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Finally, it must be observed that wakefulness may result from excitement of the brain by irritating substances transported through the blood from distant centers of disease in remote organs of the body, or derived from articles that have been absorbed with the food and drink, or with the air that enters the lungs. Thus wakefulness may accompany cutaneous disorders that interfere with perspiration. Imperfect elimination through the liver, kidneys and intestines, leaves the blood charged with excrementitious substances which arouse the brain to wakefulness. In like manner, various poisons, like lead, arsenic, etc., different miasms of telluric origin, the products of putrefaction, and the various animal contagia, may produce insomnia by their prejudicial effect upon the nutrition of the nervous structures throughout the body.

REMEDIES FOR INSOMNIA.

O, true apothecary! Thy drugs are quick. --ROMEO AND JULIET.

An occasional attack of wakefulness may fall to the lot of any one as a consequence of the various disturbances of health or equanimity of mind to which all are liable. Occurring as an accident in a state of health, it produces merely a feeling of lassitude and weariness during the subsequent day. This soon disappears, after a night of refreshing sleep, and the subject is nothing worse for the incident. But the recurrence of the disorder is a thing to be deprecated, not only for the reason that it denotes a departure from the physiological order of life, but because its frequent repetition prevents the adequate repair of the tissues of the body. The great function of nutrition suffers as a consequence, and the patient rapidly falls into a condition of premature old age. When this takes place as a result of some temporary error of hygiene, or as a consequence of diseases which admit of successful treatment, the patient may be restored to health by judicious management, but lost youth and elasticity of the tissues can never be fully regained. The most formidable cases of insomnia are those for which no adequate cause can be recognized in the habits, mode of life, and state of health of the patient. Grave and permanent disorder of the brain is then to be feared. Such wakefulness is a frequent precursor of acute meningitis in children and adults. It frequently ushers in the early, insidious, formative stage of tubercular meningitis, and of the infective fevers--notably typhoid fever. It forms one of the most suspicious symptoms among the introductory phenomena of insanity; and during the course of protracted diseases, its intrusion is an omen of most unfavorable augury. It will, therefore, be found useful to consider with some degree of detail the circumstances under which insomnia may occur, and the best means of averting its onset.

Before proceeding to a discussion of the therapeutics of insomnia in connection with particular diseases, it will be advantageous to pass briefly in review the different remedies which are useful in the treatment of wakefulness. These may be divided into two classes: Nervous stimulants, and nervous sedatives. Among the first may be also reckoned food, heat, baths, and counter-irritants. Like all nervous stimulants, they promote the complete and harmonious action of all parts of the nervous system, favoring that equilibrium of the circulation which is most favorable to the development of sleep. The second class of agents comprises all such remedies as act directly upon the nervous tissue of the brain, depressing its functional activity, and hushing to rest those particular organs which, by their undue excitement, serve to keep the remainder in a state of wakefulness. All these substances produce decided effects upon the spinal cord and the peripheral nerves, but it is their operation upon the brain which principally interests us in connection with insomnia.

NERVOUS STIMULANTS.

Heat. Baths. Massage. Electricity. Counter-irritants. Food. Digitalis. Camphor. Musk. Valerian. Cannabis indica. Belladonna. Hyoscyamus. Stramonium. Phosphorus. Acids. Opium.

NERVOUS SEDATIVES.

Cold. Alcohol. Paraldehyde. Ether. Chloroform. Chloral. Butylchloral hydrate. Amyl nitrite. Opium and opiates. Bromides. Hops. Gelsemium. Conium.

NERVOUS STIMULANTS.

It may at first sight seem to be a contradiction in terms when it is asserted that sleep may result from the administration of a nervous stimulant. This does occur, but only indirectly, and as a consequence of a restoration of energy to those portions of the nervous system which serve to moderate the activity of the organ of the mind--the cortex of the cerebrum.

Dilute five quarts of milk with three quarts of hot water. When lukewarm, add half a cupfull of sugar of milk , and one bottle of well fermented koumiss . Stir the mixture thoroughly, and let it stand in an open jar, at a temperature of about 72? F., till it begins to curdle. Then stir in half a cupfull of pulverized coffee sugar, and cork tightly in champagne bottles with the best velvet corks. The bottles should be kept quite cool, as fermentation proceeds very briskly, and will break the containers if left in a warm room. A large ice-box is the best receiver during hot weather. The koumiss thus prepared is ready for use at the end of a week. It may be most conveniently drawn from the bottle with a champagne tap. The entire cost of the article need not exceed seven cents a bottle.

Sleeplessness caused by chronic dyspepsia will often yield to a diet of koumiss, when every other remedy has failed. When the stomach is very intolerant, it should at first be taken in very small doses, repeated as often as every hour. It will soon become possible for the same patient to drink two or three quarts each day.

Neurasthenic patients, whose insomnia results from physical exhaustion, should never retire at night without taking some form of light and easily digested food. A simple slice of bread, or a piece of plain sponge-cake, with a glass of koumiss, forms an excellent model for such a meal.

NERVOUS SEDATIVES.

The remedies thus far considered are but indirectly hypnotic in their effects, though exceedingly valuable as agents for the production of conditions favorable to sleep. We may now pass to the consideration of a class of remedies which operate more directly upon the brain to depress its energy. They are, therefore, called nervous sedatives, and they include the majority of narcotic substances.

According to Ringer, the sitz-bath, taken at a temperature between 60? and 80? F., is very useful to soothe "an irritable restless state of the nervous system." It should be employed once or twice a day, from five to thirty minutes at a time. Among other beneficial consequences is the promotion of quiet sleep.

