Insomnia; and Other Disorders of Sleep

by Henry M. Lyman

Belladonna is not directly hypnotic, unless given in poisonous doses, but its medicinal operation tends to overcome certain conditions that hinder sleep. By its anti-spasmodic effects it relieves many forms of spasm which would otherwise interfere with sleep. Spasmodic asthma furnishes an example of such an affection. This may be relieved by the hypodermic injection of atropine. Whooping cough is another disease which may be largely controlled by the internal administration of the drug, especially by inhalation of a spray that has been medicated with belladonna. Neuralgia, especially the form that involves the head, face, and intercostal nerves, is greatly mitigated by the use of belladonna, or its alkaloid, atropia. Its association with opiates seems to increase their hypnotic effect, while at the same time neutralizing their disagreeable action. According to Curci,[41] it opposes the tendency of opiates to cause cerebral hyperæmia. For this reason it is generally advisable to combine sulphate of atropia with sulphate of morphia for hypodermic use. Of the former 1-100—1-80 grain may be used with ¼ grain of the latter. Certain patients are exceedingly intolerant of belladonna and its derivatives, a fact that must be kept in mind, especially when using the alkaloid, atropia. Fatal consequences are very rare, but uncomfortable dryness of the throat, dilatation of the pupils, and some degree of delirium are not uncommon. At the same time it must be admitted that in many instances relief from suffering is not obtained until these physiological effects of the drug have been manifested.

Hyoscyamus.—As might be inferred from their close botanical relationship, hyoscyamus and belladonna present many points of similarity. Their alkaloids are almost identical in chemical and physiological properties. The extract of belladonna is considerably stronger than the extract of hyoscyamus. Like other solanaceous plants, this is powerfully narcotic and anodyne. Sleep is produced only by the use of the drug in large doses, which also tend to excite delirium, sometimes even reaching to the height of maniacal fury. Children tolerate hyoscyamus in doses proportionally larger than can be taken by adults. By many physicians it is considered the hypnotic par excellence for children. In the various forms of insanity the tranquilizing influence of hyoscyamus is highly esteemed. The derivative preparations, hyoscyamine and hyoscyamia, are preferable for use in this class of cases. The first may be given in doses of 1-16—1 grain; the latter is much more powerful, and should be given in doses not exceeding 1-100 grain until the degree of its tolerance has been ascertained.

Stramonium.—This is another of the solanaceous plants, possessing many qualities like those found in belladonna. It is not directly hypnotic. Poisonous doses produce delirium and persistent insomnia. But its anti-spasmodic effect upon the paroxysm of nervous asthma renders it indirectly hypnotic in that affection. For the relief of bronchial spasm the smoke of the dried leaves should be inhaled in considerable quantity. It may be smoked in a pipe; or, mixed with saltpetre, it may be made to smoulder upon a tin plate, while the smoke is drawn by inspiration into the lungs. Various kinds of medicated pastiles have been prepared, to effect a similar result by furnishing the drug in a convenient form for use. Tobacco and lobelia operate in a very similar manner upon all spasmodic affections of the respiratory passages; but their energy is almost too great for the comfort of the patient.

Phosphorus.—Bartholow has recommended this drug in “cases of wakefulness dependent on cerebral anæmia and exhaustion,” and in “the wakefulness of the aged, accompanied with muscular cramps, feebleness of memory, giddiness, and trembling of the voluntary muscles on exertion.” In minute doses, it is true that phosphorus acts as an irritant of nervous tissue. It promotes destructive changes in the tissues of the body, and thus produces a temporary excitement which may favor the processes of nutrition. Indirectly, it may thus prove beneficial in many cases of cerebral exhaustion; but as a direct hypnotic it will be found of very little service. It should be given in doses of 1-100 grain every four hours.

Acids.—In those forms of sleeplessness which are dependent upon disordered conditions of the digestive apparatus, acids are often useful. Their topical effects upon the mucous membrane of the stomach are stimulant and alterative; hence they are useful in atonic dyspepsia, where there is deficient secretion of the gastric juice. In such cases hydrochloric acid and lactic acid are useful. The first should be given, in doses of five drops diluted with half a pint of water, after each meal. Lactic acid may be given in doses of one or two teaspoonfuls, similarly diluted. It has been asserted, on theoretical grounds, that lactic acid and the lactate of sodium are directly hypnotic, but its experimental use has never given satisfactory results. Phosphoric acid has been used in the same way, with very similar effects. An impure solution of phosphoric acid, known as Horsford’s Acid Phosphate, has been extensively used for its supposed hypnotic properties. It assists digestion, stimulates the kidneys, and by its general diffusion promotes molecular activity throughout the body. It is thus indirectly beneficial in cases of insomnia. No small part of the benefits thus obtained must, however, be ascribed to the water with which these acids are diluted. When the liver becomes sluggish in its action, nitric acid, in doses of five drops diluted with half a pint of water, may be taken every four hours with great advantage. Thus used, the mineral acids may often yield invaluable service in the treatment of insomnia occasioned by cachectic conditions of the body—notably such as are produced by malaria, oxaluria, and the so-called phosphatic and rheumatic diatheses.

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.

Cold.—The operation of cold upon the body has already been sufficiently considered. It only remains to note the effects of cold applied through the agency of baths and local refrigerants. A full account of the theory and practice of hydrotherapeutics can be found in the second volume of Von Ziemssen’s Handbuch der Allgemeinen Therapie. The English reader will find the subject treated at sufficient length in Ringer’s Handbook of Therapeutics.

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.