most natural thing for the Association to do, for its Psychic Insomnia.—It is taught that the brain in Code of Ethics reads as follows : natural sleep is relatively anemic. When the brain is in It is derogatory to professional character for a physician to full working activity the cerebral arteries are well filled prescribe or dispense a secret nostrum whether it be the com¬ with blood from which the brain cells are rapidly re¬ position or exclusive property of himself or others. For if nourishment and themselves of waste. it ceiving ridding such nostrum be of real efficacy, any concealment regarding During the blood flows more gently and in smaller is inconsistent with beneficence and sleep professional liberality, streams the brain ; and the brain cells are not and if alone it value and importance, such craft through mystery gives but are it up. implies either disgraceful ignorance or fraudulent avarice. expending energy, storing Anything, therefore, which tends to keep up the activity of the And, in conclusion, it seems pertinent to ask why the brain cells and keeps the blood circulating freely through present is not as good a time as any for the American the brain tends to the brain cells Medical Association to discuss for the mat¬ emphatically keep plans taking from repose and the finds himself The ter to in patient sleepless. Congress Washington. psychic causes of such brain activity may be the habit of thinking over business or work after going to bed, worry, HYPNOTICS, ANALGESICS AND RESULTANT anxiety, excessive mental work that will not let the DRUG ADDICTIONS.* brain cells cease working for several hours after the real work sudden or or form of SMITH ELY JELLIFFE, M.D. stops, grief shock, prey¬ remorse or loss of Clinical Assistant in Neurology, Columbia University ; Visiting ing sorrow, hope. Neurologist, City Hospital. Toxic Insomnia.—The toxic causes of brain activity NEW YORK. are due to some poison, that maintains the arterial sup¬ Insomnia and pain are the banes of existence of the ply of the cortex of the brain at such a height and so patient with any nervous affection, and from his stand¬ long that wakefulness is inevitable. These poisons may point are in themselves the maladies from which he is be in the form of drugs that have become a habit; al¬ suffering. He prays his physician for relief from one cohol, or the milder stimulants of tobacco, tea or coffee, or both, knowing, alas too well, that the market is full or, on the other hand, the poisons may be certain accum¬ of drugs that will bring him relief. It does not often ulated waste products of the patient's own metabolism. occur to him that the physician has any more compli¬ Senile Insomnia.—Senile causes of sleeplessness are cated mental process to go through than merely to choose due to the age of the arteries. As the smaller cerebral the right drug to bring healthful sleep and to banish arteries lose their elasticity their walls grow weak, and pain. Insomnia and pain may each be the cause of the they are physically unable to regulate the flow of blood other, or they may be the outward symptoms of an ex¬ to the brain which ought to be diminished at night to ceedingly complex condition of derangement. cause the sleep of youth. CLASSIFICATION OF INSOMNIA. On this brief classification of the causes of insomnia I would establish an of the treatment In trying to study the causes of sleeplessness have outline kinds of found it helpful to remember the classification of in¬ that are recommended by men of wide experience, with somnia that Sir James down in his "Con¬ a discussion of the question of how far hynotics may be Sawyer lays to tributions to Practical Medicine." He : used relieve insomnia and analgesics employed to says alleviate Cases of insomnia seem to divide themselves naturally into pain without danger of resultant drug ad¬ diction. two groups, namely, of cases of what may be called sympto¬ matic insomnia, and of cases of what may be called intrinsic THE DECLINE OF STOICISM. insomnia. Symptomatic insomnia attends a vast variety of In the first I would that the them. place, say demand for morbid states, and is secondary to them, or is part of relief from minor and insomnia has in¬ Intrinsic insomnia, or insomnia per se, is a kind of wakeful- pains slight creased with the of remedies. ex¬ that to on the of the brain to supply Although my ness seems depend inability limited to ten adapt itself to the conditions of sleep. perience is some or twelve years of prac¬ and I can not Symptomatic insomnia, or the sleeplessness that is one of tice, with authority compare the older the symptoms of a disease attended by severe pain is not days with the present, yet I think I may safely say that so difficult to treat, provided the pain, or the elevation of people, as a rule, do not bear pain as bravely as they the temperature, or the coughing be the only cause. We did before the days of anesthetics, analgesics and hyp¬ may control it either by using hypnotics or sorporifics, or by notics. Such scenes of fortitude