1.1 Sleeplessness: Lessons from History
Literature owes much to Charles Dickensā poor sleep when, on occasions, he would get out of bed and tramp the nighttime streets of London, encountering the people and places that gave him so many inspirations for his novels and for his conceptions of the tortured minds of many of his characters. His remarkable accounts of these wanderings and wonderings, which he called his āhouselessnessā, are described in his little known book of āNight Walksā, which might be seen as a positive side to insomnia and how he turned this affliction very much to his advantage. After walking for many miles, he would return home at sunrise, to his northwards pointing bed, to sleep exactly in the middle, placing his arms out and checking that his hands were equidistant from the bedās edge. At other times, when he could not sleep, he would stand at his bedside until feeling chilly, shake up and cool his pillows and bedclothes, then get back into bed. In fact, unlike the rest of his methods this latter technique is based on sound science as the body indeed needs to cool in order to ensure more rapid sleep onset.
Nevertheless, his was a magnetic personality in more ways than one as, away from home, he would realign the bed to the north, which is why he always carried a compassāto foster his creativity as he also had to be facing north before he would put pen to paper. He believed in mesmerism (also called āanimal magnetismā), thought to be linked to real magnetism, as Mesmer, himself, would use pieces of magnetic iron ore (ālodestoneā) as part of his mesmeric treatments, even for curing insomnia. But this was too much for Dickens, who dismissed such use of magnets as āunnaturalā. Nevertheless, lodestones embedded in pillows were a very popular cure-all amongst the Victorians. But we shouldnāt mock, as even in the 1960s, a āmagnetic field deficiency syndromeā, with symptoms including insomnia, was a common diagnosis in Japan, and even today, magnetic pillows and mattresses continue to be advertised to alleviate insomnia.
However, Dickens, who died in 1870, couldnāt really be called an āinsomniacā as the term was seldom used at the time. Yes, he suffered from insomnia, but then it was called āsleeplessnessā, and another 30 or so years elapsed before āinsomniaā became the word of choice, coinciding with the development of new medicines and changes to medical practice (more about this, later).
Until then, the obvious remedies for sleeplessness were either alcohol (gin for the poor and whisky or brandy for the wealthier), or the readily accessible and cheaper āfixā of opium in one form or another, with the most popular being laudanum, a tincture of alcohol and morphine. Being unrestricted, it could be bought almost anywhere. In fact, so popular was opium, that the British had largely gone to war with China, in the āopium warsā, to maintain the lucrative supplies. Byron, Shelley, de Quincey, Coleridge, Poe and even William Wilberforce were āopium-eatersā, using the drug not just as a sleeping aid, but also for pleasure or out of addiction. Meanwhile, cannabis, also easily available, was regarded to be more dangerous than laudanum, until it became known that Queen Victoria had been prescribed it by her personal physician, Dr JR Reynolds, to āassist sleep during menstrual crampsā. Some years later, in 1890, he reflected in an article for the Lancet, that cannabis was āone of the most valuable medicines we possess for treating insomniaā.
For those after a milder treatment for their sleeplessness, there was the herb valerian, named after the sleepless Roman emperor Publius Licinius Valerianus, who advocated its use throughout his empire. Although, pharmacologically, it had only a modest soporific effect, it benefited from having such an influential user and patron, and became the medicine of choice for the sleepless Romans, especially when coupled with the power of such a celebrity endorsement. Human nature being what it is, such placebo effects remain with us, more than ever with todayās āover-the-counterā remedies, including modern prescription medicines that are truly hypnotic, but also have additional placebo effects.
But to return to the Dickensian era, where there was good insight into insomnia, albeit quaintly amusing and still relevant today, lamentations about sleeplessness abounded in the then medical literature. For example, an editorial in the BMJ of 29 September 1894 (p. 279) bemoaned, āThe subject of sleeplessness is once more under public discussion. The hurry and excitement of modern life is held to be responsible for much of the insomnia of which we hear; and most of the articles and letters are full of good advice to live more quietly and of platitudes concerning the harmfulness of rush and worry. The pity of it is that so many people are unable to follow this good advice and are obliged to lead a life of anxiety and high tensionā.
The editorial went on to review various attested treatments, pointing out that different remedies suit different people, to the extent that one apparently effective remedy can be the exact opposite of another. For example: hot baths versus cold baths, hot drinks versus cold drinks, long walks (in bare feet) versus sitting whilst attempting āsteady but monotonous countingā or āthe more difficult feat of thinking about nothingā. The article concluded with what must be the most extraordinary account of a cure, originally taken from the
Glasgow Herald:
Soap your head with the ordinary yellow soap; rub it into the roots of the hair until your head is just lather all over, tie it up in a napkin, go to bed, and wash it out in the morning. Do this for a fortnight. Take no tea after 6 pm . I did this, and have never been troubled with sleeplessness since. I have lost sleep on an occasion since, but one or two nights of the soap cure put it right. I have conversed with medical men, but I have no explanation from any of them. All that I am careful about is that it cured me.
The editorial wisely ends with the comment that āwe cannot help thinking that some of our sleepless readers would prefer the disease to the cure. But if any should like to try it, may we advise that they should first, at any rate, follow that part of the advice which relates to the tea, and leave the soap part as a last resourceā.
