Insomnia; and Other Disorders of Sleep

by Henry M. Lyman

For the relief of the pungent heat and restlessness which add so much to the danger of the specific fevers cold baths have been highly recommended. These have been employed with great energy in many of the German hospitals; and often with great benefit to the patient. The preferable method is the one advised by Von Ziemssen and Immerman. The patient is placed in a tub of water at 95° F. This is very gradually cooled down, in the course of half an hour, to 60° F. The bath should be repeated from three to five times a day, according to the temperature of the patient. By this method of treatment the patient is made more comfortable; he becomes less restless or delirious, and secures a larger amount of refreshing 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.

Anæsthetics.—All anæsthetics are hypnotics. In other words, they possess the power to abolish consciousness, and thus to produce a condition resembling sleep. This is effected by the direct action of the anæsthetic substance upon the cellular structure of the brain, reducing the molecular movements of the living protoplasm below the degree requisite for the excitement of consciousness. This sedative effect is preceded by a brief period of cerebral exaltation, occasioned by the disturbances caused by the first introduction of the drug into the current of the circulation.[42] It is with the subsequent hypnotic effect only that we are now concerned. Of the numerous anæsthetic substances that have been discovered, but few comparatively have been found sufficiently manageable and safe for general use. These are alcohol, paraldehyde, ether, compound spirits of ether, chloroform, chloral, butylic chloral, and amylic nitrite.

Alcohol.—The hypnotic effect of alcoholic drinks is very decided, though not speedily manifested unless the beverage be taken in considerable quantity. Distilled liquors produce the effect of alcohol in its simplest form; wines, containing various forms of ether, arouse the nervous system more thoroughly and agreeably than the pure alcoholic stimulants. Beer and porter are rendered more powerfully narcotic by the active principle of hops which they contain. The nutritive substances held in solution by these last render them peculiarly appropriate in cases that require nourishment as well as rest. The considerable quantity in which they must be taken, renders them inconvenient for use in cases of severe illness. Wines and distilled liquors are then most available.

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.

The insomnia that attends excessive fatigue may be very quickly relieved by the use of food and alcohol. For this purpose any form of alcoholic drink will be found useful. The quantity administered should only be sufficient to produce a uniform and general vascular relaxation. By this means the circulation is equalized throughout the body, and the brain passes into a state of tranquil sleep. Any excess in the use of alcohol under such conditions will be followed by headache and discomfort on awaking. In all cases the intoxicating dose of alcohol must be avoided, if its truly hypnotic effect be desired.