as Ailie's operation in giving drugs that will reduce the fever or diminish pain, or Dr. John Brown's story of "Rab and His Friends," are, the or we combine and stop cough; may the treatments, we are thankful to say, unnecessary now ; but at the use in with the remedies that will sorporifics conjunction same time the day is past when women bore the pain of remove the causes of pain or fever. cancer, or the knowledge that they were dying of a The family plrysician who uses sulphonal or trional tumor, to their graves without opening their lips to any¬ for the purpose of inducing sleep in severe illness, em¬ one save their physician. The brave serenity of spirit one of ploys the most valuable aids to recovery, for sleep showed by Sydney Lanier, who was carried to his class as a in disease as as natural remedy is necessary any room to give his lectures, and who never permitted his therapeutic remedy. But, at the same time, these drugs, illness to be mentioned, and the gay stoicism of Robert if used continually, will of themselves cause the worst Louis Stevenson, whose reference to his hemor¬ kind of only insomnia, that in which natural sleep is ab¬ rhages were as to his friend "Bloody Jack, who was with solutely impossible without the aid of a drug. him that morning," are examples of that heroism in to to Intrinsic insomnia, refer again the classification suffering which I believe has become much more rare of Sir James Sawyer, is due to various causes, which he with the introduction of the many pain-relieving divides into three groups, viz., the psychic, the toxic remedies. and the senile. Any sufferer may to-day, at the cost of ten cents, pur¬ * Read at the Fifty-third Annual Meeting of the American chase temporary relief from a headache that is due to Medical Association, in the Section on Materia Medica, Pharmacy or an artificial and Therapeutics, and approved for publication by the Executive overwork, night's sleep where sleep should Committee: Drs. A. W. Baer, A. B. Lyons and W. J. Robinson. have come naturally. To suffer is no longer deemed

Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 05/30/2015 brave, it is deemed ignorant; but the little knowledge be purchased for from ten to twenty cents per pound, that will bring relief is too often a dangerous thing. the robbery is made possible only under the guise of a The result of this easy and sure means of obtaining trade name, and if the education of the physician is relief has led patients, and sometimes physicians, to be not sufficient to protect the public, then legislation is too easily satisfied with relieving pain and giving arti¬ imperative. ficial sleep instead of ferreting out the cause of the HOW TO TREAT INSOMNIA. do in the trouble and removing it, as they were obliged to As a rule the few doses of such drugs that are neces¬ old days if they would stop pain. sary to bring relief in acute diseases, whether to ease I do not purpose to speak of drug habits acquired by or to lead to no habit. As soon as the to that pain bring sleep, patients who treat themselves, except say every body has recovered its tone, and so soon as the cause of analgesic and every hypnotic is dangerous if used indis¬ the is removed and the itself has disappeared, all should be pain pain criminately; and that patients emphat¬ the body does not crave a repetition of the drugs. Even is that can take ically warned that there nothing they opium, in any of its forms, can be borne well and leaves regularly and persistently to relieve pain or sleepless¬ no bad effect when The sole Para¬ intelligently prescribed. ness without doing themselves permanent injury. danger in such cases, I believe, lies in the fact that the doxical as it may seem, the least harmful drugs are often patient knows what has given him relief, and will, in¬ the most deadly. Fewer men and women ruin their evitably, tamper with the fascinating drugs when he has than do the use nerves by the abuse of chloral they by' some minor ailment in the future. He then almost in¬ I had the victims of of bromids. have many patients variably runs a twofold danger : by continually giving the bromo-seltzer habit, who took high moral grounds himself relief from a pain that ought to be investigated of and I have entered a against the use morphin chloral. he ignores the cause of his pain until his disease is pro¬ seen stocked with a winter's business man's office and it nounced, and in the meantime has by repeated use of the he as was supply of bromo-seltzer, with which proposes, drug habituated his nervous system to overstimulation. to ward off his afternoon headache; his wont, regular These cases in which pain and insomnia were at first I had hard a to means and have as fight bring him, by merely secondary phenomena form a large percentage of exercise and to a normal state of health travel, diet, of the patients who afterwards come to us to be treated in a fiend of his habit. as breaking morphin for the toxic form of insomnia per se. It would lessen the of habits if greatly dangers drug