Three basic concepts

To define insomnia from a medical standpoint, we must refer to difficulty in falling asleep along with difficulty in staying asleep, as well as waking earlier than desired. These conditions require an opportunity for the sleep process to proceed naturally. One essential characteristic of insomnia is that it interferes with everyday activities, manifesting itself in things like lack of concentration, memory lapses and some behavioral changes ¹. These parameters are evaluated using the Athens scale developed by Soldatos et al. ².

The disease or "plague" of insomnia is a constant in Gabriel García Márquez's (GGM's) universe; it consists in the inability to fall asleep that leads to a more critical condition: loss of memory. Likewise, it is understood that one must sleep in order to rest and be able to perform properly while awake. Moreover, sleep must be found again if one awakens prematurely.

In the medical world, insomnia is recognized as chronic (more than three times/week in the last three months) and acute or transient (having lasted less than three months), the latter being related to a reversible trigger. Initial or onset insomnia, consisting in a delay in falling asleep, is distinguished from terminal insomnia, in which it is hard to stay asleep, and early wakening ³.

In One Hundred Years of Solitude (OHYS), the disease of insomnia arrives in Macondo, which, according to the narrator was usually a problem of the indigenous Guajiro people. In the novel, GGM relates that the indigenous woman Visitación, Úrsula Iguarán's servant, who had escaped the disease, was responsible for announcing the arrival of the plague in Macondo. She warned that the hardest part of this ailment was not the inability to sleep, since the disease did not physically affect people; the most difficult part was that the insomnia led to a loss of memory. To which José Arcadio Buendía responded "If we never sleep again, all the better. ...life will be more productive"⁴.

Forgetfulness, memory loss, according to Moliner's "Diccionario de uso del español" [Spanish Use Dictionary] (1967) consists of the "mental faculty used to remember or the greater or lesser capacity to remember"; that is, to be unable to retain things in the mind. Why this faculty is lost is a persistent question that affects personal identity ⁵. On the other hand, according to the Real Academia Española [Royal Spanish Academy], the term has three definitions: 1. "Cessation of the memory that existed", 2. "Cessation of the regard that existed", and 3. "Neglect of something of which one needed to be aware"⁶.

Loss of memory refers to losing the faculty of bringing to mind past information, images, experiences or actions as though they were in the present. Memory involves different brain structures: the amygdala, in charge of assigning emotion to the process involved in remembering (motivation); the frontal lobes, which supply the attention needed to acquire new information; and the hippocampus, that acquires and consolidates new memories that are distributed throughout the cerebral cortex. This widespread distribution allows some memories to be evoked by and related to smells, people, objects, sounds or moments ⁷.

Forgetting is understood to be the involuntary action of not remembering; that is, the inability to store some information that is acquired or has already been acquired in thememory. Often, forgetfulness occurs due to interference learning, which is learning that replaces an unconsolidated memory and erases it from consciousness. Sometimes, one remembers that one has forgotten something; knows that knowledge existed that is no longer there. However, according to Jacoby, Debner and Hay ⁸, forgotten memories do not disappear. Rapid eye movement (REM) sleep buries them in the unconscious.

Sleep is a complex biological process. When people sleep, they are in a state of unconsciousness, but their brain and body functions continue to be active, and they do not lose the ability to perform a series of important functions required to maintain life. When we speak of sleep, we refer to the act of sleeping as a mental activity during periods of rest.

Sleep should be understood as an everyday activity that entails rest as a natural function of the human body, and as one of the most important and necessary functions for human beings. Sleep plays an essential role in health and wellbeing. How a person feels while awake generally depends on what happens during sleep. During sleep, the body works to support healthy brain functioning and maintain physical, intellectual and emotional health ⁹.

In García Márquez's literature, the concept of sleep appears in the short story "Dreams for Hire," which is part of the Twelve Pilgrim Tales collection ¹⁰. It says: "I dreamt that he was dreaming with me…Sometimes, amidst so many dreams, one sneaks in that has nothing to do with real life." In this story, the narrative and social world fluctuate between reality and the dream. In Gabo, marvel and magic always mean possibility.

From the author's perspective, some of his characters are infringed upon during their sleep time. Thus, in OHYS, José Arcadio Buendía dreams unending rooms to find a man whom he had murdered some time ago, and after several dreams, never wake again: "When alone, José Arcadio Buendía consoled himself with the dream of the unending rooms.from this room he went on to another exactly the same, whose door opened to another exactly the same, and then another exactly the same, to infinity"⁴. Here, the dream is a nightmare that repeats unendingly.

