TREATMENT OF INSOMNIA IN PARTICULAR DISEASES.

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

Insomnia in acute affections of the brain.—Acute intra-cranial inflammations may result from general diseases, like rheumatism, the eruptive fevers, tubercular infiltration, insolation, the development of tumors, or syphilitic growths. In all such cases the earlier stages are marked by a painful exaggeration of cerebral function which renders sleep impossible. The wakefulness of this stage soon becomes complicated with delirium; and the whole is finally merged in a fatal coma. Cerebral excitement is the principal feature which arrests attention. This is accompanied by an inordinate determination of blood to the head, producing that cerebral hyperÆmia which figures so largely in the works of the humoral pathologists. The treatment of acute inflammation becomes the best means of relieving this excitement, allaying the hyperÆmia, and procuring sleep. The treatment should be derivative, counter-irritant, and calmative. The first indication must be fulfilled by the exhibition of an active purge. Ten grains of calomel with five grains of sodium bicarbonate may be given for this purpose. Leeches or wet cups should be applied to the temples, or to the back of the neck. The feet should be placed for a short time in a hot foot-bath, and an ice-cap must be drawn over the scalp. The internal medication must consist of arterial sedatives and cerebral depressants. For the first, tincture of aconite forms an admirable example—better even than the tartar emetic so much lauded by Graves. Aconite may be given with the bromides. When sleeplessness in an acute meningitis is accompanied by severe pain, an excellent combination will be found in the following:

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

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

Insomnia in insanity.—Persistent insomnia is often one of the premonitory symptoms of insanity. It is likely to present itself as a most formidable complication at any stage of the disease. To consider aright the relations that exist between sleeplessness and insanity would far exceed the limits of this work; we can only review the leading indications for its treatment. It is occasioned either by an excited state of the brain, accompanied by hyperÆmia and general functional exaltation, or by an exhausted and irritable condition of the cerebral substance. The first of these two varieties of wakefulness is encountered in cases of violent maniacal excitement where the disorder is comparatively recent, and the bodily vigor has not been depressed by long continued disease. The indications for treatment call for sedative measures. Leeches behind the ears and the application of the ice-cap are sometimes of great service. Derivative action upon the bowels with aloetic purgatives has often yielded good results. In like manner, hot mustard foot baths are recommended. The soothing effect of a warm bath at 90°-95° F. is sometimes sufficient to calm excitement, and to induce sleep. The combined effect of cold applications to the scalp and a warm bath to the general surface is still more tranquillizing. This method of treatment is particularly useful in maniacal forms of insanity, and in certain cases of melancholia—especially those in which the skin is dry and the secretions are disordered.

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

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

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

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

Cannabis indica associated with bromide of potassium is a useful hypnotic in cases of moderate depression and excitement. Clouston finds as a result of his experiments that “forty-five grains of bromide of potassium and forty-five minims of the tincture of cannabis indica are rather more than equivalent to a drachm of laudanum as a means of allaying maniacal excitement.”[50] In his recent work,[51] the same author deprecates the use of opiates in states of depression, and advises the substitution of tincture of cannabis indica (x min.) and bromide of potassium (xx grs.). He also emphasizes the importance of abundant exercise in the open air, as the best hypnotic in every case that can be trusted abroad.

Insomnia in Chronic Alcoholism and Delirium Tremens.—The insomnia of chronic alcoholism is dependent upon the extensive morbid changes produced in the digestive apparatus and in the nervous system by the habitual use of alcoholic drinks. Sleep becomes greatly disturbed and unrefreshing. It is frequently broken by horrible dreams. The successful treatment of this condition requires complete abandonment of the use of alcohol, and a general correction of the condition of the alimentary canal. For the immediate relief of insomnia, full doses of bromide of sodium will be of service. Strong infusions of hops may be given ad libitum. Cannabis indica, in the form of the extract, so as to avoid the use of alcohol in the tincture, is of service. Hypodermic injections of morphia are frequently employed, but should be avoided if possible, for fear of the opium habit. Chloral hydrate is exceedingly useful, but should be given in milk, and as seldom as possible, for fear of adding to the injuries already sustained by the stomach. For the same reason the use of paraldehyde in such cases is quite inadmissable.

