must be conducted on antiphlogistic 
 principles. Opium or cannabis indica are required to alleviate 
 the pain. 
 
 Chronic Prostatitis. In this the symptoms are of the 
 same description, but modified in degree. They are always 
 aggravated during the night. 
 
 Treatment. Here counter-irritation has a large field of 
 usefulness. 
 
 Chronic Hypertrophy of the Prostate. This is one of the 
 troubles of advancing years. Many such patients spend their 
 days and nights in constantly relieving the bladder; sleep is 
 consequently much curtailed. The act of micturition is usu- 
 ally both preceded and accompanied by pain. Eventually a 
 catarrhal condition of the bladder ensues, the urine becoming 
 ainmoniacal, and copiously mixed with glutinous ropy mucus 
 and pus. 
 
 Treatment. These cases demand great care, as they are 
 apt to be made worse by all exacerbations, such as slight con- 
 gestions initiate. Every effort must be made to prevent these 
 untoward occurrences by avoiding chills, etc. Dietetic errors 
 are to be guarded against. Fluids should be sparingly taken 
 in the latter part of the day. Tonics are sometimes useful. 
 Pulque appears to act beneficially upon catarrhal affections of 
 the mucous membrane of the urinary tract. The occasional 
 passing of a soft catheter is often advantageous. Opiates 
 are sometimes absolutely required; they are best used in the 
 form of a suppository. As they are not curative, they must 
 be employed judiciously. It is in this class of case that the 
 morphine-habit is most likety to be formed. Belladonna must 
 not be used, as it tends to impair still further the expelling 
 power of the bladder. The subcutaneous injection of ergotin 
 has done good service; but the constant electrical current 
 seems to promise still better results. 
 
 Acute Cystitis. This may arise from chills, from reten- 
 tion of urine, from various lesions connected with the nervous 
 system, from calculus, from septic contamination, etc. It in- 
 variably gives rise to much distress. The collection in the 
 bladder of a few drops of urine leads to exquisite pain, and to 
 an uncontrollable desire to expel the accumulated contents.
 
 274 Insomnia and its Therapeutics. 
 
 It is usually associated with well-marked constitutional dis- 
 turbance. 
 
 Treatment. This must be in most cases decidedly anti- 
 phlogistic, in which opiates and diluents hold a prominent 
 place. A suppository of morphine and. belladonna at bedtime 
 is a useful means of procuring- sleep. The tincture of collin- 
 sonia eanadensis, in doses of 3 ss. to 3 ij-, appears to act bene- 
 ficially. Aconite and belladonna are also useful. 
 
 Chronic Cystitis. This depends upon the same causes as 
 the acute variety. It may also be caused by gonorrhoea, 
 stricture of the urethra, etc. The symptoms resemble in 
 some degree those of an enlarged prostate. 
 
 Treatment. This is very unsatisfactory in many cases. 
 The medicines mostly employed are tonics, buchu, triticum 
 repens, b^drastis, uva ursi, copaiba, and sandal-wood oil. 
 Saccharine has been recommended of late. years. Washing 
 the bladder once or twice daily with weak solutions of quinine, 
 resorcin, boracic acid, cocaine, carbolic acid, etc., is the most 
 reliable remedy. Opiates at night are sometimes unavoid- 
 able; they are best given per anum. In females, dilatation of 
 the urethra is occasionally useful. 
 
 Pyelitis. This disease may result from many causes, often 
 from inflammatory mischief spreading up the ureters, but it 
 more commonly arises from calculus in the kidnej'. It is ac- 
 companied by much more marked constitutional disturbance, 
 fever, loss of flesh and strength, progressive anasmia, night 
 sweats, etc. 
 
 Treatment. This is even more unsatisfactor} 1 - than that of 
 chronic cystitis. Tonics, hydrastis, eucalpytus, yellow santal 
 oil, pulque, collinsonia canadensis, and opiates, with nutritious 
 diet, are probably the best remedies. In this as well as in the 
 other similar diseases just considered, the exciting cause must 
 always be the guide to the remedy selected. When calculus 
 is the cause, the nature of the stone must be accurately ascer- 
 tained. 
 
 Irritability is invariably caused by vesical and renal calculi, 
 which may also induce secondarily cystitis and pyelitis. 
 
 Vesical Calculus. This always disturbs sleep from the 
 pain it causes. In children sleeplessness and dreams are fre- 
 quently the only symptoms of stone in the bladder. Irrita- 
 bility may be absent. The treatment of vesical calculus is
 
 Insomnia and its Therapeutics, 275 
 
 obviously surgical. Palliative relief can be obtained only 
 from opium. 
 
 Renal calculus very frequently gives intimation of its pres- 
 ence during the night. That appears to be the favorite time. 
 
 Treatment. Morphine is urgently called for during the 
 attack of pain. General treatment must be varied with the 
 nature of the stone. 
 
 Irritability of the bladder may be set up reflexly by 
 hemorrhoids, fissure of anus, worms, displacements of the 
 womb, and in rarer instances by a floating kidney. It can 
 only be relieved by remedial measures directed to these condi- 
 tions. 
 
 Sleep may be disturbed by attacks of chordee, and by a 
 distended bladder, which sometimes causes restlessness and 
 dreams, without incontinence following. In children this 
 source of sleeplessness should never be overlooked. A long 
 prepuce requires surgical treatment. In all such cases the 
 child should be wakened three or four hours after going to 
 bed to empt}*" the bladder. 
 
 Sleep disturbance in children is occasionally due to an ex- 
 cessive excretion of uric acid. In many, this has no clinical sig- 
 nificance. Limiting the quantity of nitrogenous food, and the 
 administration of alkalies, are always followed by improved 
 sleep. 
 
 Incontinence of Urine. This disorder depends upon a 
 paroxysmal neurosis, and is closely allied to sleep-walking. 
 It consists in passing water during sleep, involuntarily and 
 unconsciously. 
 
 Beginning in some instances in the early years of youth, i'o 
 usually ceases at puberty, although in a few cases it is con- 
 tinued into adult life. In the latter group it is important to 
 discriminate between this variety of incontinence and that 
 which occurs in connection with epileptic seizures during sleep. 
 It is most commonly met with in those who have neurotic ten- 
 dencies, and a hereditaiy predisposition to it. Like chorea, 
 epilepsy, and other allied disorders, it may be excited by 
 fright, fear, or other impressions acting strongly upon the 
 emotional centres; but it may be originated by reflex irrita- 
 tions, such as are caused by a long and tight prepuce, increased 
 acidity or alkalinity of the urine, constipation, worms, or fis- 
 sure of the anus. The bad habit instigated by these exciting
 
 276 Insomnia and its Therapeutics. 
 
 causes may be perpetuated for years; their removal not being 
 immediately followed by immunity from it. The centres 
 which control micturition being unstable, they respond to pre- 
 ternaturally slight impressions; and their stability requires 
 to be achieved ere the bad habit is checked. 
 
 The affection is always troublesome, and the feeling of 
 degradation it excites in the minds of those who suffer from it 
 is extremely annoying. Ashamed of their infirmity, they are 
 apt to become shy and morose ; this is particularly the case 
 in young women. Males and females are equally liable to it. 
 Boys have been known to manfully suffer the pain of the pre- 
 puce sloughing off, brought about by themselves tying a cord 
 round it, in the hope of controlling the disagreeable symptom. 
 It occasionally gives rise to serious consequences. Nearly 
 twenty years ago the writer amputated at the upper third of 
 the thigh the limb of a young female, which had been shattered 
 in a railway accident. She was a woman of weak intellect. 
 The following morning he found the dressings saturated with 
 urine, and he was then told that the patient suffered from in- 
 continence. No medication nor mechanical device rendered 
 any effectual service; whenever she slept she spasmodically 
 expelled her urine. The flaps sloughed, and she died of septic 
 poisoning. 
 
