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.