In the severer grades of insomnia it is often would encourage to en¬ psychic family practitioners patients necessary to secure a few nights of artificial sleep at dure a certain amount of the and of pain sleeplessness any cost ; for the of itself will in a few induce never "I will leave some¬ sleep days general diseases, saying, you sleep and the doses may be off, or the need for harmless that will make you or, tapered thing perfectly sleep"; them will stop naturally. In the cases of insomnia fol¬ "I will give you something very new and very powerful sudden mental the that will that in ten minutes." The for lowing shock, great excitement, stop pain drugs anxiety attendant on strain of business, or the nervous relief as far as be combined in should, possible, pre¬ state of worry in women that is a that or left accompanied by scription with the drugs treat the disease, hysterical breakdown, it is wise to give hynotics and to without name or emphasis to be taken at the right time. induce until the is refreshed. In case the abuse of sleep body thoroughly In almost every phenacetin, antipyrin, such cases I with the and allied has many physicians prefer, think, good acetanilid, salieylates products begun reason, opium or chloral, or their combination, a attention to the although by physician calling especial efficacy of late the use of trional with some of to years and sulphonal and harmlessness these drugs first prescribed ease of the modifications of chloral, chloralamid, etc., have the pain and sleeplessness of some acute disease, such as given excellent results. tonsillitis or grippe. Sir Lauder Brunton has suggested with much wisdom THE USE OF FAKE SYNTHETIC FORMULA. that a combination of hypnotics is more successful than In this connection I can not refrain from calling at¬ any one of them singly. He recommended the now well- tention to a large number of combinations of well- known mixture of small quantities of morphin, chloral known drugs of this class that are given fake chemical and the bromids, and this is a favorite combination of a formulae, and which, while substantially mixtures of great many of us. as such remedies antipyrin, acetanilid, phenacetin and POPULAR KNOWLEDGE OF OPIUM UNDESIRABLE. allied nevertheless are claimed to be new synthetics, yet Whenever enters into the for and important synthetic discoveries. It is to be re¬ opium prescription the relief of insomnia or too much caution can not be gretted, moreover, that there are to be found physicians pain, who will describe at great length and in much detail urged. This is an oft-repeated tale, and yet from the of habitués of this I see the wonderful cures which have resulted from the use crop drug that yearly, it seems not to have been learned. At the same of some of these impossible synthetics. All honor should altogether time, be and to the chemist it is my own firm conviction that there is too much popu¬ paid support given enterprising lar of the effects of and I who has devised a really new product. The knowledge opium, personally good profit should condemn in the manner that he may make from it is his, but strongest possible the legitimately phy¬ of the Woman's Christian Union sicians, as a class, I are too prone to un¬ practice Temperance believe, accept of on the the 10 to 25 cent, of in¬ challenged the statements of some manufacturers who imposing public per out misfit combinations. formation regarding alcohol and opium which they make put in the of school books. The It is not that we as should bear obligatory publication giv¬ expected physicians to the and immature a of in mind the chemical lore of our ing young knowledge the se¬ always laboratory days, ductive activities of in humble but a more careful of the flood of newer any agent is, my opin¬ scrutiny great a of synthetics is advisable if not imperative. Moreover, ion, practice worthy the severest criticism. when it is to be borne in mind that many of these so- THE NEWER OPIUM DERIVATIVES. called newer synthetics are sold for from fifty cents to But this leads away from the last topic of my paper, one dollar an ounce, when their constituent parts may the new opium derivatives. These, heroin, dionin and

Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 05/30/2015 peronin, as is well known, are derivatives of morphin; subject of self-medication and on the dispensing of medicine modifications by chemical substitution of groups of by the physician who thus invades the province of the phar¬ macist. I think that this is attended atoms. They are distinctly not morphin, and their ac¬ practice by great danger have individualities. The to both professions, and to the patients as well. tivities definite and distinct With the of Dr. about in¬ who would alone blood regard to suggestion Spratling pharmacologist register pres¬ the I think that it would be better to remove maintain structing laity, sure, respiratory activity and heart beat, may the beams from our own before to remove but does eyes attempting that these drugs have an identical action; he