 It may occur once or even twice during the same night, 
 generally soon after going to bed or early in the morning; 
 often at the same hour or hours, and always when sleep is 
 deepest. Trousseau, who studied this subject most carefully, 
 pointed out that these sufferers are usually deep sleepers, and 
 that they may rise in the early part of the night to empty 
 the bladder, yet later on, when sleep is most sound, they pass 
 water involuntarily. It does not depend upon the quantity of 
 water in the bladder, for if the quantity were large it would 
 awake the sleeper; nor upon the quantity of fluid imbibed: it 
 is a neurosis. Like other centres, those of micturition are 
 affected by mental influences. This is demonstrated by the 
 urgent desire to pass water induced by fright ; as also by the 
 ability we possess of inhibiting, in our waking moments, the 
 calls to micturate, or, in other words, of inhibiting the centres 
 which dominate the detrusor urinse. When we are awake 
 and in good health the detrusor urinse and sphincter muscles 
 are equally balanced ; in this affection the former acts spas-
 
 Insomnia and its Therapeutics. 277 
 
 medically during sleep, and expels the urine forcibly. Where 
 the sphincter is weak it is more easily overcome, but in these 
 cases there are usually some signs of weakness displayed dur- 
 ing- the day. 
 
 The complaint may cease during 1 an illness if sleep be in- 
 terfered with, and reappear as health and sleep are re-estab- 
 lished. Although the urine is passed unconsciously, in many 
 instances the act immediately awakes the patient; it is thus 
 a disease of sleep and a disturber of sleep. 
 
 Treatment. All causes capable of setting up reflex irrita- 
 tion must be removed; the bowels unloaded and regulated; 
 worms expelled ; fissures cured ; a tight prepuce stretched or 
 incised, and if adherent, removed; a contracted meatus di- 
 lated ; and abnormal conditions of the urine rectified. 
 
 In the enfeebled and ansemic, in whom the sphincter is apt 
 to be weak, general and local faradization is sometimes, if not 
 always, useful. The food must be carefully selected. A cold 
 spinal douche given every day, lasting two or three seconds, 
 followed by gentle friction with a warm towel, with change of 
 air, preferably to the country, are useful aids. 
 
 Tonics combined with small doses of cantharides are often 
 serviceable. 
 
 For a child of six years: 
 
 5 Tinct. canthar., . . . . , . HI x. 
 
 Vin. ferri, f iv. 
 
 M. Sig. A dessertspoonful thrice daily in water. 
 
 For a youth of fifteen years : 
 
 ]J Syr. phosph., ferri, quin. et strychn., . . f rj. 
 
 Syr. phosph. ferri co., ij. 
 
 Tinct. canthar., 3 ss. 
 
 M. Sig. A teaspoonful in water after meals thrice daily. 
 
 In the cases in which the general health is obviously not 
 depressed, careful attention must be paid to the points just 
 referred to, for everything should be done to raise the tone of 
 the nervous system. The hour at which the water is usually 
 passed should be noted, and if it is possible sleep should be 
 interrupted shortly before not to pass water unless the desire 
 to do so be present, but to cause the sleep to be less deep. 
 Belladonna is the foremost remedy for this affection, and it
 
 278 Insomnia and its Therapeutics. 
 
 acts in a remarkable way in reducing the irritability of the 
 centres of micturition. It also acts by lessening the excita- 
 bility and conductivity of the sensory and motor nerves. This 
 is not infrequently seen in adults, who are so susceptible to its 
 influence in some cases that \ or \ of a grain of the extract, in 
 a laxative pill, is sufficient to cause retention of urine. Chil- 
 dren, however, are very tolerant of the drug, in most instances 
 bearing much larger doses than adults. It is well to begin 
 with a dose ranging from five to ten minims of the tincture 
 three times a day, and gradually to increase the dose until 
 its physiological effects are produced, for until that point is 
 reached the therapeutic benefits are seldom obtained. Should 
 belladonna fail, chloral hydrate will be found a reliable remedy.
 
 CHAPTER XVI. 
 
 INSOMNIA PECULIAR TO FEMALES. 
 
 SLEEPLESSNESS or disturbed sleep is apt to appear in fe- 
 males from causes peculiar to the sex, notably at the epochs 
 of puberty and the menopause, at the catamenial periods, 
 during 1 pregnancy, and after parturition. It chiefly affects 
 those of the neurotic temperament, with highly-strung- and 
 unduly-sensitive nervous systems, and those debilitated by 
 neurasthenic conditions. 
 
 Puberty. At this time the body and mind participate in 
 rapid evolution, the physique is changed, and new instincts 
 and desires arise; the whole creature emerges into woman- 
 hood. In the course of transition the equilibrium of the nerv- 
 ous and vascular systems is liable to be perturbed. This oc- 
 casions such young- females to exhibit emotional tendencies, to 
 suffer from malaise, headache, and palpitation, and sometimes 
 to become affected with chorea and epilepsy. 
 
 Disturbed sleep at this time is by no means rare, and once 
 initiated it is apt to recur at the catamenial periods, when evi- 
 dence of increased nervous excitability and fatigue is seldom 
 wanting*. Insomnia is a most undesirable symptom at such a 
 juncture, for a plentiful amount of sleep is urgently required 
 for the development and recuperation of the nervous system. 
 
 Treatment. This consists in adopting measures calculated 
 to restore the stability of the nervous sj-stem, such as regu- 
 lating the diet and regimen of the patient. Occasionally, rest 
 in bed for two or three weeks answers admirably, by recruit- 
 ing the g-eneral tone of the body. Galvanization in some in- 
 stances suits excellently. The bromides may be given in full 
 doses at bedtime. It is best to avoid morphine and other 
 powerful narcotics. 
 
 Menstruation. Insomnia occurring- at the menstrual 
 periods depends upon like causes, the process, though a natu- 
 ral one, perturbing- the sj^stem. The perturbation is a gen-
 
 280 Insomnia and its Tlierapeutics. 
 
 eral, as well as a local, one. The body-temperature is modified, 
 and the nervous and circulatory systems are disturbed. The 
 implication of the nervous system is readily recognized; 
 sudden mental emotion can arrest the flow. On the other 
 hand, the recurring periods give rise, in many, to sick-headache, 
 variations in temper, and restlessness during the day, and to 
 dreams and sleep disturbance at night. Its effects can also 
 be well studied in this class of patients, when they are also 
 the subjects of slight visual defects. They complain of errors 
 of refraction at these recurring times, being powerless to over- 
 come them by accommodation as they are able to do in the 
 intervals. They can be equally well observed in a large num- 
 ber of females whose digestive powers are limited whose 
 organs are able to cope with the daily work in the intervals, 
 but which are quite inadequate at these periods. The excre- 
 tions also are all more or less interfered with. Hence it is 
 that dyspeptic troubles arise at these times, and so frequently 
 become a source of sleep disturbance. The derangement of 
 the' equilibrium of the vascular system leads, occasionally, to 
 alterations in the quantity of blood in the thyroid gland. As 
 that gland exercises an important influence, both over the 
 cerebral circulation and on sleep, modification of its functions 
 may account, to some extent, for the sleep troubles. It is un- 
 doubted that sleep derangement is more common in young 
 women than in young men. They are more susceptible to the 
 influence of toxic agents, notably of lead. This can only be 
 explained by the vulnerability of their constitutions which the 
 menstrual functions inaugurate. It is more marked in some 
 families than in others, just as some families have a greater 
 proclivity to sleeplessness. 
 
