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commence from zero, slowly increase until felt as warm," and finally decrease in the same way, without shock. The use of strychnin hypodermatically in large, repeated, and increasing doses, the patient being meanwhile confined to bed and carefully fed, as advocated by Dana, is a promising line of treatment. Commencing with of a grain every four hours, doses of of a grain are sometimes well tolerated. It is well to employ general massage at the same time, and, as the pain subsides, massage and vibrations to the tender area and sensitive points may be added with advantage. As a last resort, operation may be advised, but only when a careful, intelligent, and persistent use of general and special measures has failed, or there is evidence of organic changes in the nerve or nuclei. There are three general varieties of operations upon the trifacial (1) Those for the purpose of section, exsection, stretching, divulsing, or twisting out the various branches at some point below the floor of the skull; (2) those directed to enucleation of the trifacial ganglion; (3) division of the sensory root of the fifth above the ganglion. Operations upon the ganglion are very difficult and dangerous. Frequently, the eye on the same side has been lost. The operation of Horsley, in which the skull is opened and the sensory root divided beneath the pons, is much less mutilating and disfiguring, but seems to be attended by danger to life. After root divisions the fibers degenerate upward, thereby producing a permanent result. This operation is worthy of more frequent employment, in spite of its difficulty and danger. Operations on the branches below the ganglion usually give temporary freedom from pain, but relapses are common in the same or in adjoining branches. (For details the student is referred to surgical works.) Fortunately, with proper systemic and local treatment these severe operations are very rarely demanded. As the slighter ones of neurectomy, etc., occasionally give permanent relief, they should be tried first.

CHAPTER II.

DISORDERS OF SLEEP.

THE disorders and disturbances of sleep, while mainly symptomatic, in some instances reach an important development and almost attain the dignity of a disease. Sleep may be defined as a recurring, necessary state of lessened muscular, mental, and organic activity, attended by comparative unconsciousness of surroundings. No physical or mental function is absolutely abeyant. Respiration, circulation, metabolism, catabolism, muscular movements, and dreams demonstrate the persistence of functional activities. Entirely dreamless sleep probably does not occur. Sleep, therefore, is a composite which may be variously disintegrated. Sleep-walking, talking in the sleep, nightmare, nightterrors, and nocturnal enuresis may be considered as localized or partial 1 L. F. Barker, “Jour. Am. Med. Association," May 5, 1900.

sleeplessness. In somnambulism the motor apparatus is awake, as it is in night-terrors. In enuresis we have a somnambulism of the lumbar cord, to adopt a term from the French. Of the physiology of sleep, though it is more necessary to life than food, we know comparatively little.

Physical Features of Sleep.-In sleep there is muscular relaxation. The lids are lowered over the upturned eyeballs; the expression is one of repose. Respiration is slower and less deep. Mosso states that the amount of air inspired by a normal man during sleep is one-seventh of that used during similar periods of quiet wakefulness. Breathing is distinctly thoracic in character, the diaphragm acting but slightly; inspiration is more prolonged and the respiratory pause is absent. There is a decrease in carbonic acid elimination and an increase in the absorption of oxygen. The circulation presents important modifications. The pulse is less rapid. The superficies of the body has an increased vascularity and is often reddened; there is lowered arterial pressure and a

HOURS 05 LO 15 20 25 30 35 40 45 5.0 5.5 60 65 70 75 78

Fig. 252.-Curve illustrating strength of auditory stimulus (falling ball) necessary to waken a sleeping person. The hours are marked below, and the tests were made at half-hourly intervals. The curve shows that the height from which the ball must be dropped reaches its maximum at the end of the first hour (Kohlschütter).

