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As has been indicated, recurrent daytime sleepiness may be the presenting symptom in a varied number of disorders other than narcolepsy and cataplexy When chronic daytime sleepiness occurs repeatedly and persistently without known cause, it is classi ed as essential or idiopathic hypersomnolence Roth distinguishes this state from narcolepsy on the basis of longer and unrefreshing daytime sleep periods, deep and undisturbed night sleep, dif culty in awakening in the morning or after a nap ( sleep drunkenness ), all of these occurring in the absence of REM-onset sleep and cataplexy Admittedly, this condition proves dif cult to distinguish from narcolepsy unless laboratory studies exclude the latter, and even then there is overlap between the two syndromes in some cases (Bassetti and Aldrich) Treatment, however, is the same as that for narcolepsy Idiopathic hypersomnia, as de ned in this manner, proves to be a rare syndrome once narcolepsy and all other causes of daytime sleepiness have been excluded

This state, as remarked earlier, has been induced in animals by lesions in the tegmentum (median raphe nuclei) of the pons Comparable states are known to occur in humans but are very rare (Lugaresi et al; see page 340) The commonest causes of asomnia in hospital practice are delirium tremens and certain drugwithdrawal psychoses Drug-induced psychoses and mania (bipolar disease) may induce a similar state We have seen a number of patients with a delirious hyperalertness lasting a few days to a week or more after temporofrontal trauma or in association with a hypothalamic tumor (lymphoma) None of the various treatments we have tried has been successful in suppressing this state Fortunately, it was transitory in the traumatic cases

Several types of paresthetic disturbances, sometimes distressing in nature, may arise during sleep Everyone is familiar with the phenomenon of an arm or leg falling asleep Immobility of the limbs

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and maintenance of uncomfortable postures, without any awareness of them, permit undue pressure to be applied on peripheral nerves (especially the ulnar, radial, and peroneal) Pressure of the nerve against the underlying bone may interfere with intraneural function in the compressed segment of nerve Sustained pressure may result in a sensory and motor paralysis sometimes referred to as sleep or pressure palsy Usually, this condition lasts only a few hours or days, but if compression is prolonged, the nerve may be severely damaged, so that recovery of function awaits remyelination or regeneration Deep sleep or stupor, as in alcohol intoxication or anesthesia, renders patients especially liable to pressure palsies merely because they do not heed the discomfort of a sustained unnatural posture Acroparesthesias are frequent in adult women and are not unknown in men The patient, after being asleep for a few hours, is awakened by numbness or a tingling, prickling, pins-and-needles feeling in the ngers and hands There are also aching, burning pains or tightness and other unpleasant sensations With vigorous rubbing or shaking of the hands or extension of the wrists, the paresthesias subside within a few minutes, only to return later or upon rst awakening in the morning At rst, there is a suspicion of having slept on an arm, but the frequent bilaterality of the symptoms and their occurrence regardless of the position of the arms dispels this notion Usually the paresthesias are in the distribution of the median nerves, and almost invariably they prove to be due to carpal tunnel syndrome (see page 1167)

inception, and often, as time decreases, the volatility value will reduce leaving some pro tability, especially if the underlying trades near the short premium The spread worked out well, but the ability of high volatility markets to cling to value is sometimes remarkable and should not be discouraging Risk control on a butter y is fairly straightforward, but here are some helpful hints on using butter y spreads: It is a limited risk purchased premium spread Plan on risking the entire premium on the spread Apply butter y spreads with as low a premium cost as possible Try to keep your risk to reward above at least 1:3 A ratio of 1:4 risk to reward is preferred and is a sign of better than average volatility on the short option premium Be aware that liquidating one or more options without liquidating the entire spread will expose the trade to risk that may not be limited Be patient with these spreads; they can be very successful if they are left to do what they are designed to do at expiration Make sure you are calculating your commission costs and premium into the spread breakeven prices At expiration if the trade is not liquidated prior to the expiration date, long butter y spreads can have some interesting combinations of possibilities: If the original at-the-money option is the only in the money at expiration, the trade will be assigned the represented shares or futures contract, and the remaining options will