 Treatment, This must be conducted upon the foregoing 
 principles, but the following pill may be given for a few nights. 
 
 IJ. Ext. stramon., ...... gr. . 
 
 Pulv. camphor., . . ... gr. ij. 
 
 Ext. hyoscy., gr. iij. 
 
 Ft. pil. i. Sig. Take one at bedtime. 
 
 Tonics sometimes do good. 
 
 Dysmenorrhcea, menorrhagia, and over-lactation cause 
 insomnia. It is usually due, in the latter cases, to cerebral 
 anaemia. The symptoms which these patients complain of are
 
 Insomnia and its Therapeutics. 281 
 
 all indicative of mal-nutrition of the nervous centres; their 
 sight is dim, and it is greatly affected by all sudden altera- 
 tions of posture. Hearing 1 is dulled, and noises in the ears are 
 seldom absent, while the general sense of touch is usually im- 
 paired. The general symptoms are those of anaemia. 
 
 Treatment. Such cases of insomnia require that the bodily 
 drain be checked, and that the tone of the nervous and vascu- 
 lar systems be invigorated by suitable remedies, such as were 
 indicated in discussing the subject of cerebral anaemia. 
 
 Displacements of the womb, with which frequent micturi- 
 tion is often associated, and some diseases of the ovaries, give 
 rise reflexly to insomnia, a symptom which can only be re- 
 lieved by the rectification and alleviation of the disturbing 
 causes. 
 
 Amenorrhcea with chlorosis has insomnia as a symptom. 
 A few words must be said regarding it. It depends upon the 
 depravity of the blood peculiar to the latter, which not only 
 interferes with the nutrition of the nervous system, but brings 
 about modifications of vascular tension, and invariably leads 
 to defective digestion, often characterized by painful symp- 
 toms, as gastralgia. These combine to disturb sleep. The 
 late Dr. Graves pointed out a very curious fact concerning 
 this form of insomnia. He wrote : " It is singular how long 
 sleeplessness often continues in chlorosis without inducing 
 those serious consequences that are produced by this symp- 
 tom in other morbid states of the system." The writer has 
 no explanation to offer of this fact; he can only confirm the 
 accuracy of the observation. His friend, Dr. Mackintosh, has 
 suggested that it may be due to the small amount of tear and 
 wear of the tissues in chlorosis, requiring less recuperative 
 action. 
 
 Treatment. This consists in remedying the state of the 
 blood and re-establishing the menstrual flow, which is best 
 accomplished by means of warm laxatives and ferruginous 
 tonics. The old combination of Griffith's mixture and the 
 compound decoction of aloes, is an admirable one. Blaud's 
 pills, in doses of from one to four, taken after meals thrice 
 daily, with an efficient dose of infusion of senna pods at bed- 
 time, also answers well. Arsenic is occasionally valuable. 
 This medication may be varied at the recurring periods by 
 the administration of the precipitated oxide of manganese, or
 
 282 Insomnia and its Therapeutics. 
 
 the permanganate of potassium, to promote the menstrual 
 flow. 
 
 Menopause. At the menopause, as at puberty, sleep is apt 
 to be disturbed. Cases of unusually prolonged sleep occurring 
 in this connection have frequently been recorded, but the 
 more common disturbance is that of want of sleep. It will be 
 seen from the tables (page 550) that the menopause caused 18 
 out of 273 consecutive cases of insomnia. The changes at this 
 important epoch are vast and momentous; the whole repro- 
 ductive apparatus is functionally metamorphosed from a state 
 of nervous and vascular activity into one of repose. As this 
 does not take place in the various parts involved in the gen- 
 erative functions simultaneously, disorders are apt to super- 
 vene. For instance, the ovaries during this important period 
 are preternaturally irritable and excitable. In the course of 
 the months or years that this decadence is progressing, be- 
 sides a liability to floodings, which are productive equally of 
 anaemia and sleeplessness, a train of nervous symptoms are 
 apt to ensue, such as occipital headache, giddiness, depression 
 of spirits, hypochondriasis, hysteria, irritability of temper, 
 flushings, chills, perspirations, etc. The perspirations fre- 
 quently come on at 4 or 5 A.M. and cause awaking, and they 
 are often associated with palpitation. In some cases there is 
 perversion of the moral sense, and even insanity. Lithiasis 
 very often manifests itself at this time, and gives rise to in- 
 creased arterial tension and palpitation of the heart. 
 
 Dr. Saundby, of Birmingham, and others, have described a 
 form of tingling and numbness (" pins and needles ") which is 
 apt to come on in the limbs during sleep and to interrupt it. 
 Dr. Ormerod thought it most common at the menopause. 
 The writer has met with several cases at that epoch, in which 
 the upper and lower limbs were variously affected. Its onset 
 certainly terminates sleep. In most of the cases it appeared 
 to depend on the gouty taint ; it quickly disappeared on anti- 
 gouty treatment. 
 
 Sleeplessness and sleep disturbed by dreams are usually 
 the most constant symptoms of all. Probably unmarried 
 women suffer more from these disagreeable symptoms than 
 their married sisters. 
 
 These cases are mainly divisible into two classes, the ple- 
 thoric and anaemic.
 
 Insomnia and its Therapeutics. 283 
 
 Treatment. The plethoric, in' whom blood-pressure is 
 markedly increased, and those in whom headache is a promi- 
 nent symptom, may be relieved by bleedings from the temples, 
 repeated at the periods when the catamenial flow shall have 
 appeared, and also by mercurials and alkalies. 
 
 1J Subchlor. hydrarg., gr. L 
 
 Ext. hyoscy., gr. iij. 
 
 Ft. pil. i. Sig. Take one every tenth night. 
 
 5 Tinct. aconit. (B. P.), . . '. . .Til xxiv. 
 lodid. potass., , . . . . .3L 
 
 Bicarb, potass., 3 iij. 
 
 Aq. menth. pip., ad vi. 
 
 M. Sig. Take a tablespoonful in water before meals thrice 
 daily. 
 
 The nitrites are efficient remedies. 
 
 Turkish baths carefully managed are useful adjuncts to 
 treatment. The inhalation of amyl nitrite (TTJ, iij.) at bedtime, 
 or during the night if sleep be interrupted, occasionally acts 
 as a hypnotic. This can be convenientl}* prescribed in cap- 
 sules. The bromides may be given for limited periods, as 
 during the week when the loss should naturally recur. The 
 dose most suitable is 3 ss. at 6 and again at 10 P.M. A resi- 
 dence at Kissingen or Bath is beneficial. 
 
 In the anaemic cases arsenic and iron are the remedies 
 called for. The syrup of bromide of iron, or of bromide of iron 
 with quinine and strychnine, in 3 i. doses thrice daily after 
 meals, answers well. These should be taken through a tube, 
 as they are apt to discolor the teeth. The feeding should be 
 generous, but stimulants must be prescribed cautiously, if at 
 all. Some of these patients improve at Schwalbach and Hom- 
 burg, others in Switzerland. The bromides must not be given 
 for any length of time, as they increase the anaemia. Chloral 
 hydrate and morphine, like alcohol, are dangerous remedies 
 on account of the especial tendency at this epoch to the 
 formation of injurious habits. In a case recently under treat- 
 ment sulphonal failed to induce sleep satisfactorily, although 
 it was pushed to the extent of causing very pronounced 
 drowsiness, and some inco-ordination of movement in the day- 
 time. Belladonna with cannabis indica and camphor eventu-
 
 284 Insomnia and its Therapeutics. 
 
 ally produced sleep. Paraldehyde and urethane are generally 
 reliable and suitable drugs. 
 
