To Sleep, Perchance

I have to confess I felt some sympathy for the Prime Minister when she admitted last week that Brexit was keeping her awake at night.  Unlike Dr Axel Munthe of The Story of San Michele who was a chronic insomniac, I’ve seldom had any trouble dropping off.  Moreover I’ve always been able to get back to sleep having been woken in the night.  When I was a child our pet dog Jet used to scratch my door in the night and ask me to let him out to answer a call of nature.  He must have known that I was going to spend a career being woken in the night.  In ten minutes I’d be back in bed and out like a light.  The few times I can remember lying awake through worry, it has not so much been at the thought of an impending disaster, rather it has been because I have felt myself to be in the middle of an impossible situation, or what the psychiatrists call a “bind”.  I can think of a few occasions in medicine when I made a mistake that kept me awake.  The bind here was that I had taken the Hippocratic Oath, “First do no harm”, and then gone on to break it. That is an existential threat.  Yet it is unavoidable.  You cannot have a career in medicine and not, at some point, several points, foul up.  The hardest thing in medicine is, having made a mistake, not to curl up in bed, but to carry on practising.  Honesty, humility, and the support of colleagues are what get you through.

Shakespeare’s Othello suffers an existential threat.  It’s not mere jealousy that keeps him awake.  It is the self-doubt, the chink in the armour of “my parts, my title, and my perfect soul” that puts him on the rack.  And Iago says, “Not poppy, nor mandragora/ Nor all the drowsy syrups of the world/ Shall ever medicine thee to that sweet sleep/ Which thou owedst yesterday.”

Disturbed sleep is a very common symptom in the GP surgery.  Patients come in requesting some mandragora, or, more likely, temazepam.  GPs constrained to consult within ten minutes might be tempted to write the prescription, and before you know it, the patient is hooked on benzodiazepines and maybe the GP will have to explain to the GMC what he’s playing at.  Far better, surely, to introduce the patient to the concept of “sleep hygiene”; regular sleep habits, avoidance of caffeine or alcohol in the evening, the importance of fitness and physical exercise, and so on.  Yet there is always a deeper level to which the doctor might delve.  What existential crisis is keeping the patient awake?  Depression, fear, and anxiety in the face of some impossible situation?  Worth asking.

A New Zealand friend of mine was once asked what her favourite pastime was, and she replied without hesitation, “Sleeping”.  When asked, “But isn’t sleep just unconsciousness?” she offered a panegyric to the experience of sleep, particular of falling asleep, that in its sensuousness I do believe some people found unseemly.

Sleep is essential to our wellbeing; sleep deprivation is a device of the torturer and a cruel and unusual punishment.  We cannot function without sleep.  Yet our neurophysiologists are not quite sure what function it serves.  One theory is that sleep is a process whereby the brain reorganizes itself in terms of cataloguing data in folders.  The hippocampus, seat of short term memory, gets saturated.  During sleep, the files are taken out of the hippocampus and transported to multiple sites of long term memory that are more secure.  This may be why people who have conditions of memory impairment such as Alzheimer’s may lose short term memory but cling on to more hard-wired information.  Musical melody might be the last thing to go, and perhaps a lifetime of music appreciation and even more so of music making, may be protective.  One of Mrs May’s predecessors who was famous for thriving on four hours’ sleep a night, developed memory impairment.

The PM has been quoted as saying, “In this job, you don’t get much sleep.”  I wonder about that.  Most professions now recognise that lack of sleep is generally detrimental to professional performance.  My obstetrics job as a junior doctor was a “one in two”, that is, every second night on call.  It is worth painstakingly mapping that out:  go into hospital at 8 am on Monday morning and emerge at 6 pm on Tuesday evening.  Return at 8 am Wednesday morning and emerge at 6pm on Thursday evening.  Return at 8 am on Friday morning and emerge at 6 pm on Monday evening.  Return at 8 am on Tuesday morning and emerge at 6 pm on Wednesday evening.  Return at 8 am on Thursday morning and emerge at 6 pm on Friday evening.  And, believe it or not, you’ve got the weekend off.  Then go into hospital at 8 am on Monday morning…  “Do the math.”  That is a 109 hour week.  It was European directives that put a stop to that.

There have been similar regulations introduced into aviation.  Pilots cannot fly more than a given number of hours within a set time frame.  Most people would regard such regulation as eminently sensible.  After all, you would not wish your surgeon or your pilot to drop off during critical manoeuvres.  You would, on the contrary, wish them to be extraordinarily alert.  However this does not seem to apply to the political class.  How often do we hear of “all night sessions” in Parliament, in the various institutions of the EU, at the UN, and in a variety of other diplomatic forums, when politicians keep going until they have thrashed a deal out?  What sort of state of mind are they in when they eventually come to ratify some critical decision, and what, in consequence, is the quality of that decision?

One of my favourite Prime Ministers is Henry Campbell-Bannerman, a liberal who sat for the Stirling Burghs and who was PM from 1905 – 1908.  He died in 10 Downing Street.  His term of office was a quiet time, you may say.  I suspect that quietude might often be an index of successful premiership.  Campbell-Bannerman went on his holidays every September for six weeks to Marienbad in Bohemia.  Can you imagine a PM doing that now?  D’you know, I wish they would.  It would be a wonderful cure for insomnia.

In Mrs May’s case, I can only imagine that her own particular bind results from the fact that, having voted to Remain, she is now in charge of a government dedicated to Leave.  In this regard, I did find her coronation to the premiership in July somewhat puzzling.  Mr Cameron campaigned to remain, lost the referendum, and promptly resigned on that basis.  Moreover, his initial plan to stay on until September to provide a period of stability was quickly shelved and, with extraordinary expedition, Mr Cameron became a man of the past.  His eclipse was total.  He completely disappeared.  He had concluded, as had everybody else, that his position was untenable.  Yet Mrs May support for Remain did not appear to be an obstacle to her accession.  You may say that, while Mrs May’s support of the Remain campaign was low-key, Mr Cameron was the key figure in putting the government into a position which he had never intended, and therefore he had to pay the price.  Yet Brexit has become the key political issue in the UK right now, and while the PM believes in democracy and the will of the people, she does not believe in Brexit.  And that, I imagine, is why she cannot sleep.

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