When chronic alcoholism has culminated in delirium tremens, more energetic measures become necessary in order to procure sleep. If the patient be of a vigorous constitution, and if the delirium be very active, tartar emetic with morphia may be given, as advised by Graves. Large doses of tincture of digitalis, sometimes reaching an ounce every four hours, were used by Jones, of Jersey. Capsicum, in scruple doses every three hours, is said to induce sleep in many cases of delirium,[52] especially in exhausted conditions of the circulatory organs. Hydrate of chloral and bromide of sodium, each in scruple doses, may be given every two hours. Opiates should be used with moderation, and all attempts to induce profound narcosis should be avoided. Drachm doses of tincture of cannabis indica and of compound spirit of ether, may be given when a diffusible stimulant must be associated with the soporific. In desperate cases it is sometimes necessary to resort to inhalation of ether, but if sudden death should occur, it would be popularly ascribed to the effects of the anÆsthetic. By reason of a certain tendency to death from syncope during this disease, it is imprudent to place such patients under the influence of chloroform or the other stronger anÆsthetics.

Insomnia in diseases of the heart and blood vessels.—I can fully indorse the opinion of Ringer regarding the beneficial effects of morphia in the treatment of the wakefulness caused by advanced diseases of the circulatory organs, “In such a case, the comfort afforded by a hypodermic injection is almost incredible.... In cardiac dyspnoea, a sixth of a grain twice or three times a week often suffices, but the dose and frequency in severe cases must be gradually increased to a quarter of a grain each night. Doctors are often afraid to administer morphia in the case of a patient propped up in bed, with livid ears, nose and nails, with distended jugulars and dropsical extremities, with weak, frequent and irregular pulse. They dread lest the morphia should weaken the heart, make the patient worse, if not kill him outright. This fear is quite groundless,” if the opiate be given in moderate doses. It is the stimulant effect of the medicine that is safe and useful.

When wakefulness is caused by angina pectoris, or by simple cardiac neuralgia, such as sometimes follows excessive use of tobacco, relief may be obtained through the exhibition of alcoholic stimulants, hydrate of chloral, or nitrite of amyl. These remedies act more speedily than morphia, and may be associated with it, to the great advantage of the patient. They should not be habitually used, however, in cases of cardiac exhaustion, as their chronic employment favors accumulation of blood in the right side of the heart, with a tendency to paralysis of the cardiac muscles. It is in stenosis of the coronary arteries, and in aortic obstruction, that nitrite of amyl and nitro-glycerine are most useful. The insomnia that results from the remote consequences of these diseases is often relieved by remedies which assist the circulation of blood. For this purpose digitalis is the most useful stimulant in mitral disease; nitro-glycerine, in aortic valvular lesion.

Insomnia in diseases of the respiratory organs.—Pleuritic pain and its consequent wakefulness may be relieved with opiates, guarded by appropriate vascular sedatives. Dover’s powder, or morphia and aconite, form excellent examples of the remedies most useful, so long as the lungs are not overwhelmed by excessive exudations into the pleural cavities. Pneumonia and bronchitis are accompanied by wakefulness, in their earlier stages, as a consequence of harassing cough. This may be allayed by the judicious use of expectorants and sedatives. If symptoms of asphyxia appear, indicated by blueness of the lips and nails, opiates should never be given. Respiratory stimulants are then indicated, and sleep must be allured by the use of alcoholic beverages and moderate doses of chloral hydrate, with musk and camphor. The early, irritative cough of incipient pulmonary consumption may be soothed with camphor and opium. Paregoric and a demulcent, like Iceland moss tea, or flaxseed tea slightly acidulated with lemon-juice, form an excellent type of such a compound. But the chronic duration of the disease renders the constant use of opiates undesirable. Chloral hydrate, for the same reason, cannot be given without intermission. It is well in such cases to employ the different alcoholic beverages at bedtime. Inhalation of warm vapor, and respiration of air charged with ether, or carbolic acid, will often quiet an irritative cough. In advanced cases belladonna is useful, to check the profuse sweating and to calm the thoracic pain that hinders sleep. In the later stages of the disease, when relief from suffering is the only end in view, morphia and dilute hydrocyanic acid will often render quite tolerable the few remaining nights of life.One of the most distressing forms of insomnia is occasioned by the different varieties of asthma. 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.