The interesting word, here, was ādiseaseā , as this was still a time when āthe mindā was somewhat of a little understood, embarrassing enigma, largely ignored by physicians and well before the era of Freud and his contemporaries. None of the numerous remedies for sleeplessness involved anything along the lines of what one might call psychological therapy, even though stress and a troubled mind were well known to be the common basis, as reflected over 30 years earlier, in another insightful BMJ editorial (9 November 1861, p. 489), entitled āOn Sleeplessnessā, by Dr James Russell:
In treating these cases [of sleeplessness], the key to success lies in the management of the patientās mind, and unless we recognise the large share which is taken by mental disorder in producing and perpetuating the various and puzzling symptoms which present themselves, we shall not only fail in our object, but shall be in danger of actually aggravating the malady. Much may be done by soporifics and tonics; but our chief attention must be directed to regulating and strengthening the mind, otherwise our medicines will only serve to fix the patientās attention more closely upon the symptoms, and induce reliance upon external measures rather than upon self discipline . The treatment required is suggested by the nature of the malady. We find self-control diminished, the will inert, the emotions dominant, the thoughts of the sufferers occupied entirely about themselves, and the idea of disease the one subject engrossing their attention; we find every sensation registered, every fresh complaint welcomed and symptoms which at first seem to belong to organic disease are discovered, by further experience of the case, to have their origin in nothing but exaggerated sensitiveness or disordered fancy ā¦ The task of ministering to such a condition is no light one; and it is hard to say whether the discipline is more severe to the patient or to the attendant ā¦
This was also the era when fortitude and a āstiff upper lipā were expected of patients, and when the prevailing medical opinion was that emotions caused bodily changes, particularly within the cardiovascular system, to the extent that treatments for āemotional problemsā often involved targeting the heart and blood in some way. It was certainly reflected by the Danish physician, Carl Lange, who claimed that, āwe owe all the emotional side of our mental life to our vasomotor systemā, which attracted much interest in Europe. He soon came to the attention of William James, the famous American philosopher and psychologist, who was thinking along similar lines, and invited Lange to co-author their renowned book, The Emotions (1887). Thus, the JamesāLange theory of emotion was born, whereby emotions were the result of the perception of bodily changes. It also explains why insomnia, despite its link with stress and anxiety, continued to be viewed as a āphysical disorderā with so many treatments aimed at the heart one way or another, often with bizarre remedies. For example, the authoritative reference book on home management The American Housekeeperās Encyclopedia (1883), advocated, āwhen overwakeful, get out of bed, dip a piece of cloth in water, lay this around the wrist; then wrap the dry portion over this and pin it, to keep it in place. This will exert a composing influence over the nervous system, and producing a sweet sleep, reducing the pulse; a handkerchief folded lengthwise will do. It is easy; try it.ā
Absurd as this may be, the radial pulse in the wrist was seen as the primary medical route to the heart, and ātaking the pulseā was a comforting touch by the doctor for the patient. Thus many physicians saw sleeplessness as being due to insufficient blood flow somewhere in the body, often resulting in contrasting opinions. One school of thought believed that insomnia was due to brain congestion from excess blood in the head, reduced by being propped up by pillows. Another, that as there was insufficient blood in the brain, this was rectified by raising the feet, again with pillows. Of course, again, superstitious behaviour and the placebo effect were largely responsible for the efficacy of these treatments.
1.2 Insomnia: āMedicalisingā Sleeplessness?
By the 1890s a variety of new drugs had been discovered, and found to be effective in treating sleeplessness. Reinvigorated by this new armoury, the British Medical Association campaigned against what it called āsecret remediesā and forced the removal of opiates and cannabis (and also cocaine) from tonics and non-prescription medicines. Also, by now, physicians were responsible for prescribing most drugs, and the old style apothecaries had to cede to the professional pharmacists. Thus, medicine and its practice had become more powerful, especially as these new drugs provided real ācuresā. Moreover, sleeplessness, or insomnia as is was becoming known, was now increasingly attributed to ābrain dysfunctionāāthat is, still as a physical illness brought on by anxiety and stress but with little regard for tackling psychological cause. Given that physicians now had effective drug treatments, āinsomniaā as a diagnosis came into its own, and with its treatment solely under their control, this allowed the disorder to be medicalised to a much greater degree. Patients could be diagnosed as āinsomniacsā in their own right, rather than belittled for lacking moral fibre and becoming reliant on bizarre remedies or hopelessly addicted to opium.
Such a viewpoint was reflected by the distinguished John Buckley Bradbury, Professor of Medicine at Cambridge University, when he gave his influential Royal Society Lecture entitled, āSome points connected with sleep, sleeplessness and hypnoticsā (BMJ, 15 July 1899, p. 134). For him, āthe reason [for insomnia] is that the cerebral cells have assumed an irritable condition and it is necessary to depress their activity to bring them back to a more natural state ā¦ it is here that hypnotics are of such great valueā. Paraldehyde, chloralamide, chloralose, chloral hydrate, sulphonal, potassium bromide were seen to be the least harmful ā¦ā He also recommended āa scantily furnished, quiet, well ventilated bedroom, having moderate temperature, with light excluded, and that there be a firm mattress, light, warm beddingā. Despite many pages in each of four successive issues of the BMJ being devoted to his further lectures on sleeplessness, he made little mention of anything which could be interpreted as psychological treatment of the underlying causes, apart from remarks such as: āsleeplessness from overwork especially literary work requires mental rest and change of air and sceneā. As well as: ācool air of bedroom, wet pack, whisky and water ā¦ Hang feet out of bed, walk about naked, rub feet if cold ā¦ā Nevertheless he did note that the treatment of insomnia was āone of the most difficult subjects in therapeutics ā¦ have a number of drugs ā¦ given in sufficient doses ā¦ produce a desired result ā¦ may make the patient a slave to the habit ā¦ more disasterous than the insomnia itselfāā (p. 136).
More hypnotics appeared with such rapidity that it was impossible to compare their advantages and disadvantages as sleep producers. In the cool light of day, so to speak, it soon became apparent that all these hypnotics had greater side effects than anticipated, and were often t...