In The General in His Labyrinth¹¹, Bolívar has recurrent nightmares that keep him from sleeping: "The general refused to return to the room where he had stayed before, which he remembered as the nightmare room, because every night he slept there he dreamt of a woman with bright hair who would tie a red ribbon around his throat until he awoke, and again and again until dawn." Once again, the dream crisscrosses with nightmares, not because of the content of the dream but rather the same thing being repeated over and over throughout a long and unexplainable night that seems unending. This text shows the general's aversion to the bedroom where he has experienced bad nights; in these cases, it is challenging to make the patients aware of this fact and help them recover the idea of the bedroom as a sacred place of rest.

In The Autumn of the Patriarch¹², the main character senses omens of nightmares in his dreams, dreaming that he is defenseless, surrounded by men who threaten him with knives "... he saw himself in the large and empty house of a bad dream, surrounded by pale men wearing grey frock coats who stabbed him with butcher's knives...." As the narrator says, the patriarch has "bad dreams" that envisage and predict his proximity to a solitary suffering stronger than his own pride.

Evidently then, for GGM, sleep is not a space for rest, but rather a space to reveal human suffering. This may be due to what his biographers relate, who argue that when the Colombian Nobel laureate had a nightmare, his deepest wish was not to awaken but rather to write. He was a dreamer of nightmares who knew that his bad dream would end when he awakened at last and was able to transcribe it into literature. After having a nightmare, he would invite it to his desk and force it to cooperate with his stories. All he had to do was strike the keys on his typewriter, because the story had already been dreamt ¹³.

Causes of insomnia

Undoubtedly, sleep is not a useless action. Human beings spend a third of their life sleeping, and the quantity and quality of sleep have been directly related to a person's health status. Therefore, adults are considered to need seven to eight hours of sleep per day, and our responsibility as physicians is to do whatever is necessary to make this possible, teaching them about the so-called sleep hygiene measures. However, there are "short sleepers" (five or less hours of sleep) and 'long sleepers" (eight to nine hours, maximum) ⁹.

There are many causes of acute or transient insomnia, most of which are reversible. Some are emotional, like anxiety, fear, sadness, depression, and constant persistent ruminations at night. There are also environmental causes, including the weather, light, smells, and living conditions. Other cases of insomnia are due to acute symptoms like fever, pain, dyspnea and itching, among others, or worsening chronic diseases like congestive heart failure, chronic obstructive pulmonary disease, Parkinson's disease, dementia or sleep apnea, among others ¹.

In One Hundred Years of Solitude, the narrator initially thought that the insomnia was caused by some candies which were made in José Arcadio Buendía's house: "Children and adults sucked delightedly on the delicious little green insomnia roosters, the delectable pink insomnia fish, and the sweet little yellow insomnia horses, and so Monday's dawn found everyone awake"⁴. This description clearly shows that GGM considered too much sugar to be the main cause of insomnia. Today, we recommend controlling stimuli, which may include cutting down on calories and stimulating beverages, especially in the three hours before going to bed ¹⁴.

In OHYS, insomnia is a disease that can be transmitted by mouth: "everything to eat or drink was contaminated with insomnia"⁴. However, the population needed to eat and was consciously and simultaneously feeding the disease. The author explains that this ailment was confined to the town of Macondo, and any strangers who arrived had to ring a little bell that the townspeople had taken from some goats "so that the sick people would know that they were healthy"⁴. In the novel, the disease was considered to be an epidemic that required quarantine and that became endemic over time, which is why "nobody concerned themselves any more with the useless habit of sleeping"⁴.

In Love in the Time of Cholera, GGM also mentions how someone can grow accustomed to a symptom. One of his main characters, Florentino Ariza, found it to be very useful. The narrator explains that he "quickly incorporated that ritual into his routine: he took advantage of his episodes of insomnia to write..."¹⁵.

In the presentation of the book by Juan Vicente Fernández de la Gala, The Physicians of Macondo. Medicine in the Literary Work of Gabriel García Márquez, Dr. Fernando Sánchez Torres speaks of a telephone call he received from Dr. Pierluigi Gambeti, a researcher at a university in Cleveland, Ohio. Gambeti had compiled data on five complete families who suffered from insomnia, in order to determine its genetic origin. Dr. Gambeti asserts that, after reading OHYS, he wanted to ask the novelist if he knew anything about the genetic origin of insomnia, given his magnificent literary description, and expressed his desire to travel to Macondo to conduct his study in situ. The response of our Nobel laureate in literature to Dr. Gambeti was "...don't bother to come and research anything in Macondo, because that disease never existed. I made it all up: this insomnia plague came out of my imagination. Besides, as far as I know, that disease is never cured, but in my plague, all the patients were cured in the end, because it was to my advantage for all the sick people in the novel to recover their sleep so they would not infect my readers, and that is why I took it upon myself to cure them all."

In this regard, it should be noted that, while rare, there is such a thing as the so-called fatal familial insomnia, a genetic prion disease described in 1986 by Lugaresi et al. ¹⁶, several years after OHYS was published. But it clearly coincides with part of the Buendía family's story and, by extension, that of the entire town of Macondo.