Insomnia in renal disease.—In the acute forms of renal disorder this is usually caused by pain and fever. It is, therefore, to be relieved with opiates given in connection with such arterial sedatives and diaphoretics as each individual case may require. But the tendency of inflammatory diseases of the kidney to merge in urÆmia must not be forgotten, and the soporific must be used in such cases with great caution. For this reason hyoscyamus is often preferable to an opiate. In extreme dropsical conditions the measures that are useful for the reduction of anasarca constitute the most efficient means for the induction of sleep. In nephritic colic pain is too severe to admit of any rest while it lasts. The general treatment of colic is all that can occupy the attention until relief is secured. The dyspnoea and wakefulness sometimes experienced in advanced cases of Bright’s disease may be greatly relieved by the judicious use of morphia, very much as in the similar disorder occasioned by chronic diseases of the heart.

Insomnia in diseases of the liver.—Inasmuch as the majority of these diseases interfere with the formation and proper discharge of bile it is desirable to avoid, as far as possible, the use of opiates in the disturbances of sleep that are so commonly consequent upon disorder of the liver. Simple restlessness at night can usually be obviated by the ordinary treatment that is remedial of the disease by which it is caused. But it often happens that hypnotic remedies must also be employed. Hyoscyamus, belladonna, chloral hydrate, and compound spirit of ether, are frequently useful. Sometimes when the evacuations exhibit a deficiency of biliary coloring matter, a grain of opium, with a few grains of calomel, forms a very efficient hypnotic. Alcoholic soporifics are not well tolerated when the gastro-intestinal mucous membrane is diseased. Biliary colic demands treatment similar to that that is required in nephritic attacks. Warm baths, fomentations, and a broad belt of oiled silk around the body, are very grateful, and are favorable to the induction of sleep. A course of nitro-muriatic acid, internally and externally, is often useful when wakefulness is associated with torpidity of the liver.[53]

Insomnia in gastro-intestinal diseases.—In acute inflammatory conditions of the stomach and bowels, sleep must be invited by the use of opiates. Bismuth and morphia, with hydrocyanic acid, are the favorite means of obtaining relief. Opium in solid form is sometimes preferable when a slowly developed and long continued impression is desired. Warm baths and hot poultices also give great relief.

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

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

Insomnia in febrile conditions.—In the early stages of all acute fevers wakefulness is a very common incident. It is then occasioned by irritation of the brain, and must, therefore, be relieved with opiates. If the patient is not depressed by the disease, the opium should be associated with tartar emetic or aconite, or ipecac. Dover’s powder is very useful in such conditions. In malarial fevers wakefulness should be combatted with full doses of quinine in addition to the opiate. Gelsemium is sometimes a very satisfactory remedy—especially in the febrile attacks to which children are liable. If any evidence of cerebral hyperÆmia be observed, it is well to give chloral hydrate and the bromides. Hyoscyamus, belladonna, and cannabis indica are useful when the pupils are contracted and when spasmodic symptoms are present. Lukewarm baths, wet packs, and cool sponging are exceedingly grateful, and often assist in the evolution of a suppressed eruption in the exanthematous fevers.

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

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

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

Insomnia in rheumatism and gout.—Opium in a diaphoretic preparation, and associated with alkalies or with colchicum, has always been the most approved remedy for sleeplessness in the acute forms of these painful diseases. Salicylic acid and the salicylates have in great measure superseded the use of opiates for the relief of pain and wakefulness in rheumatism, but they are not always efficient. Opiates, with or without chloral, must then be used. Sometimes a painful case that has resisted all other remedial agents yields promptly to the action of a series of blisters. The chronic forms of rheumatism require the use of stimulant diaphoretics, anodyne liniments containing chloroform and belladonna, and chloral hydrate, or even a Dover’s powder, at night.