the mote from our brother's eye. For instance, many of the so on very meager and insufficient data. The psychologic preparations now in use among physicians are nothing more manifestations of the activities of these drugs are distinct than secret preparations. Only this afternoon, in coming into and in the genesis of drug habits, the brain and its ac¬ the room, I picked up a circular containing the advertisement tivities is the factor, heart beat and blood of a preparation made by Rigaud and Chapoteaut, which is all-important advertised the but also advertised pressure are secondary. not only to profession, is Of the habit I need to the public in the daily papers for self-medication. The opium say nothing; physicians for this evil is difficult to find. Dr. has are with its but in this remedy Spratling sug¬ acquainted general features, day lectures as a means of the ; and what on account of this gested popular instructing public generation may happen perhaps some papers read before medical societies might afford out of . our ? widening therapeutic possibilities a good introduction to the general discussion of the subject. I and ace¬ believe that just as phenacetin, antipyrin The final recommendation is not in the United trional and combinations have possible tanilid, the newer chloral States. The sentiment of the people would be against it as to at¬ so richly supplied the profession with weapons being antagonistic to American ideas. Much, however, can tack pain and insomnia and have thereby lessened the be done by the proper exercise of legislative control. The danger of the opium habit, so the introduction of the greater part of the protection to nostrums is due to the copy¬ new morphin derivatives will afford a like refuge for right laws. Probably the protection by copyright is more than those patients for whom opium seems imperative. They is needed. If the profession would try to overcome the copy¬ will lessen the great amount of the habit even right protection of nostrums, it would accomplish a great deal morphin toward this kind of self-medication the if at times induce a habit of their own. That breaking up by laity. they may Dr. W. J. New York both no I with sub¬ Robinson, City—The papers are they do is question, but have dealt this The elsewhere. valuable and timely. suggestion that physicians should ject contribute articles to be published in the daily papers is a To my mind the question of drug habits, so far as the but to for their would cost too resolves into good one; pay publication physician is concerned, in large part itself much. If the articles were well written, no doubt the papers a number of simple restrictions that we shall place on would be glad to get them as matters of interest to their ourselves. These may be expressed as follows : readers. CONCLUSIONS. I am surprised to hear Dr. Spratling's remarks on the careful regulation of the sale of patent medicines in France. 1. Prescribe the which will do the work re¬ drug I have been in France myself, and that is not the opinion that to or relieve so quired produce sleep pain, but let it be I would have formed from own observation. There is with to my graduated reference dosage and choice of remedy hardly an old wall in Paris that is not covered with advertise¬ if that it will be the least harmful used steadily. ments of proprietary articles, and the little kiosks, or public 2. Keep our mouths tightly shut as to what we are urinals, are covered with directions for self-treatment for using. Do not say, "Take 1 gr. phenacetin, 10 grs. of venereal disease and lost sexual power, the remedies to be salol. Y2 gr. of codein." Give it to the patient if neces¬ bought at all pharmacists. Possibly the laws are on the sary, but do not under any circumstances permit him books but are not enforced. Patent medicines are everywhere in evidence in Paris, even the illuminated kiosks at to know what it is. That is a medical question, and if night the information is its circle of are covered with announcements of new nostrums. imparted pernicious ac¬ With regard to the remark about radiates further than we can patients bearing pain tivity imagine. much less than formerly, I believe this to be true. We can 3. incessant on AVage warfare the many pirates who not go into the lying-in chamber without taking with us a provide all sorts of reliefs to the public, going directly bottle of chloroform or ether, and we use them for slight to them through the lay press and the magazines. surgical operations, often, indeed, against our better judgment. 