Such

smaller central circulation. The brain is comparatively anemic. The arterial changes take place in a precise way, increasing with some rapidity during the first hour, maintaining a maximum for an hour or two, and then gradually decreasing to the waking moment. curves have been shown by the plethysmograph and correspond fairly well to those indicating the depth of sleep as demonstrated by Kohlschütter and others. In accordance with universal experience, the first few hours of sleep are, therefore, most profound, refreshing, and valuable. The thorax and limbs actually increase in size during sleep, owing to the circulatory conditions; and we readily comprehend the increased activity of the skin, the tendency to night-sweats, and the ease with which one is chilled during sleep. Lombard, Rosenbach, and others have observed that the muscle reflexes are exaggerated just before 1 Howell, "Jour. of Experimental Med.," 1897.

and during the early moments of sleep, but gradually subside, and the knee-jerk may even disappear. Slight disturbances tending to awaken the individual are attended by a corresponding increase in the reflex activity and the central circulation. We are all familiar with sudden startings when dropping off to sleep-a manifestation of the increased reflex excitability, constituting one of the epiphenomena of sleep. The pupils are contracted in proportion to the profoundness of the sleep.

Requirements for Sleep.-Individuals vary greatly in the amount of sleep required, and at different ages there are different needs. While some few adults find four or five hours sufficient, the great majority demand eight or ten. There are also temperamental differences and many variations, the result of habit and circumstances. Crichton Brown says that at four years twelve hours' sleep are needed; at fourteen years, ten hours; at seventeen, nine and one-half hours; then seven or eight hours during adult life. In old age continuous sleep is rare, and the requirement is less; but frequent naps and dozing, by day as well as at night, maintain a fair average. Infants may sleep most of the twentyfour hours. More sleep is required in cold than in temperate or warm countries.

Conditions Favoring Sleep.-A cool, dark, quiet, well-ventilated room, a comfortable bed, and adequate, not excessive, covering, are conducive to sleep. A preparatory period of sleepiness is natural, and, in cases of insomnia, must be cultivated. Active emotions, mental worries, intense thought, cold extremities, or a chilled skin defeat the rearrangement of the circulation, on which so much depends. No physical function is so readily disturbed as sleep. If a person is awakened at an unusual hour several nights in succession, he tends to establish a habit of awakening at that hour. Habit is all-powerful, both for good and evil, in this matter. Regular hours for retiring and awaking are most important. The use of hypnotics to put patients to sleep regularly for a few nights do good mainly by reëstablishing the natural initiative.

Disturbances of sleep are (1) those presenting a deficiency, and (2) those marked by a morbid increase of sleep.

WAKEFUL DISORDERS OF SLEEP.

Insomnia. Insomnia is a symptomatic condition, marked by more or less inability to sleep the individual's usual required length of time. Etiology. The causes of sleeplessness are numerous. Practically, every deviation from health is marked by disturbance of sleep; but in many instances, once a bad sleep habit is established, it tends to persist, and may be the chief complaint of the patient. Many persons are hereditarily poor sleepers. In such instances every trivial sound or unusual circumstance-a light, an odor, a jar, or even the discontinuance of a customary noise or light-may arouse them. Hunger, over-feeding, indigestion, constipation, intestinal worms, lithemia, uremia, various drugs, tea, coffee, tobacco, alcoholism, fevers of all sorts, malaria, syphilis,

lead-poisoning, cerebral hyperemia or anemia, as from cardiac disease or diathetic states, psychic disturbances, discomfort, pain, neurasthenia, grief, worry, old age, mental preoccupation, and intense study are among the principal inciting causes of sleeplessness.

Symptoms. Some patients readily fall asleep, but shortly awake, and are then sleepless the balance of the night, or merely secure fitful periods of sleep. Others spend several hours getting to sleep, and may then rest fairly well. Still others complain of broken sleep, the night being passed in intervals of sleep and wakefulness, which may be quite uniform in a given instance. As a rule, patients troubled with insomnia are disposed to exaggerate the amount of sleeplessness, and it is a common experience to find such patients sleeping soundly at times, or even for much of the night, if they are put under watch. Much loss of sleep manifests itself in a haggard, weary air, and in lessened muscular and mental force. Appetite, digestion, energy, courage, and good nature are diminished. The patient loses weight, and, in cases of absolute sleeplessness, the loss may equal that due to deprivation of food. The eyes lose their clearness and look dull, and the sclerotic may be congested. The tongue is coated, constipation may be present, and the entire organism is deranged.