Acute gout is rarely seen in this country, but its rudimentary forms, described by Da Costa as lithÆmia,[54] are not uncommon. They are associated with wakefulness of a very troublesome character, which only yields to a persistent and long continued course of treatment directed against the diathesis. Careful regulation of the diet, change of air, and anti-arthritic remedies, are of infinitely greater service than any particular hypnotic drug.

Insomnia in syphilis.—In advanced stages of syphilitic cachexia, a variety of wakefulness independent of pain is sometimes observed. It is marked by a tendency to wake at a fixed hour of the night, frequently about two o’clock in the morning, after which time sleep is impossible. The symptoms of constitutional disease are not prominent in these cases, but the history and the evident cachexia make their nature apparent. They usually yield to a mercurial treatment. In their comparative freedom from severe pain, such patients present a striking contrast to certain cases of syphilitic rheumatism, or neuralgia. The nocturnal suffering in such instances is frightful. It can be finally overcome by anti-syphilitic treatment; but, while waiting for the radical cure, palliatives are needed. Chlorodyne and similar combinations of all the anodyne drugs afford the most effectual means of relief. I have sometimes found it necessary to increase the dose until the characteristic delirium produced by solanaceous drugs was manifested. The relief thus procured sometimes continues for many days after the cessation of hypnotic medication.

Insomnia in various disorders of nutrition.—The wakefulness experienced by syphilitic patients is not peculiar to their cachexia. It is a result of blood disorder and impoverishment that is common among the victims of rheumatism, lithÆmia, syphilis, malarial poisoning, cancerous dyscrasia, chronic toxÆmia of every form, and ordinary anÆmia. Imperfect blood supply deteriorates the nutrition of the brain, and renders it so excitable that sleep is interrupted so soon as the period of profound repose is past. This occupies about four hours (see p. 16), hence the patient who falls asleep at ten o’clock is ready to wake up at two in the morning, and only sleeps again, if at all, when wearied with tossing till daylight. Such patients often derive great benefit from a morning nap thus obtained between the hours of five and seven.

The most successful treatment of this variety of insomnia is that form of medication which is addressed to the particular cause of the cachexia or dyscrasia. But the palliative treatment necessitated by the immediate suffering of the patient will often tax to the uttermost the ingenuity of the physician. Usually, there is a chronic atonic dyspepsia, or a chronic catarrhal gastro-enteritis, or a combination of both conditions, to be remedied. Gently stimulating laxatives are needed for the relief of these disorders. An animal diet is most easily digested. Milk and rare beefsteaks supply this form of nutriment, to which must be added oranges, grapes and lemons, to prevent the development of incipient scurvy. The kidneys may be excited with small doses of iodide of potassium or chlorate of potassium. Only after a considerable course of elimination are “tonics” admissible. For the immediate relief of the insomnia by which the patient is exhausted, a rather complex method is needful. Such subjects often pass the day in tolerable comfort, but, as evening advances, the wearied brain becomes irritable, and bedtime finds the patient in an excited state which cannot be easily overcome by large and repeated doses of chloral. Paraldehyde is too disagreeable to be used with impunity, and only towards morning does the sufferer yield to the narcotism induced by successive doses of chloral and bromide. A night thus occupied adds nothing to the vigor of the individual, and its frequent repetition will most surely lead to starvation of the nerve-centers,—perhaps to consequent “chloral-mania.”

When the tendency to cerebral irritation becomes thus apparent, great assistance can be obtained by a resort to the use of opium, combined with tartar emetic and camphor. A pill containing one grain each of opium and camphor, with one-twelfth or one-sixteenth of a grain of tartar emetic, should be given early in the evening. This calms the brain, and prepares the way for a moderate dose of chloral at bedtime. In this way sleep can be procured with much less expenditure of nervous force and medicine than is wasted in the ordinary routine method. The rest thus obtained is followed by less depression than when it follows stupefaction with large quantities of an exciting narcotic.

