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 assafœtida 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, assafœtida, 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 homœopathic 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.