Insomnia; and Other Disorders of Sleep

by Henry M. Lyman

Opium is a remarkably complex substance, no less than nineteen different alkaloids having been separated from it. Of these, however, only one has stood the test of therapeutical experiment—morphia. Several other constituent alkaloids, notably codeia, have been lauded as hypnotics, but they are, at their best, far inferior to morphia, and may well be omitted from the list of sleep producers. But, though the soporific properties of opium are chiefly due to the morphia which it contains, there are certain points of difference between the action of the two medicines that often render a choice desirable. According to Stillé and Maisch,[48] morphia does not stimulate circulation and the nervous system as much as opium, and its narcotic effects are less decided and speedy, though its after effects are more enduring. Opium increases the bodily temperature and sense of heat; morphia produces the last effect, but diminishes the temperature. Opium at first increases the frequency of the pulse, while morphia diminishes it. Opium is of the two the less liable to excite nausea and vomiting; hence the superiority of the tinctures and aqueous solutions of opium when nausea is specially feared.

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 dyspnœa, 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.

Codeine is a mild hypnotic which may be used in doses about twice as large as those of morphine. It is expensive and not very efficient, but may be sometimes prescribed with advantage when moral considerations render the use of ordinary opiates inexpedient.

Lactucarium may be classed with the weaker opiates. It possesses very little value. Its fluid extract is sometimes prescribed at night to allay the cough of pulmonary consumption, so as to favor sleep.

Bromides.—According to Mitchell, Echeverria, and Bartholow, the soporific energy of the bromides may be ranked as follows: Lithium bromide first, sodium bromide second, potassium bromide third. Hammond praises calcium bromide. Hydrobromic acid is also employed as an hypnotic in certain cases. As a clinical fact the bromides of sodium and potassium are most frequently employed for the relief of insomnia. Of these the second is most useful when sleeplessness is associated with the phenomena of irritability; the first is less energetic in its effects upon the motor structures of the body.

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.