Insomnia during pregnancy, and after parturition.—Closely akin to the insomnia of anÆmia is the wakefulness experienced by hysterical subjects. The irritable weakness of their brains renders them peculiarly liable to disturbances of sleep. The state of pregnancy often serves to fill their nights with excitement sufficient to interfere with quiet rest. Loss of blood during parturition, by the induction of temporary anÆmia, may greatly aggravate this condition.

The suppression of nervous irritability is the principal indication for treatment. This may be temporarily accomplished by the use of the bromides. But these must be reinforced by an ample dietary, with stimulant nervines and anti-spasmodics. Good wine, camphor, valerian, hyoscyamus, cannabis indica, and occasional doses of opium, will generally suffice to induce the needful repose. If confinement in bed precludes muscular movement for any length of time, passive exercise must be secured through the aid of massage.

Insomnia in spasmodic diseases.—This class of ailments will usually be encountered among patients who are enfeebled by unfavorable conditions of health, either congenital or acquired. Together with the specific treatment appropriate to the particular disorder, it often becomes necessary to make use of hypnotic remedies against sleeplessness. Thus chorea may sometimes reach a degree of inveteracy that renders sleep impossible. Alcohol and chloral hydrate must then be given in large and frequent doses. A laryngeal catarrh may excite spasmodic croup—a disorder speedily relieved with chloral hydrate. Old people of a nervous temperament sometimes experience paroxysms of a similar character, interfering with sleep whenever they suffer a catarrhal attack. Liberal doses of assafoetida and a Dover’s powder at night, associated with a course of antilithic treatment, afford great relief. Iodide of potassium, in the majority of asthmatic affections; the bromides and gelsemium in cases marked by excitability of the spinal cord; valerian, musk, assafoetida, camphor, and carbonate of ammonia, in cases of cerebro-spinal weakness and irritability; oxide of zinc, quinine, and chloral hydrate, when weariness and exhaustion are connected with a hyperÆmic condition of the brain; such are the principal remedies against this variety of insomnia. Convulsions, if frequently repeated, may be subdued by the inhalation of ether or chloroform, until a sufficient quantity of the bromide of potassium can be introduced into the system.

Insomnia in childhood.—According to Vierordt,[55] the duration of sleep in the first week of life is only interrupted by the act of nursing. During the first month the infant should sleep at least two hours after each meal, waking only three or four hours out of the twenty-four. This period gradually increases; but, when a year old, the healthy child still sleeps more than he wakes. During the second and third years, he should sleep for ten or eleven hours at night, besides a nap of two hours in the daytime. After the fourth or fifth year, the daily nap may be discontinued. The fifth and sixth years require ten hours of sleep at night. From the seventh to the eleventh year, nine hours are needed. After the twelfth year, eight hours are sufficient.

The causes of wakefulness are as numerous among children as among adults. Jacobi[56] insists upon the importance of attention to the ventilation of the bed-chamber, and to the quality of the bed. Everything must be light, airy and cool. He gives utterance to universal experience when he asserts that great heat can be endured by day without harm, if only the night brings coolness and rest.

Hunger is sometimes a cause of wakefulness among young children. Partial starvation endured for a considerable time induces somnolence. The opposite condition of repletion may also excite wakefulness through painful distension of the stomach and bowels. Earache, terminating in abscess, often prevents sleep, sometimes without discovery of the cause until a discharge of pus enlightens the diagnosis. Persistent wakefulness without evident cause should arouse a suspicion of incipient tubercular meningitis. Slight elevations of temperature at night sometimes occasion sleeplessness, which may be overcome with quinine in doses of two to five grains at bedtime.

Wakefulness sometimes occurs merely as the result of a bad habit. This is usually observed among delicate children of a nervous temperament, whose inclinations have never been thwarted. Such patients have been sometimes cured, after the failure of a long and expensive course of treatment with homoeopathic globules, by the adoption of a systematic moral training reinforced by an occasional forcible application of the parental hand to the gluteal region of the child. Of course such a method must not be recommended without certain knowledge that no lurking disease of the nervous system has escaped detection. Fretfulness and wakefulness are not associated with proper living and good health. Their cause must generally be sought upon the surface of the body and in its internal cavities.

