Insomnia – Victorian style

We owe much to Charles Dickens' insomnia. Sleepless, he would tread the streets of London and encounter the inspirations for many of his novels and conceive of the tortured minds of various characters. On returning to his northwards-pointing bed he would sleep exactly in the middle, placing his arms out and checking that his hands were equidistant from the bed's edge. Away from home he would realign the bed accordingly, which is why he always carried a compass; and he had to be facing north before he could write, as this would foster his creativity.

Dickens also believed in Mesmerism (better known as 'animal magnetism'), although when Mesmer used pieces of iron ore ('lodestone') as part of his Mesmeric treatments, including curing insomnia, Dickens dismissed such use of magnets, as 'unnatural'. Nevertheless, lodestones embedded in pillows were a very popular cure-all amongst the Victorians. But we shouldn't scoff, as even in the 1960s, a 'magnetic field deficiency syndrome', with symptoms including insomnia, was a common diagnosis in Japan. Even today, magnetic pillows and mattresses continue to be advertised as a cure for insomnia.

Dickens died in 1870. Although he suffered from insomnia, he wouldn't then have been called an 'insomniac' because another 38 years elapsed before the term appeared. The rapid development of medical practice over this time may be reason. At the time of his death the obvious remedy for insomnia was either alcohol (gin for the poor and whisky or brandy for the wealthier), or the easily available opium in one form or another, with the most popular being laudanum, a tincture of alcohol and morphine. It was unrestricted and could be bought almost anywhere. So popular was opium that the British had gone to war with China, in the 'opium wars', to maintain our supplies. 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 J.R. Reynolds, to 'assist sleep during menstrual cramps'. Some years later, in 1890, he reflected in an article for The Lancet that cannabis was 'one of the most valuable medicines we possess for treating insomnia'.

By the turn of that century, insomnia was quite prevalent, and lamentations abounded in the medical literature with, for example, an editorial in the British Medical Journal of 29 September 1894 (p.279) bemoaning:

The 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 tension.

The editorial went on to review various attested remedies for insomnia and to point 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 'steady but monotonous counting' or 'the more difficult feat of thinking about nothing'. 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 6pm. 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 'we can not 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 resource.'

The interesting word here is 'disease'. This was a time well before the era of Freud and his contemporaries, when 'the mind' was somewhat of a little understood, embarrassing enigma, largely ignored by physicians. None of the numerous remedies for insomnia 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 in the editorial. It was also the era when fortitude and a 'stiff upper lip' 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 treatmentsfor 'emotional problems' often involved targeting the heart and blood in some way. It was certainly reflected by the Danish physician, Carl Lange, whose claim that, 'we owe all the emotional side of our mental life to our vasomotor system', attracted much interest in Europe. He soon came to the attention of William James, who was thinking along similar lines and invited Lange to co-author their renowned 1887 book The Emotions. Thus, the James–Lange theory of emotion was born, whereby emotions were the result of the perception of bodily changes.

This emphasis further explains why insomnia, despite its link with stress and anxiety, continued to be viewed as a 'physical disorder' with so many treatments aimed at the vasomotor system, often with bizarre remedies. For example, Harriet Suddoth's authoritative 1883 reference book on home management The American Housekeeper's Encyclopedia (see tinyurl.com/5c58hn) advocated:

when 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.

Absurd as this may be, the radial pulse was seen as the primary medical route to the heart, and physicians were no better in this respect, in tending to concentrate on insomnia being linked 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 there was insufficient blood in the brain, rectified by raising the feet, again with pillows. Of course, human nature being what it was and still is, superstitious behaviour and the placebo effect was largely responsible for the efficacy of these treatments. Which is where the irony lies – in seemingly denying 'mind' as a cause of insomnia, it was the very same mind that brought about the apparent relief from so many remedies.

By the 1890s a variety of new drugs had been discovered, effective in treating insomnia. Reinvigorated by thisnew armoury, the British Medical Association campaigned against what it called 'secret remedies' and forced the removalof opiates, cannabis (and cocaine) from tonics and non-prescription medicines. Also, by now, physicians were responsible for prescribing most drugs, and the old style apothecaries had become more professional pharmacists. Thus, medicine and its practice had become more powerful, especially as these and other drugs provided real 'cures'.

At the same time, co-incidentally or otherwise, insomnia had become attributed not so much to the 'heart' but increasingly to 'brain dysfunction' – still as a physical illness brought by anxiety and stress but with little regard for tackling this underlying cause. The eminent John Buckley Bradbury, Professor of Medicine at Cambridge University, when giving his influential 1899 Croonian Lecture to the Royal Society entitled 'Some points connected with sleep, sleeplessness and hypnotics', stated: the 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…it is here that hypnotics are of such great value.

Paraldehyde, chloralamide, chloralose, chloral hydrate, sulphonal, potassium bromide were seen to be the least harmful.

Bradbury also recommended 'a scantily furnished, quiet, well ventilated bedroom, having moderate temperature, with light excluded, and that there be a firm mattress, light, warm bedding'. Despite many pages in each of four successive issues of the British Medical Journal being devoted to his lecture, he made little mention of anything which could be interpreted as psychological treatment of the underlying causes, apart from remarks such as, 'sleeplessness from overwork especially literary work requires mental rest and change of air and scene'.

At last, physicians had better drug treatments for insomnia that were solely under their control, allowing the disorder to be medicalised to a much greater degree. Patients could be diagnosed as 'insomniacs' in their own right, rather than as someone having insomnia and maybe reliant on bizarre remedies or hopelessly addicted to opium. Indeed, the first recorded use of 'insomniac' as a noun in the English language appears to have been in 1908 (see tinyurl.com/5utfz5). Whether or not 2008 is to be celebrated as the 'centenary of the insomniac' is another matter. Maybe we should look to Dickens to turn the leaf of this particular chapter in history, and end by a quote from his unfinished final tale The Mystery of Edwin Drood (Chapter XI):

With that, he extinguished his light, pulled up the bedclothes around him, and with another sigh shut out the world.

Professor Jim Horne runs the Sleep Research Centre at Loughborough University and is the author of Sleepfaring: A Journey Through the Science of Sleep (OUP, 2007)    [email protected]

Picture: The Art Archieve