 Pregnancy. Although pregnancy is a natural process, it 
 inaugurates conditions so novel as in many cases to disturb 
 the equilibrium of the nervous and vascular systems. This is 
 evidenced by a train of symptoms chiefly referrible to these 
 systems, and mainly seen in women who are neurotic, deli- 
 cate, and sensitive, and pregnant for the first time, although 
 the multiparous are not exempt. These symptoms differ 
 widely in character, and are the source of much discomfort 
 and suffering. Such patients become emotional and mentally 
 perturbed, depressed and introspective, brooding over trifles, 
 and having a groundless dread of impending evil. They suffer 
 from neuralgic pains and cramps, from morning sickness, 
 acidity, flatulence, and constipation; also from palpitation, 
 and, as Dr. Broadbent pointed out, from increased vascular 
 tension, which may be due to the cardiac hypertrophy invari- 
 ably present, and perhaps in a less degree to the rapid tissue- 
 change going on in the body. The combined vascular modi- 
 fications are so considerable as to lead, in the majority of 
 pregnant women, to the production of functional cardiac mur- 
 murs. These symptoms, united with others of less import, 
 "bring about hyperaemia of the brain and consequent cerebral 
 activity, which is attended by sleeplessness. Cramps in the 
 limbs not infrequently interfere with sleep. They are proba- 
 bly due to the rapid metamorphosis just referred to; some- 
 times they are caused by pressure on nerves. 
 
 Treatment. This must be conducted upon general prin- 
 ciples, the object being to build up the nervous system, to 
 engender confidence and hope, and to calm the vascular sys- 
 tem. The patient must be counselled to lead a regular life, 
 to be much in the open air without fatigue, to observe early 
 hours, and to have pleasant and peaceful society. All diges- 
 tive derangements and disorders, such as pruritus, must be 
 rectified. The bromides are useful, particularly bromide of 
 lithium, either alone or in combination. 
 
 $ Brom. lithii, gr. xv. 
 
 Tinct. lupul., 3 ss. 
 
 Aq. chlorof., . . . . ad f i. 
 
 M. ft. haust. Sig. Take at bedtime.
 
 Insomnia and its Therapeutics. 285 
 
 The monobromide of camphor in 4-grain doses is often 
 helpful. 
 
 Parturition. It occasionally happens that a hypersensi- 
 tive woman, during- a prolonged or severe labor, suffers so 
 much from shock to the nervous system that she becomes irri- 
 table, restless, intolerant of all disturbing- influences, and sleep- 
 less. The pulse, instead of falling in the usual marked way, 
 continues to beat quickly, and that without any accompany- 
 ing rise of temperature, indicating that the innervation of the 
 heart is perturbed. The insomnia may be complete, and it may 
 persist during several nights. It is always a symptom of 
 grave import, for if unrelieved it may usher in puerperal in- 
 sanity. It is, indeed, the most pronounced premonitory symp- 
 tom of that malady. When the want of sleep lasts some 
 days, fever and 'other constitutional symptoms appear, which 
 intensify the distress. In another class of cases the patient 
 does not sleep throughout the first night, but may feel unusu- 
 ally well, and gradually symptoms of disturbance ensue, 
 which terminate in some toxicohaemic disorder. This loss of 
 sleep, with a feeling of exaltation, not rarely prognosticates ill. 
 Euphoria after parturition, and after operations, invariably 
 portends mischief. Without an}" other symptom to justify it, 
 it inspires the physician with dread. He knows its meaning 
 only too well. The patient's manner is changed, she becomes 
 unnaturally effusive, and apparently delights to reiterate the 
 statement that she is so well she is quite able to get up. The 
 writer has been accustomed to base his prognosis on sleep. 
 If the patient has slept well and soundly she may go on nicely. 
 4 If she has not she seldom escapes an illness. 
 
 Sleeplessness may depend upon more marked causes. For 
 example, it frequently follows post-partum hemorrhage, and 
 is then due to acute anaemia of the brain; it is also maintained 
 by severe after-pains, pains which in moderation subserve a 
 useful physiological purpose, but in excess lead to constitu- 
 tional disturbance, which the loss of sleep greatly aggravates. 
 
 In no condition are the benign influence of sleep and the dis- 
 astrous effects of insomnia so well exemplified. 
 
 Treatment. That sleep may not be thwarted it is of the 
 utmost importance that there should be a complete absence of 
 sounds in the bedroom, which should be darkened and well 
 ventilated. Hypnotics are of the greatest value, and they
 
 286 Insomnia and its Therapeutics. 
 
 must be pushed until sound sleep is induced. The monobro- 
 mide of camphor, in 4-grain doses, is reliable ; also the following- : 
 
 5, Liq. morph. acet., 3ij. 
 
 Spt. chlorof., , . 3 ij. 
 
 Tinct. digital., 3ij. 
 
 Mist, camphor., . . . . . ad iv. 
 M. Sig. Take one-fourth every hour until sleep is induced. 
 
 Morphine with atropine may be given subcutaneously. A 
 small allowance of alcohol often acts beneficially. 
 
 After post-partum hemorrhage the remedy is the hypo- 
 dermic injection of morphine, with small quantities of alcohol. 
 During convalescence sleep is materially improved by the use 
 of salines and digitalis. 
 
 For after-pains sedatives are required, but when they are 
 neuralgic in character no remedy relieves them so speedily as 
 acupuncture, with a fine needle, over the lower part of the 
 sacrum and coccyx, as recommended by the late Dr. Sidey of 
 Edinburgh. 
 
 For some months after a severe confinement the patient 
 may continue somewhat sleepless and even hypochondriacal. 
 This condition is best relieved by the treatment indicated as 
 useful for hypochondriasis. It must, however, be mentioned 
 that tincture of cimicifuga, a remedy highly praised, in other 
 cases, by the late Sir J. Y. Simpson, sometimes affords excel- 
 lent results.
 
 CHAPTER XVII. 
 
 BATHS. ELECTRICITY. 
 
 THE writer appends a very brief summary of some remedial 
 measures he has found useful in the treatment of insomnia. 
 These embrace the cold bath, sitz bath, spinal douche, spray 
 or needle bath, cold foot bath, salt bath, wet pack, hot foot 
 bath, hot bath, Turkish bath, and lamp bath; and also elec- 
 tricity. 
 
 BATHS. 
 
 Baths are so serviceable in the treatment of insomnia that 
 a short reference must be made to their physiological effects. 
 
 The Cold Bath. The morning 1 plunge in cold water is an 
 important, if usual, process, being an excellent tonic and de- 
 rivative. The first effect of the bath is to cause contraction 
 of the muscular fibres of the skin, producing the appearance 
 called goose-skin, a process which has been styled cutaneous 
 gymnastics. Coincidently, the blood-vessels of the periphery 
 contract, while those of the brain dilate. The cardiac con- 
 tractions and respirations are quickened, and the blood-pres- 
 sure is raised. This is immediately followed by a concurrent 
 dilatation of the peripheral and a contraction of the cerebral 
 blood-vessels, slowing of the heart and respirations, and low- 
 ering of the blood-pressure. The reaction, as it is called, is 
 much aided by cutaneous friction. When reaction is good it 
 is accompanied by a feeling of lightness and elasticity of the 
 body, and by a desire for active mental and physical exertion. 
 