Much relief in the insomnia of children can be obtained from the use of lukewarm baths at bedtime. Supper should be a light but sufficient meal. Every disorder of digestion should be regulated as it occurs. Painful affections may be quieted with Dover’s powder. Feverish and irritable conditions yield frequently to aperients, or to gelsemium and quinine. Night terrors and screaming fits should be calmed with chloral hydrate and the bromide of sodium. As a general sedative and hypnotic for children hyoscyamus has an excellent reputation. It may be given in considerable doses with perfect safety and the best results. For patients in early life it seems to fill the place occupied by cannabis indica in the medication of adults.

Insomnia in old age.—The highest physical perfection is reached before the fortieth year of life. Between this age and the forty-fifth year man’s vigor begins to decline. The power of accommodation diminishes, necessitating the use of spectacles; adipose tissues begin to load the body; the hair grows thin, and begins to bleach. The processes of nutrition and of disassimilation become more sluggish; the appetites and passions gradually subside. Sometimes the moderation of nervous excitability thus effected permits indulgences of the appetite for food that were impossible during earlier years—the nervous dyspeptic can tolerate dainties which would formerly have been unendurable. Less disturbed by the solicitations of sense, the powers of reasoning and of judgment enlarge their authority. Under favorable circumstances this period of life may continue for about twenty years, when old age develops. From the sixtieth to the eightieth year the progress of decline is rapidly accelerated, and life is normally terminated between the eightieth and eighty-fifth years of existence. The rare examples of greater longevity are too few in number to warrant the assumption that a century of years is the physiological complement of life.

As old age advances, the time of sleep is slightly abridged. The moderated activity of the body requires only a diminished rate of repair to make good the waste of the tissues. Less sleep, therefore, is needed. But the liability of age to the incidence of arthritic diseases, rheumatism, and disorders of the heart, blood vessels, digestive apparatus, and urinary organs, renders the period of decline particularly subject to those varieties of sleeplessness which depend upon such derangements of health. The nutrition of the brain suffers under such circumstances, and the substance of the organ becomes morbidly irritable. Insomnia among the aged often owes its cause to these unwholesome conditions. The biography of the celebrated Carlyle affords numerous illustrations of this variety of wakefulness. Disease of the cerebral blood vessels sometimes originates a series of changes differing only in degree and intensity from the classical type of chronic periencephalitis. This is characterized by many of the minor phenomena of general paresis, only occasionally rising to the level of that disease. Wakefulness is one of the most troublesome symptoms of this disorder. Its management requires attention to all the details of excretion and nutrition. The diet must be carefully selected with reference to failure of the digestive function. Milk and water should be preferred for drink, and the great emunctory organs of the body must be carefully stimulated and sustained. A judicious choice of climate may accomplish much for the comfort of the patient. The mild, insular climate of Florida, or of New Providence, or of the Sandwich Islands, affords superior advantages for the relief of sleepless sufferers in the northern temperate zone of the American continent, who need the soothing influence of a continual open air bath.

During the latest stages of decline, when the cortex of the brain has become considerably atrophied, the opposite of wakefulness is experienced. Intellectual operations become less vigorous, and the patient passes lengthening periods of time in sleep. This is a genuine relapse into the apathy of infancy. The apparatus of thought is worn out, and the old man sinks gradually into the sleep from which there is no awakening.

The treatment of insomnia, therefore, resolves itself into the removal of all special and temporary causes of wakefulness, with attention to the general hygiene of the patient, and careful regulation of his diet, habits, and occupation. Pain must be quelled with anodynes. Cerebral excitement must be calmed, in sthenic cases, with anti-spasmodics and sedatives—in asthenic subjects it must be overcome with food and nervous stimulants. Since many patients present a combination of these apparently opposite conditions, there is room for a great display of penetration and tact in the management of complex cases. While seeking for the immediate relief of present suffering, the ulterior consequences of treatment must always be kept in view, and the particular cachexia or dyscrasia must be thoroughly appreciated by the physician in his choice of remedies.