The difficulty of administering such a laborious course of baths outside of a well equipped hospital renders its adoption almost impossible in private practice. Here the physician must rely upon assiduous sponging with water of an agreeable temperature. In severe cases, such as measles before the appearance of the eruption, scarlet fever during the period of heat and agitation, and typhoid fever during the corresponding stage, great benefit will be derived from the cold wet sheet. In order to humor the prejudices of the laity, this should be wrung out of warm water and applied with sufficient deliberation to insure its considerable loss of heat. A blanket should first be spread upon an empty bed; the wet sheet should be spread over the blanket. The patient must be placed naked upon the sheet, which should then be drawn around the entire body, and the blanket may be folded around the whole package. Children generally insist upon leaving their arms uncovered. This may be allowed with safety in many cases, but generally a wet napkin should cover the upper part of the chest and the neck which cannot be reached with the sheet when the arms are exposed. After remaining from half an hour to two hours in the pack, the patient becomes comparatively cool and quiet, and the eruption, if delayed, begins to appear. Sleep often occurs as an immediate consequence of the relief thus obtained.

Similar good results may be secured by the use of cold affusion in cases of high temperature and great restlessness. I well remember a little boy, about eight years old, whom I once found rolling and tossing and burning up with scarlet fever. Calling for an empty wash-tub, I had him stripped and placed upright in the tub. I then began to pour cold water over him from a large pitcher. Scarcely had the water touched his skin, before he seized the pitcher, and began to drink from it. He was permitted to completely slake his thirst, and then the affusion was resumed. After four or five gallons of water had been thus poured over him, he was wiped dry, and was returned to his bed, where he immediately turned upon his side, and fell into a peaceful sleep. A few more affusions relieved him from danger, and he made a rapid recovery. Were people less afraid of such measures, a considerable portion of the danger in fevers might be obviated. Great discretion, however, is necessary in the application of such treatment, for Ringer states that he has "seen a child, suffering from scarlet fever, killed by an over-energetic employment of cold." The temperature of the patient should be carefully noted, and its reduction below the normal standard should never be permitted.

Alcohol is principally useful as an hypnotic when wakefulness is associated with great bodily exhaustion, such as may be experienced in advanced stages of the infective fevers. In such cases the heart is weakened, the pulse is rapid and feeble, the muscular apparatus is wasted and irritable, the blood is diminished in volume and tends to accumulate in the venous channels. Under such conditions the patient is usually delirious, tossing from side to side, and quite deprived of sleep. An ounce of brandy, repeated at intervals varying according to the severity of the symptoms, and given with milk and egg, in the familiar form of eggnogg, will often quiet this harassing restlessness, and will procure refreshing sleep. The temperature of the patient will then decline; the tongue will grow moist; and the delirium will diminish or subside altogether. Sometimes, however, a contrary result is observed. Alcohol should then be administered with a sparing hand, and it will probably be necessary to resort to the bromides or other cerebral sedatives.

The great exhaustion which is manifested in delirium tremens sometimes requires the use of alcohol to support the patient, so that sleep may be procured. It is in such cases advisable to combine the administration of capsicum with that of alcohol. According to Ringer, capsicum should be given for this purpose in scruple doses, made into a bolus with honey, and repeated every three hours.

Wakefulness caused by neuralgic pains is speedily relieved by full doses of alcohol. The various species of abdominal and pelvic neuralgia may thus be temporarily suspended. In like manner the "rheumatic" pains which afflict the overworked and underfed poor may be calmed for a season sufficient to procure sleep. The obvious dangers attendant upon such medication, however, need no comment.

Old people not unfrequently suffer with a form of insomnia that is associated with feeble and painful digestion. This is probably caused by insufficient gastro-intestinal secretion. The use of wine containing a large proportion of compound ethers gives relief through the improvement in digestion consequent upon the stimulant effect of small doses of alcohol and ether. Under their influence the digestive fluids are more abundantly secreted, and all the bodily functions are quickened. Such good results, however, only follow the moderate use of the stimulant. It must never be taken in quantity sufficient to affect the intellectual functions, or to disturb any of the normal processes of life. The best results, so far as digestion is concerned, are obtained by the use of wine with the meals; but a night-cap, in the form of hot toddy, is sometimes necessary in addition. This is especially useful if there be any form of irritative cough or local excitement, such as the aged sometimes experience.

Paraldehyde, Gr. 20.0 Spirit, 100.0 Syr. Simpl., 75.0 Tr. Vanillae, 5.0

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

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

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

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

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

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

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

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

TREATMENT OF INSOMNIA IN PARTICULAR DISEASES.

Take thou this phial, being then in bed, And this distilled liquor drink thou off; When presently, through all thy veins shall run A cold and drowsy humor, which shall seize Each vital spirit. --ROMEO AND JULIET.

Excluding from consideration all cases of insomnia arising from painful injuries or diseases of the external portions of the body, which belong to the province of surgical therapeutics, we may profitably commence with the variety of wakefulness that is excited by disorder of the brain and its membranes. This includes the different forms of meningitis, the cerebral disturbances which constitute insanity, cerebral exhaustion, and chronic alcoholism.

? Morph. Sulph. gr. 1/4 Chloral Hydrat, Sodii Bromid. ? ? ?iv. Tr. Aconit., rad. gtt. xxv. Tr. Cardam. Co. ?i. Aquae, q. s. ad. ?i.

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

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

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

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

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

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

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

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

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

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

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

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

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

? Ammon. carb., gr. v. Spt. chloroform, gtt. xx. Aq. camphor, ? ss.

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

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