In acute melancholia or mania, morphia is still sometimes employed, but Hyoscinc and the newer hypnotics are generally far better. Codeine, Narceine, Pantopan or Omnopon, and the various preparations of opium, as Black Drop, Battley's Sedative, Nepenthe, &c., may be tried where the after ill-consequences of opium have been barriers to its use. Codeine is a very feeble hypnotic. Opium or morphia may be combined with most of the new hypnotics, and the writer has often relieved pain with small doses of morphia, and afterwards induced sleep by 15 grs. of 'Friona]. The dose, even when the minor action of morphia only is required, will generally need augmentation, and this is one of the chief objections to the use of opiates in insomnia and all chronic conditions associated with sleeplessness. Dionin or ethyl-morphinc-hydrochloride is also useful, especially in the insomnia of the morphia habit. It may be given in I-gr. doses. Heroin Hydrochloride has similar action, and is preferable to other opium derivatives when the cause of the insomnia is due to bronchial irritation.
Indian Hemp is open to the objections to which opium is liable, and hence it is not a suitable drug in the treatment of simple chronic insomnia, and very often fails entirely. It does not, however, disturb digestion or cause headache. Cannahin Tannate is an excellent form for the drug in doses of 5 to so grs. in the insomnia of mania. Cannabinon is also recommended in similar conditions, but the dose should not exceed gr.
Antipyrine and other analgesics by relieving pain may assist in the induction of sleep, and should always have a trial before resorting to narcotics.
lyoscine ilydrobromide in doses of 4„, to gr. administered hypo dermically is a powerful soporific, producing deep, quiet sleep in 20 minutes which lasts 6 or S hours and leaves no ill-consequences after awaking. In acute mania and other conditions of grave excitement with motor disturbance it is a most rapid and certain hypnotic. Krauss states that after its administration the maniac collapses as if struck by lightning, but the calming down of the general paralytic is gradual, his restlessness soon settling into peaceful slumber. It is obvious that a remedy of such potency is not one to be employed in a routine way in the treatment of simple chronic insomnia. Some authorities have reported sharp depres sant effects and wild delirium from A gr., and it will be wise to regard valvular disease as a contra-indication to its use. In insomnia associated with or depending upon a latent strain of insanity it is the most efficacious of all hypnotics. The drug may be given by the mouth, but it is less certain in its action than when injected.
Bromides are the least harmful of all hypnotics. In insomnia following prolonged mental activity and overwork full doses (3o to 6'o grs.) of the
sodium salt produce calm, deep, refreshing sleep. In severe casesit often fails, but failure does not leave the patient in a worse condition than if he had not taken the drug. It is indicated where sleeplessness is caused by mental over-activity, a state not of simple wakefulness, but where the brain is unusually active, as often occurs on the patient retiring to rest immediately after some mental effort or worry, without permitting a period of rest, during which the mental faculties should have been diverted into other channels. In this state there is some flushing of the face, and throbbing of the carotids and pulsations are felt in the cranium; it is a very frequent experience in public speakers and debaters. If 3o grs. of bromide produce no effect in an hour under these circumstances, the dose may be repeated, and if sleep does not soon follow, a full dose of warm whiskey punch will rapidly produce sound slumber. There is a state of restlessness of a different sort often observable in highly nervous patients after getting into bed, in which the slightest external stimuli call forth incessant and ineffectual attempts to dispose the limbs, head or trunk in such positions as will give a sensation of comfort and tranquillity. This, which might be called " acute fidgets," is controlled effectually by a few doses of the bromide, which probably acts by diminishing reflex excitability.
Insomnia shows itself often by the patient falling asleep almost imme diately on retiring and waking up thoroughly soon afterwards, and lies tossing about till morning. These types of sleeplessness must be always kept in mind whilst selecting the most suitable drug for administration, but bromides are suitable in both varieties. A fair dose if given before bed-time will prevent the waking up, or a fuller dose may be given after the patient has got his brief preliminary sleep. The first-mentioned plan is, however, a better course to pursue, since it tends to break the habit of awakening. Bromural and the other bromine compounds and combina tions will be mentioned later on.
The bromides may be taken for long periods without hurt. In one patient with a bad family history of insanity who suffered from insomnia, the Bromide of Potassium combined with a small dose of Tincture of Hyoscya mus (2o mins.) was steadily taken almost every night for 25 years with most satisfactory results, and with no necessity for augmentation of the dose, and with no ill consequences. In acute mania McLeod induces " bromide sleep " by administering 2 drs. of Sodium Bromide in 5 oz. water every two hours during the day until r oz. is taken, and this quantity is repeated during the second day.