_Insomnia in diseases of the heart and blood vessels._--I can fully indorse the opinion of Ringer regarding the beneficial effects of morphia in the treatment of the wakefulness caused by advanced diseases of the circulatory organs, “In such a case, the comfort afforded by a hypodermic injection is almost incredible.... In cardiac dyspnœa, a sixth of a grain twice or three times a week often suffices, but the dose and frequency in severe cases must be gradually increased to a quarter of a grain each night. Doctors are often afraid to administer morphia in the case of a patient propped up in bed, with livid ears, nose and nails, with distended jugulars and dropsical extremities, with weak, frequent and irregular pulse. They dread lest the morphia should weaken the heart, make the patient worse, if not kill him outright. This fear is quite groundless,” if the opiate be given in moderate doses. It is the stimulant effect of the medicine that is safe and useful.
When wakefulness is caused by _angina pectoris_, or by simple cardiac neuralgia, such as sometimes follows excessive use of tobacco, relief may be obtained through the exhibition of alcoholic stimulants, hydrate of chloral, or nitrite of amyl. These remedies act more speedily than morphia, and may be associated with it, to the great advantage of the patient. They should not be habitually used, however, in cases of cardiac exhaustion, as their chronic employment favors accumulation of blood in the right side of the heart, with a tendency to paralysis of the cardiac muscles. It is in stenosis of the coronary arteries, and in aortic obstruction, that nitrite of amyl and nitro-glycerine are most useful. The insomnia that results from the remote consequences of these diseases is often relieved by remedies which assist the circulation of blood. For this purpose digitalis is the most useful stimulant in mitral disease; nitro-glycerine, in aortic valvular lesion.
_Insomnia in diseases of the respiratory organs._--Pleuritic pain and its consequent wakefulness may be relieved with opiates, guarded by appropriate vascular sedatives. Dover’s powder, or morphia and aconite, form excellent examples of the remedies most useful, so long as the lungs are not overwhelmed by excessive exudations into the pleural cavities. Pneumonia and bronchitis are accompanied by wakefulness, in their earlier stages, as a consequence of harassing cough. This may be allayed by the judicious use of expectorants and sedatives. If symptoms of asphyxia appear, indicated by blueness of the lips and nails, opiates should never be given. Respiratory stimulants are then indicated, and sleep must be allured by the use of alcoholic beverages and moderate doses of chloral hydrate, with musk and camphor. The early, irritative cough of incipient pulmonary consumption may be soothed with camphor and opium. Paregoric and a demulcent, like Iceland moss tea, or flaxseed tea slightly acidulated with lemon-juice, form an excellent type of such a compound. But the chronic duration of the disease renders the constant use of opiates undesirable. Chloral hydrate, for the same reason, cannot be given without intermission. It is well in such cases to employ the different alcoholic beverages at bedtime. Inhalation of warm vapor, and respiration of air charged with ether, or carbolic acid, will often quiet an irritative cough. In advanced cases belladonna is useful, to check the profuse sweating and to calm the thoracic pain that hinders sleep. In the later stages of the disease, when relief from suffering is the only end in view, morphia and dilute hydrocyanic acid will often render quite tolerable the few remaining nights of life.