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:
| ℞ | Morph. Sulph. | gr. ¼ | |
| Chloral Hydrat, | |||
| Sodii Bromid. ā ā | ℨ iv. | ||
| Tr. Aconit., rad. | gtt. xxv. | ||
| Tr. Cardam. Co. | ℨ i. | ||
| Aquæ, 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.
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.