4. In conclusion, let it be remembered that the intro¬ A remark has been made about physicians of the present duction of newer drugs, rightly set forth by honest chem¬ day giving simple substances, instead of the complex prepara¬ tions that were in This ists and worthy clinicians makes most desirable acces¬ formerly use. is in the direction of more accurate and scientific This has been sions to our armamentarium ; but that false and prescribing. recog¬ pretense nized and the now has economic of an by the Pharmacopeia, physician at robbery unsuspecting public deserve his command united condemnation and many articles in the form of active principles opposition. and simple substances that it was impossible to get formerly, DISCUSSION except in combination. This is a fact known to every chemist; ON THE PAPERS OF DBS. SPRATLING AND JELLIFFE. but the average physician is slow to understand it. Dr. Frank Woodbury. Philadelphia—The author referred to About the evils of self-drugging, everyone present can recall the laws of China, but not to those of Japan, which present instances. I recall a patient who took, every day, sixty grains a marked contrast. The Japanese government apparently of phenacetin, and who claims that when he goes without it modeled its regulations of the sale of nostrums on the plan he suffers with headache. It is impossible to say whether the of Austria. It requires the registration of actual formulae, and headache is really caused by the want of the phenacetin or if any are found which do not correspond to the formula their whether a phenacetin habit has become established. Another sale is forbidden under penalty. Furthermore, if any compound patient who had a syphilitic headache when a young man, and or preparation is considered by the health board as injurious was cured of it by the biniodid of mercury, for years after¬ or dangerous, its sale is alsolutely prohibited. Finally, those ward was in the habit of recommending this drug to his that are shown to be useful have their price regulated, so friends when they complained of having headache. that the sick shall not be charged extortionate prices. These Dr. W. L. Dickerson, St. Louis—I have observed that, just laws are not only in marked contrast to the absence of regula¬ at the close of the sessions for the last four or five years, tion in China, but they are also far in advance of our own. there has been brought up for discussion this most interesting Dr. H. C. Wood, Jr., Philadelphia—Most of the members subject when there are very few to discuss it and very little of the American Medical Association have decided views on the time to do it in. It seems to me that, in trying to regulate

Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 05/30/2015 this matter of the use of proprietary preparations, we must bacillus" is the of this The with the itself. The of my purpose paper. pathologic begin profession pharmacists states of the mucous membrane which be can tell when an for a manu¬ may produced neighborhood always agent drug the and of this facturing house is going around visiting physicians, because by growth development micro-organism on them are of sufficient to warrant careful on the next day there will be several prescriptions calling for gravity these special articles to be put up. Physicians know absolutely consideration. During the past five years a great many nothing of the composition of many of these preparations, and hundred cultures which were made from inflamed yet they take the statements of the agents, or the advertise¬ throat, nasal mucous membrane, eyes, etc., have been ments, as their authority. Certainly if a man makes a really examined and it has been found that many of these local or medical he valuable discovery contribution to science, disorders were on the action of the influenza should receive the derived from the sale, but in dependent advantages bacillus, and not on the pyogenic bacteria. In a report that event he should patent the drug, and then we would in the Bulletin of the of know what it is that we use, for the composition must be published Chicago Department I referred to some of the made known of articles that are Health, January. 1899, pro¬ patented. to With to the habit of self-medication with narcotics, I nounced local disturbances which had been observed regard be due bacillus. think that there is a danger of such habits being formed to the Canon-Pfeiffer The numerous if the physician places prescriptions of this kind in the hands observations made since that time confirm the statements of his patients indiscriminately. I am in the habit, when then made. Attention was called to laryngeal, pharyn¬ prescribing for a patient suffering with pain, to give a tablet geal, nasal and ocular conditions—all severe types which of morphin from my hypodermic case and give a prescription were caused by the influenza bacillus. for whatever be In this else may required. way, the patient In cases which were cultures the without the and there is less clinically laryngitis pure gets prescription opiate of were obtained. The of the habit the this organism frequently pa¬ danger forming by refilling prescription. tients in the of instances Dr. W. P. N. Y.