 The Sitz Bath. As regards the action of the sitz bath it 
 is found that the cold water causes contraction of the blood- 
 vessels of the cutaneous surface and of the superficial muscles, 
 and reflexly those of the pelvis and abdomen, the cardiac con- 
 tractions at the same time becoming less frequent, and the 
 blood-pressure being raised. After the bath reaction sets in, 
 and the blood-vessels dilate, attracting and retaining for a
 
 288 Insomnia and its Therapeutics. 
 
 time a large volume of blood, so that the cerebral vessels are 
 partially depleted; and this, together with the marked tonic 
 effect produced by the bath on the nervous system, renders 
 intelligible the favorable results so often accruing in the treat- 
 ment of insomnia by the sitz bath. 
 
 When a more pronounced effect is desired it can be accom- 
 plished in one of two ways: by a particular construction 
 known as the " running sitz," in which an inlet and exit pipe, 
 each of equal calibre, allow of a constant supply of cold water, 
 and by having two sitz baths placed side by side, the one con- 
 taining- cold and the other hot water, so that the bather can 
 move quickly from one to the other. This is probably one of 
 the most efficacious derivatives we possess. 
 
 The sitz bath should be raised from the floor to such a 
 height as will allow the bather to sit in it comfortably, and 
 should contain from four to five inches of cold water, this 
 being usually sufficient to cover the hips and lower part of 
 the abdomen. During 1 the process the body should be covered 
 with a warm wrap, and the duration of the bath varied ac- 
 cording to the strength of the bather and the effect desired, 
 from five to thirty minutes being the usual limits. After the 
 bath has been completed the skin should be dried with a warm 
 towel, and then rubbed briskly with a flesh brush. 
 
 The Spinal Douche. This is a column of cold water fall- 
 ing from a height with some force upon the back of the neck 
 and down the spine. It is a most powerful stimulant to the 
 medulla oblongata and the centres it contains, and is best 
 taken standing with the feet in hot water. If, however, no 
 special arrangement exists in the bath room, it can be im- 
 provised with a large can of water poured from a height while 
 the patient sits in a sitz bath. In enfeebled states this power- 
 ful remedy must be cautiously used. The alternate spinal 
 douche of hot and cold water is less severe, and is almost 
 equally efficacious. 
 
 Spray or Needle Baths. These are highly stimulating to 
 the nervous system, imparting a sharp shock to it, which is 
 speedily followed by reaction. They should be of short dura- 
 tion, the time being proportioned to the strength of the pa- 
 tient, who ought to stand, during the process, with his feet in 
 hot water. When reaction is slow they may be used hot and 
 cold alternately, or warm throughout, a cold wave being
 
 Insomnia and its Therapeutics. 289 
 
 allowed to flow upon the upper part of the spine for a few 
 seconds to " finish." 
 
 The Cold Foot Bath is in certain cases an energetic de- 
 rivative. The feet and ankles are placed in cold water for 
 five or more minutes, then rubbed with a warm towel, warm 
 stocking's put on, and a short walk taken to induce a some- 
 what lasting hypersemia of the feet. 
 
 The Salt Bath. Sea-bathing is particularly invigorating, 
 especially when the patient can swim. Within strict limits 
 (the duration not to exceed the onset of reaction) the salt bath 
 is one of the most powerful tonics we possess, acting upon the 
 nervous and circulatory systems so as to raise the tone of the 
 whole body. This is evidenced by a feeling of well-being and 
 an inclination for exertion, by the appetite increasing, and di- 
 gestion and assimilation becoming more speedy and complete. 
 The motion of the waves against the body considerably aug- 
 ments the tonic effects of the salt bath. 
 
 "Whatever cold bath be selected, it is best taken an hour 
 before meals, and it should always be followed by brisk flesh- 
 brushing and a short walk. 
 
 All cold baths are unsuitable at the menstrual periods. 
 
 The Wet Pack. This is a derivative and calmative of the 
 highest order, and is very advantageously used, in pronounced 
 cases, in connection with either the cold sitz or the Turkish 
 bath. Ringer, in his work on Therapeutics, quotes the follow- 
 ing directions for managing the wet pack from Dr. Johnson's 
 writings on Hydropathy, which are so good that they are 
 here reproduced. "Upon the mattress, and extending over 
 the pillow, two blankets are spread, and over this a sheet 
 wrung out as dry as possible with cold water. The patient 
 lies down on his back, perfectly unclothed, with his head com- 
 fortably placed on the pillow ; an attendant now approaches, 
 say on the patient's left, and first puckering the blanket from 
 the back of the head down to the back of the neck, reaches 
 across his chest, seizes the right upper corners of the blanket, 
 and brings them tightly across under the chin to his own side 
 (the left), and tucks them well and evenly under the left shoul- 
 der, where it joins the root of the neck, and under the point of 
 the same shoulder. He now reaches across the body again, 
 and brings over all the rest of the right sides of the blankets 
 to the left side of the patient, and then proceeds to tuck them
 
 290 Insomnia and its Therapeutics. 
 
 well and evenly under the left side, beginning" where he left 
 off, at the point of the shoulder, and proceeding quite down to 
 the heels. The patient is now entirely enveloped in one half 
 of the blankets and the attendant finishes the operation by 
 passing over to the right side of the patient, and then pro- 
 ceeding to tuck the left sides of the blanket under the right 
 side precisely in the same manner as we have seen him tuck 
 the right sides- of the blanket under the left side of the pa- 
 tient. The attendant, standing on the right side of the pa- 
 tient's legs, finally insinuates his left hand under the backs of 
 the ankles, lifts them up, and then with his right hand turns 
 back the lower ends of the blanket under the heels. . . . The 
 wet sheet should reach to the ankles, and ... be wide enough 
 to overlap in front of the body about eight or twelve inches; 
 over the whole four or five blankets are placed, and pressed 
 down close to the sides." 
 
 It is a great improvement to put a hot water bag to the 
 feet before folding them up in the manner specified, and also 
 to apply a cold water cloth to the forehead. The patient may 
 drink cold water if he desires, and should remain in the pack 
 for an hour, during which time he will probably fall asleep. 
 At the end of the process he should sponge himself rapidly 
 dow r n with tepid water, and get into bed. Some patients ob- 
 ject to this remedy on account of the trouble it involves, but 
 if the details are methodically arranged beforehand the whole 
 application is easily and speedily managed. 
 
 Hot Foot Bath. This has long been recognized as a do- 
 mestic hypnotic. It acts as a derivative to the brain by 
 dilating the blood-vessels of the feet and limbs. This vascular 
 relaxation may persist for several hours, during which time 
 there is a corresponding anaemia of the brain. 
 
 The Hot Bath acts in a similar manner, though much 
 more powerfully. It first increases the force and frequency 
 of the action of the heart, and produces hyperasmia of the 
 brain; but these conditions are speedily reversed, the heart 
 beating with diminished strength, the blood-vessels of the 
 body generally dilating, while the cerebral vessels become 
 concurrently anaemic. If it is unduly prolonged these condi- 
 tions tend to induce a sense of oppression and faintness. The 
 utility of a hot bath at bedtime in promoting sleep is some- 
 what uncertain, suiting many patients admirably, but in
 
 Insomnia and its TJierapeutics. 291 
 
 others causing a degree of excitement which is fatal to 
 sleep. 
 
 The Turkish Bath, taken under medical advice, is an effi- 
 cacious means of restoring sleep in Certain forms of insomnia. 
 This bath is derivative in all its stages the copious perspira- 
 tion causing rapid elimination through the skin, the sham- 
 pooing and kneading exciting a quicker flow of blood and 
 lymph through the whole body, while the subsequent cold or 
 cool douching induces rapid oxidation. 
 