Treatment. The treatment of the symptom insomnia implies the management of the basic condition of which it is a manifestation. All hereditary, digestive, toxic, circulatory, nervous, and reflex causes must be systematically investigated. The examination of a patient complaining of insomnia omits nothing. Very frequently, modes of living, and especially bad sleep-habits, must be corrected before any improvement is secured. The physical state often requires to be thoroughly well reëstablished by baths, proper diet, exercises, and good hygiene. Attention at once falls upon the conditions favoring sleep, as previously outlined. The patient must be instructed in the importance of these minutiæ, and not expect to secure complete relief by a few doses of medicine. As adjuvants, a warm bath, taken quietly at bedtime, not followed by stimulating frictions, is conducive to sleep. A cold pack or an alcohol rub acts well in some cases. The stomach should not be empty. A glass of hot milk, or milk and water, or malted milk, or hot lemonade, or even of hot water, acts beneficially in decongesting the head in cases not anemic. With the hot bath it favors the dilatation of the cutaneous vessels, and establishes the circulatory conditions found in natural sleep. In the same way a pint of beer not only starts the abdominal organs, but flushes the skin. Large doses of whisky are never advisable, although sometimes efficient for a night or two. Anemic cases require cardiac stimulants and blood-makers.

Any drug that sufficiently masters the organism to produce sleep is a dangerous remedy, and should be used with circumspection, and only as a last resort. Of all the hypnotics, chloral alore is uniformly reliable. In cases attended with much nervousness it is decidedly assisted by the addition of sodium bromid in equal amount. The administration of hypnotics should be done with a definite purpose. It is important to exhibit whichever one is selected at such time that its systemic effect

may be operative when the sleeplessness is due. In cases experiencing difficulty in getting to sleep chloral may be given thirty minutes before retiring. Cases awakening at one or two o'clock may be given trional, in dry powder, at bedtime, as its action is liable to be delayed for a few hours. A sufficient dose should be used to have a decided effect, repeated several nights, if its action meets the requirements, and then discontinued. In some instances five-grain doses every two hours after mid-day act much better than a large dose at bedtime. If the underlying cause has been corrected, the proper routine will thereby be reëstablished in a few nights. Finally, some cases only yield after a complete change of scene. An ocean or lake voyage is especially valuable, as it is devoid of exhausting excitement and sight-seeing.

Somnambulism.—In sleep-walking the individual acts his part of a dream. The motor apparatus is awake and responsive to the mind. It is sleep with motor automatic activity, and presents a peculiar increase of the subjective powers of the affected person. There is often great keenness of touch and analgesia combined. The special senses may be active or not, but the patient only takes cognizance of those things which pertain to the dream-story. Usually, the pupils do not respond to light, and the face has a blank, apathetic appearance. The eyes may be open or closed. The sleep-walker has no subsequent waking recollection of his somnambulistic acts; but these may be revived or repeated in a subsequent attack. Talking in the sleep is a minor degree of somnambulism, and the state of double-consciousness may be considered as its largest development.

Somnambulism may ordinarily be considered as a neurotic stigma, and is commonly encountered in those of a neuropathic heredity. Puberty is the ordinary age for its appearance, and both sexes are then about equally affected. Later in life there are more female than male cases. The individual attack is often traceable to some mental precedent condition. Even the suggestion of sleep-walking, in the discussion of the subject, has led to its appearance. In other cases the patient carries out in sleep the line of action on which he had been intent before retiring. In most cases presenting repeated attacks there is a similarity of action in all of them, or one attack may continue the action of its predecessor.

The treatment of the condition should be broad enough to cover the neuropathic make-up of the patient, and is most successful in proportion as it is directed to the mental element in the disturbance. If the patient takes with him to bed a firm intention not to walk, it is often sufficient to inhibit the attack. In nervous subjects of impaired selfcontrol a vigorous suggestion, that will be operative during sleep, must be implanted. This, in children, may be accomplished by a system of rewards or deprivations, by a cold spinal douche at bedtime, associated with the suggestion that it is to prevent walking during the night, or by an emphatic admonition from a respected source. The individual attack may be brought to an end by a dash of cold water, or a sharp puff of breath in the face, or by firm pressure over the supraorbital foramina. So rude a shock may be curative, but in highly nervous