—The tone of one of majority presented symptoms Spratling, Sonyea, which did not from those of acute catarrhal the speakers would seem to indicate that general legislation vary laryn¬ could not regulate the manufacture and sale of proprietary gitis. A feeling of rawness, tickling sensation, hoarse¬ medicines in the United States. Such may be the case, but I ness and disposition to cough were the usual manifesta¬ thing that the profession can secure some legislation if an tions. Occasionally the symptoms were decidedly croupy effort is made. We can get laws to control the adulteration in character, marked hoarseness, difficult respiration and of food supplies, and I think the necessity for the protection a harsh, ringing cough were present. The mucous mem¬ of the medicines is as public against injurious just great branes were bright red, and in severe cases much swollen. in some instances as that of better food. The state¬ securing The bacilli were found in the expectorated sputa and also ments I made concerning the regulation of drugs in foreign in cultures made from these secretions. countries was taken from consular reports made to the Depart¬ In which clinical ment of State in 1898. other cases presented the usual of and tonsillitis the Pfeiffer bacillus Dr. S. E. Jelliffe, New York—The proposition seems to me aspects pharyngitis to I to be a very simple one, and one that could probably be settled appeared be the exciting cause. Many times have in five minutes if we, as a profession, were all ideal ourselves; made bacterial examinations of exudations from mucous but we are not all ideal by any means. For instance, I have known membranes which were congested, red and swollen and this to occur: In New York City a very enterprising manu¬ found no other organism. In many instances coming facturer devised a scheme to increase the sale of his particular under observation the throat symptoms were so marked with produce. He issued pads, printed prescriptions; each that a physician would feel justified in pronouncing the one had a for one of these coupon attached; every coupons cases the Klebs-Loeffler bacillus was not orders sent to the store, the would diphtheria, yet representing drug physician examinations were made. Red¬ receive 25 cents. If there are physicians of such character found, although repeated of the tonsils and mem¬ us as to to ili a scheme like this, what ness, swelling well-developed among stoop participate brane—manifestations of can we say to the public or to the manufacturer of propri¬ certainly suggestive diphtheria etaries? —have frequently been demonstrated to depend on the committee appointed to make recommendations. influenza bacillus. Indeed, cultures have been sent to Dr. A. W. Baer, Chicago, moved that a committee of three the city laboratory many times for diagnosis which were members of the section be appointed on the subject of these taken from cases in ïvhich the probable clinical diagnosis papers, to report at the meeting of the section in 1903, making was given as diphtheria by the attending physician, but such recommendations as they think fit. The resolution was instead of the diphtheria bacillus being found the in¬ unanimously adopted and the chair appointed to serve on the fluenza bacillus has been obtained in conditions almost Drs. and Wood. committee, Baer, Robinson, pure. The power of this organism to excite such grave local disturbances is deserving of thoughtful inquiry and A FURTHER STUDY OF THE INFLUENZA greater consideration than has heretofore been given to BACILLUS.* it. The proper treatment demands it. Diphtheria anti¬ F. ELDREDGE WYNEKOOP, M.D. toxin administered to a with a of Illinois Bac¬ patient suffering diph¬ Professor of Biology, University ; First Assistant on teriologist, Chicago Board of Health. theritic inflammation dependent the Canon-Pfeiffer CHICAGO. bacillus would fail to produce the desired results. Of recent years such thorough study has been given It would seem that when the influenza organism enters by so many competent observers to systemic conditions the system its field of action is not limited to some par¬ as other produced by the Bacillus influenza in the human organ¬ ticular part of the body that of many patho¬ it and on ism, that we may say wc are fairly familiar with and genic bacteria, but that attacks spends its force able to recognize all the important points in the general any and every organ which offers least resistance. A symptomatology of influenza. There are condi¬ throat may become the seat of severe manifestations and special clinical tions, however, concerning which we are not so well in¬ exhibit symptoms—as already noted—differing formed, and to direct attention to what may be called not greatly from diphtheria, or in milder cases, from ton¬ "some of the atypical manifestations of the influenza sillitis. The stomach and intestines do not escape this * minute its in the one case Read at the Fifty-third Annual Meeting of the American fungus, activity producing Medical Association, in the Section on Hygiene and Sanitary Sci- gastritis, and in the other a condition ence, and approved for publication by the Executive Committee : simulating typhoid Drs. Arthur R. Reynolds, George Cook and Heman Spalding. fever. It may advance along the eustachian tubes and

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