 It has, further, a derivative action, flushing the skin and 
 superficial muscles with a large volume of blood, while the 
 surcharged cerebral vessels are relieved to a corrseponding 
 extent. As regards vascular tension, the commonly received 
 opinion, with which the writer agrees, is that during the time 
 spent by the bather in the hot chamber it is lowered ; although 
 it must be mentioned that Dr. W. J. Fleming, of Glasgow, in 
 some interesting observations made upon himself, and recorded 
 in the thirteenth volume of the "Journal of Anatomy and 
 Physiology," states that "the principal effect upon the arterial 
 tension seems to be an increase produced bj T the greater rapid- 
 ity of the heart's action combined with the dilated, w r e might 
 almost say gorged, condition of the capillarj' circulation." 
 
 The Turkish bath exactty suits the requirements of many 
 cases of insomnia, relieving the cerebral congestion, acting as 
 a tonic to the nervous and circulatory systems, aiding diges- 
 tion, and increasing assimilation. Well and judiciously used, 
 it is a great boon to the sedentary and wakeful brain-worker, 
 and the cases in which it is contra-indicated are extremely 
 rare. The full benefit, as a rule, is not derived until after six 
 or seven baths have been taken; in fact, discomfort may be 
 increased and wakefulness intensified after the first or second, 
 especially if perspiration is not easy and free. Subsequently, 
 a buoyant feeling of well-being is experienced, and the weight 
 of the bod}" shows a tendency to increase, the latter being a 
 point of some importance. Decrease in body-weight, after a 
 course of six or eight baths, ought to lead to the question of 
 the advisability of their employment being reconsidered. It 
 is important that these baths should not be resorted to with- 
 out advice as to the extent to which they should be carried, 
 and the frequency with which they ought to be taken. For 
 it must not be forgotten that the effects of a prolonged stay
 
 292 Insomnia and its TJierapeutics. 
 
 in an extremely hot rcom (200 Fahr.) are very marked. The 
 pulse is much quickened, possibly to 120, the temperature is 
 raised to 103 Fahr., and the number of respirations to twenty 
 per minute. An equally useful bath may be obtained by 
 spending 1 the time in a much lower temperature, in which the 
 respiration, temperature, and pulse rate are unaffected. It 
 is likewise of some consequence that the bath be thoroughly 
 ventilated and the air quite dry. 
 
 A few general directions as to the use of the Turkish bath 
 may not be out of place. In London most of the public baths 
 have four hot rooms, the temperature ranging from 110 to 
 240 Fahr. That in the first room averages 110, in the 
 second 140, in the third 175, and in the fourth 230 to 240. 
 Upon entering the first room the bather should have his head 
 douched with tepid or cold water, so that it may be the first 
 part of the bocty to perspire, thus lessening any tendency to 
 increase the cerebral congestion. During the course of the 
 bath, throbbing of the blood-vessels of the head may be allayed 
 by the application of a cold wet turban; and palpitation of 
 the heart, or oppression of breathing, may likewise be relieved 
 by placing a cold wet towel over the chest, while, at the same 
 time, cold water is freely sipped. After a short time the 
 bather should proceed into the second room, and again, after 
 a few minutes, into the third, and there recline until perspira- 
 tion is freely established, when he should retrace his steps in 
 reverse order, and pass the bulk of the hour or half hour he 
 spends in the hot chamber in the first room. It is a mistake 
 for the beginner to enter the fourth or hottest room at all 
 until he is " seasoned," though old bathers prefer, and rightly, 
 to proceed at once into either the third or fourth room, and 
 remain until perspiration has commenced, returning to the 
 first room to spend there the rest of the time. Should there 
 be any difficulty or delay in starting the perspiration, the 
 bather had better request the attendant to spray him with 
 warm or hot water in the spray room, and it will be found on 
 returning to the hot room that the skin begins to act freely. 
 After being shampooed, soaped, and washed down, it is de- 
 sirable to " finish " with a tepid, cool, or cold spray, or with a 
 short swim through the moderately cold plunge bath, accord- 
 ing as it is deemed best for the health of the bather, and as 
 the temperature of the weather permits. He should then
 
 Insomnia, and its Therapeutics. 293 
 
 proceed to the dressing apartment, and recline for at least 
 half an hour, with the feet warmly wrapped up in a thick 
 towel. In dressing, the hair ought to be thoroughly dried. 
 During the sweating process in the hot room it is common to 
 see bathers drowsy, and making efforts to resist sleep; and 
 still more common is it to see a number of bathers sound 
 asleep in the dressing room after the completion of the bath. 
 Attendants engaged daily in the occupation of shampooing 
 are good sleepers; indeed the writer never, in the prosecution 
 of his inquiries, heard of one who was not. 
 
 The efficacy of the Turkish bath is greatly enhanced if it 
 can be had jusl before going to bed, for the sleep which natu- 
 rally follows its use is continued uninterruptedly during the 
 night. This can only be accomplished, of course, by having 
 the bath at home; and the writer can speak from personal 
 experience, having used for some time in his own house the 
 " Matlock Domestic Turkish Bath," invented by his friend Dr. 
 Thomas Maccall, formerly assistant physician to Smedley's 
 Institution, Matlock. It consists of a small chamber contain- 
 ing a couch for reclining on, with heating apparatus, and 
 graduated taps for controlling the heat at will. Any tem- 
 perature up to 200 Fahr. can be obtained quickly by simply 
 regulating the quantity of gas used; and the heat may be 
 as rapidly lowered, so that the one apartment combines the 
 use of the three or four rooms usually met with in a public 
 bath. The arrangements are of a simple kind, and are easily 
 and safely controlled by the bather. The ventilation is per- 
 fect, the bath is quite portable, and occupies no more space 
 in a room than an ordinary bed. It is so constructed that a 
 small chamber can be added, fitted with cold and hot water, 
 the latter heated from the same source as the bath, so that it 
 forms in itself a complete Turkish bath. 
 
 Various substitutes for the Turkish bath are in use, but 
 they all fall far short of the original in point of efficacy. Ex- 
 amples are to be found in the lamp bath, or in the old Malvern 
 gas bath, which resemble each other closely. The bather sits 
 upon a wooden chair, surrounded by several thick blankets 
 securety fastened round his neck, a safety spirit lamp or gas 
 arrangement is lighted underneath the chair, and perspira- 
 tion soon commences. After it has continued for fifteen or 
 twenty minutes he is released, takes a hot soap bath, and
 
 294 Insomnia and its Therapeutics. 
 
 finishes with a cold shower bath or cold sponging 1 . A too 
 frequent practice is the use of methylated spirit in a gallipot, 
 without any wick or other precaution for safety. The la- 
 mented death of Dr. Carpenter, from an accident arising out 
 of an arrangement of this kind, ought not to be without its 
 warning. 
 
 ELECTRICITY. 
 
 This remed3 T , whether in the form of central galvanization 
 or general faradization, is often attended by an improvement 
 in the quantity of sleep. The writer has frequently noticed 
 this in instances where it was used without reference to sleep 
 at all, it being remarked by relatives and friends as a coinci- 
 dence; and it is not surprising that it should be so, since 
 Nothnagel demonstrated that cutaneous electrical stimula- 
 tion was followed by reflex contraction of the vessels of the 
 pia mater. Mr. Skene Keith, who has had a somewhat large 
 experience of electricity in cases where its use was not adopted 
 for the relief of wake fulness, has kindly summarized his ob- 
 servations on this subject for the writer. " During the treat- 
 ment of fibroid tumors of the uterus, and of other pelvic con- 
 ditions, by the passage of a continuous current of electricity 
 from the abdomen to a sound placed in the uterine cavity, or 
 vice versd, one noticed that in quite a considerable number 
 of cases sleep is affected. In perhaps rather more than half 
 the cases there is not any change, but in the great majority 
 of the remainder there is a marked improvement in this re- 
 spect, and this before there has been sufficient relief of the 
 symptoms to account for it. The patients often fall asleep 
 in the afternoon after an application has been made, and will 
 often sleep for ten hours at night. In a few cases the patients 
 did not sleep so well as they did before." From this it follows 
 that electricity has the power of lengthening the duration and 
 deepening the intensity of sleep in some persons in whom it is 
 not abnormal. 
 
 The writer has found it beneficial in about three-fourths of 
 the patients who have used it for inscmnia. In the majority, 
 the improvement came slowly, and apparently as concomitant 
 symptoms were alleviated; in a few, it came quickly; while in 
 the remainder it came not at all, the remedy entirely failing 
 to relieve the wakefulness. Reference has been made to this 
 subject elsewhere.
 
 INDEX. 
 
 ADEQUATE repose, 39 
 Affections of the circulatory sys- 
 tem, 219 
 
 of the respiratory system, 238 
 Age, influence on sleep, 41 
 Alcohol as a hypnotic, 61 
 Alcoholism, 141 
 Amenorrhoea, 281 
 Ansemia, cerebral, 130 
 
 conducive to sleep, 19 
 Aneurism, aortic, 235 
 Angina pectoris, 228 
 Antecedents, influence on sleep, 47 
 Aortic insufficiency, 232 
 Asthma, 247 
 Ataxy, locomotor, 138 
 Atheroina, 132 
 Atropine in shock, 76 
 Azoturia, 272 
 
 BATHS, 287 
 
 Bladder, irritability of the, 271 
 
 Blood-supply of brain, variation 
 
 of, 11 
 
 Brachialgia, 140 
 Brain, blood-supply of, 11 
 
 and nervous system during 
 sleep, 2 
 
 circulation during sleep, 11 
 
 movements of, 12 
 Bromides in insomnia, 72 
 Bronchitis, insomnia in, 245 
 
 CACHEXLZE. 270 
 
 Calculus, vesical, 274 
 
 Carbonic acid, elimination of, dur- 
 ing sleep, 8 
 
 Cardiac centres in the medulla 
 oblongata, 36 
 
 Causation of sleep, 11 
 
 Cerebral arteries, degeneration of, 
 
 132 
 cells, difference in, 30 
 
 Cheyne-Stokes' respiration, 227 
 
 Children, position of limbs in 
 healthy sleep, 56 
 
 Chloral, 83 
 
 Chloralism, 145 
 Chorea, 67, 115 
 Circulation during sleep, 7 
 Climate, 47 
 
 influence on sleep, 47, 60 
 Cocainism, 146 
 Coffee, 147-148 
 Cold foot-bath, 289 
 Congestion, cerebral, influence on 
 sleep, 33 
 
 cerebral, 127 
 Constipation, 182 
 Convalescence, 132 
 Cough, 239 
 Croup, spurious, 254 
 Cystitis, 273 
 
 DEPRESSING emotions, 77 
 
 Depth of sleep, 10 
 
 Devices for producing sleep, 48, 69 
 
 Diabetes rnellitus, 271 
 
 Diagnosis, 54 
 
 Diet, standard daily, 212 
 
 Dreams, 25 
 
 difference in quality of, 26 
 Dukes, Dr., of Rugby, his opinion 
 
 of time required for sleep, 74 
 Durham on sleep, 15 
 Dysmenorrhcea, 280 
 Dyspepsia, 134-156 
 
 gastric, 156 
 
 gastric, causes, 157 
 
 gastric, symptoms, 168 
 
 gastric, treatment, 171 
 
 intestinal, 178 
 
 overfeeding a cause of, 165 
 
 symptoms of, 168 
 
 underfeeding a cause of, 165 
 Dyspnoea, 225, 241 
 
 ECZEMA, treatment, 216 
 Effects of sleep upon the body, 7 
 Electricity, 294 
 
 in neurasthenia, 95 
 Emotions, depressing, 77 
 Emphysema, 249
 
 296 
 
 Index. 
 
 Enteric fever, 261 
 Epilepsy, 118 
 
 FEVERS, 256 
 
 Food, constituents of, 212 
 
 GOUT, 195 
 acute, 199 
 causes, 206 
 irregular, 200 
 pathogeny of, 195 
 treatment, 210 
 
 HABIT of sleep, 44 
 
 Hay fever, 249 
 
 Hearing during sleep, 5 
 
 Heart, fatty degeneration of the, 
 
 233 
 
 Herpes zoster, 140 
 History of case, 47 
 Hot bath, the, 290 
 Hours for exercise and sleep in 
 
 children, 73 
 Hyperaemia, 126 
 
 of the nervous centres, dimi- 
 nution of, 68 
 Hyperpyrexia, 242 
 Hypnotics, 72 . 
 
 action of, 61 
 Hypnotism, 26, 
 Hypochondriasis, 104 
 Hysteria, 101 
 
 IDIOTS, sleep of, 21 
 
 Incontinence of urine, 275 
 
 Insanity, 108 
 
 Insomnia and its therapeutics, 1 
 and nightmare, 121 
 and night-terrors, 122 
 and somnambulism, 123 
 baths in, 287 
 causes, 49 
 definition, 28 
 diagnosis, 54 
 electricity in, 294 
 frequency at different ages, 53 
 from amenorrhcea, 281 
 from angina pectoris, 228 
 from Cheyne-Stokes' respira- 
 tion, 227 
 from cough, 239 
 from depressing emotions, 77 
 from dysiiienorrhcea, etc., 280 
 from dyspnoea, 225, 241 
 from hyperpyrexia, 242 
 from incontinence of urine, 275 
 from irritability of the blad- 
 der, 271 
 
 from overwork, 64 
 from pain, 242 
 from palpitation, 220 
 
 Insomnia from shock, 74 
 
 from tea and coffee, 147 
 
 from tobacco, 154 
 
 from uterine displacements, 
 281 
 
 from vesical calculus, 274 
 
 general remarks on, 28 
 
 in alcoholism, 141 
 
 in aortic aneurism, 235 
 
 in aortic insufficiency, 232 
 
 in asthma, 247 
 
 in atheroma, 132 
 
 in azoturia, 272 
 
 in bronchitis, 245 
 
 in cachexige, 270 
 
 in cerebral anaemia, 130 
 
 in cerebral congestion, 127 
 
 in children, 73 
 
 in chloralism, 145 
 
 in chorea, 115 
 
 in cocainism, 146 
 
 in convalescence, 132 
 
 in cystitis, 273 
 
 in diabetes mellitus, 271 
 
 in dyspepsia, 134, 156 
 
 in emphysema, 249 
 
 in enteric fever, 261 
 
 in epilepsy, 118 
 
 in fatty degeneration of the 
 heart, 233 
 
 in fevers, 256 
 
 in functional disorders of the 
 liver, 188 
 
 in gout, 195 
 
 in hay fever, 249 
 
 in hepatitis, 193 
 
 in hypertrophy of the pros- 
 tate, 273 
 
 in hypochondriasis, 104 
 
 in hysteria, 101 
 
 in insanity, 108 
 
 in intra-cranial tumors, 136 
 
 in jaundice, 192 
 
 in laryngismus stridulous, 253 
 
 in locoiiiotor ataxy, 138 
 
 in mania, 110 
 
 in measles, 263 
 
 in melancholia, 112 
 
 in migraine, 120 
 
 in mitral insufficiency, 230 
 
 in morphinism, 143 
 
 in myelitis, 138 
 
 in rnyxcedema, 114 
 
 in neuralgia, 139 
 
 in neurasthenia, 85 
 
 in paralysis agitans, 116 
 
 in phthisis pulmonalis, 251 
 
 in pleuritis, 253 
 
 in pneumonia, 250 
 
 in prostatitis, 272 
 
 in pruritis senilis, 135
 
 Index. 
 
 297 
 
 Insomnia in pyelitis, 273 
 in rheumatism, 265 
 in rickets, 266 
 in scarlet fever, 263 
 in spinal meningitis, 137 
 in spurious croup, 274 
 in syphilis, 278 
 in typhus fever, 256 
 in whooping-cough, 243 
 in wry-neck, 118 
 of menstrual periods, 279 
 of pregnancy, 284 
 of puberty in females, 279 
 of the menopause, 282 
 of the puerperium, 285 
 peculiar to females, 279 
 prognosis, 55 
 remarks on, 28 
 
 treatment, 56, 68, 76, 89, 102 
 et seq. 
 
 Intestinal worms, 187 
 
 JAUNDICE, 192 
 
 LAMB, CHARLES, on early rising, 
 
 44 
 
 Laryngismus stridulous, 253 
 Liver, functional disorders of, 188 
 Living, mode of, influence on sleep, 
 
 146 
 
 Locomotor ataxy, 140 
 Lumbago, 140 
 
 MANIA, 110 
 
 Measles, 263 
 
 Medulla, condition of, during 
 
 sleep, 8 
 Melancholia, 112 
 
 treatment of, 113 
 Meningitis, spinal, 137 
 Menopause, 780 
 Men require less sleep than 
 
 w.omen, 40 
 
 Menstrual periods, 279 
 Methods of life as affecting sleep, 
 
 46 
 
 Migraine, 120 
 Mitral insufficiency, 230 
 Morphinism, 243 
 Motor centres during sleep, 4 
 Music, benefit from, 68 
 Myelitis, 138 
 Myxoedema, 114 
 
 NERVOUS centres, calming and 
 strengthening them, 71 
 
 system during sleep, 2 
 Neuralgia, 139 
 Neurasthenia, electricity in, 95 
 
 stimulants in, 92 
 Normal metabolism, 32 
 
 OCCUPATION, influence on sleep, 45 
 Opium, 77 
 
 Ovarian neuralgia, 140 
 Overfeeding, evils of, 65 
 Overwork, 64 
 
 evils of, in children, 67 
 Oxygen taken in during sleep, 9 
 
 theory of sleep, 22 
 
 PAIN, 242 
 
 Palpitation, 220 
 
 Paralysis agitans, 116 
 
 Parturition, 285 
 
 Pathological conditions during 
 sleep, 8 
 
 Periodicity of sleep, 24 
 
 Phosphorus, 76, 82 
 in shock, 76 
 
 Phthisis pulmonalis, 251 
 
 Pillows for sleep, 32 
 
 Pleuritis, 253 
 
 Pneumonia, 250 
 
 Pregnancy, 284 
 
 Prescriptions, 71, 73, 77, 82, 83, 84, 
 97, 99, 100, 103, 107, 111, 113, 116, 
 118, 121, 123, 129, 130, 132, 135, 136, 
 138, 143, 145, 153, 175, 177, 181, 185, 
 186, 191, 193, 213, 215, 217, 225, 231, 
 235, 245, 247, 251, 252. 260, 262, 277, 
 280, 283, 286 
 
 Prognosis, value of sleep in, 55 
 
 Prostate, hypertrophy of the, 273 
 
 Prostatitis, 272 
 
 Pruritus ani, treatment, 216 
 senilis, 135 
 
 Puberty in females, 279 
 
 Puerperium, 285 
 
 Pyelitis, 274 
 
 RECUPERATION, sleep favorable 
 
 for, 3 
 
 Reflexes during sleep, 10 
 Respiration during sleep, 8 
 Rheumatism, 265 
 
 SALT bath, 289 
 Scarlet fever, 263 
 Sciatica, 140 
 
 Season, influence on sleep, 47 
 Seasons as related to sleep, 47 
 Secretions during sleep, 9 
 Sex, influence on sleep, 40 
 Shock, 74 
 
 treatment of, 76 
 
 Sleep, absence of stimuli as cause 
 of, 23 
 
 amount required, 42 
 
 and sleeplessness, conditions 
 influencing, 40 
 
 as a measure of possible work, 
 67
 
 298 
 
 Index. 
 
 Sleep, by suggestion, 24 
 
 causation, 2, 11 
 
 cerebral hyperseuiia incompat- 
 ible with, 14 
 
 cerebral slight anjeinia condu- 
 cive to, 19 
 
 condition of nervous system 
 during, 2 
 
 conditions favoring, 29, 57 
 
 depth of, 10' 
 
 effects of impure blood on, 32 
 
 effects of leucomaines on, 21 
 
 effects of light on, 31 
 
 effects of noise on, 31 
 
 effects of pain on, 32 
 
 effects of smells on, 31 
 
 effects of vascular tension on, 
 35 
 
 effects of waste products on, 20 
 
 effects on circulation. 7 
 
 effects on respiration, 8 
 
 effects on temperature, 9 
 
 effects on the secretions, 9 
 
 favors recuperation, 3 
 
 habit of, 44 
 
 importance of, 29 
 
 in church, 23 
 
 insufficient, 36 
 
 mode of incursion, 4 
 
 onset, gradual, 4 
 
 onset of, 4 
 
 oxygen theory of, 22 
 
 periodicity of, 24 
 
 physiology of, 1 
 Sleeping sickness, 19 
 Sleeplessness. See Insomnia 
 Smell during sleep, 6 
 Somnambulism, 26, 123 
 Sound nervous structures, 29 
 Spasmodic neuroses, 114 
 Spinal douche, 288 
 Spray or needle baths, 288 
 Stimulants in neurasthenia, 92 
 Strychnine in insomnia, 76, 82 
 
 Sweating during sleep, 9 
 Syphilis, 268 
 
 TASTE during sleep, 7 
 
 Tea and coffee, constituents of, 147 
 and coffee, insomnia from, 147 
 drinkers, 150 
 
 Teas, classification of, 153 
 commercial, 153 
 
 Temperament, influence on sleep, 
 43 
 
 Temperature during sleep, 9 
 
 Thyroid gland regulating blood- 
 supply of the brain, 19 
 
 Tobacco, 154 
 
 Tonics, 60, 71 
 
 Touch, sense of, during sleep, 7 
 
 Treatment, 56 
 
 Tumors, intra-cranial, 136 
 
 Turkish bath, the, 291 
 use of, 70 
 
 Turpentine for insomnia, 72 
 
 Typhus fever, 256 
 
 UNDERFEEDING, evils of, 165 
 Uterine displacements, 281 
 
 VASCULAR tension, 35 
 Vaso-motor centres in the medulla 
 
 oblongata, 36 
 
 nerves, restoring tone to, 71 
 Vital alkaloids, 21 
 
 WASTE products during sleep, 20 
 
 Wet pack, the, 289 
 
 Whooping cough, 243 
 
 Women need more sleep than men, 
 
 40 
 
 Wood-carving, benefit from, 68 
 Worms, intestinal, 187 
 Worry, 78 
 
 treatment of, 80 
 Wry-neck, 118
 
 University of California 
 
 SOUTHERN REGIONAL LIBRARY FACILITY 
 
 Return this material to the library 
 
 from which it was borrowed. 
 
 
 PR.NTEOIN U.S.A. CAT. NO. 24 161
 
 A 000510519 2 
 
 3 1970007590174 
 
 WML88 
 
 1891 
 :Iac far lane, Alexander W 
 
 Insomnia and its therapeutics. 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664