Medicine and literature

Both in literature as well as film and journalism, Gabo frequently touched on topics related to disease and plagues, with a high degree of rigor and precision. These topics appear not only in One Hundred Years of Solitude⁴, but also in and through his medical characters, with Juvenal Urbino in Love in the Time of Cholera¹⁵; Dr. Abrenuncio de Sa Pereira Cao in Of Love and Other Demons; and the apathetic, depressive, suicidal and unnamed foreign doctor in Leaf Storm²⁵. One of García Márquez's sons, Rodrigo García Barcha, wrote in a posthumous letter to his father: "You were always fascinated by plagues, real or literary, as well as things and people who return"²⁶.

Like literature, medicine is a profession full of tensions and responsibilities. Fernández de la Gala says that "friendly bridges" can be established between literature and medicine, which have many common elements like approaching societies and flesh and blood human beings, as well as those on paper, to understand the human condition through empathetic exercises using stories. Thus, it is said that when Dr. Gregorio Marañon was asked to name the best medical advance of the twentieth century, after some thought answered: "the chair," which allows the physician to sit next to the patient, ask questions, listen to him, understand him and explore him. According to Fernández de la Gala, literature is a teaching strategy to train physicians, and he recommends using it in medical schools.

Today, in the age of artificial intelligence, human beings are being replaced by technology in many professions. Will this occur in the practice of internal medicine? The best medical histories, a narration of the disease, should be those taken by internal medicine specialists, with high values that involve a humanistic perspective, as a machine only handles fixed algorithms, with no capacity for dialogue, reasoning, interpretation and deduction. Artificial intelligence is gaining ground as an important support tool but will never replace the essence and responsibility of professions and professionals. As Torres-Iregui ²⁰ has stated, this means that "the success of medical practice does not depend so much on technology and therapeutic innovations as it does on the closeness and communication between physicians and their patients."

Medicine, physicians, bodily ailments and death were constant concerns of the Colombian Nobel laureate and, therefore, topics that inspired his stories. He narrated them hand in hand with science and fiction, managing to shape a whole that overlaps science and fiction, using both according to his convenience as he told the stories that make up his work. This is the opinion expressed by Dr. Carlos Francisco Fernández in the presentation of Juan Vicente de la Gala's book at the National Academy of Medicine.

Many pages in GGM's books are made up of narrations and descriptions that have enormous "clinical brilliance." This is due to various reasons: one, because Gabo did not have good health; another, because he always had a whole team of medical and dental advisors when writing his books to help guide and orient him to establish a firm foothold in the world of medicine together with his magical universe, as expressed by Fernández de la Gala.

Baños and Guardiola explain that medicine and literature have a two-way relationship (27). Literature, as a narrative art, helps acquire communications skills, like reading and writing in an understandable, clear, concise, precise and coherent fashion. Thus, literature favors reflection and the development of empathic attitudes for listening and un derstanding, and a better approach to disease and patients, especially for understanding many facts, circumstances and situations that are not found in medical discourses or publications. There are innumerable stories in the medical world that are worth being told through literary stories.

The section above highlighted the importance of dialogue between physicians and patients. When a physician receives a patient, he/she is subject to hearing a story that may end up being not only complex but also decontextualized and messy. The patient relates events and feelings, using his/her language with words and gestures, and therefore the physician must be alert, willing and prepared to hear the story, mentally underline what is important and discard what is superfluous and, finally, synthesize the data that will allow him/her to make a diagnosis. To accomplish this, physicians need techniques to help them organize the important points into a single story that must be both oral and written. Sir William Osler, the father of modern internal medicine, was quoted by Silverman, Murray and Bryan ²⁸ as saying that it is important to listen to the patients, because they end up describing their own diagnosis. The key point is knowing when and how to interrupt the patient's narration to focus his story, and often realize what Torres-Iregui ²⁰ affirms: "Several times I finished office visits in which the patient left satisfied without having told me why he had come, because he had come simply to be heard."

According to Cabral ²⁹, literature contributes to promoting the difficult and paradoxical task of "humanizing" medicine. He argues that the study of literature contributes to enlarging the physician's human dimensions in the following ways: 1) The literary narrations teach many aspects of the lives of sick people; 2) Works of fiction help physicians to understand the strength and ramifications of their practice; 3) Through stories, physicians are trained to better capture their patients' medical histories and thereby increase their diagnostic and therapeutic certainty; 4) Literature increases physicians' narrative experience and deepens their ethical discernment; 5) The study of literature helps face some of medicine's challenges, like determining the position of physicians as both social entities and change agents in their environmental setting; and 6) Literature mitigates the potential problems caused by the experiences of disease and suffering.

Note

Below, references are provided for four (4) speeches which were given during the presentation of the book The Physicians of Macondo. Medicine in the Literary Work of Gabriel García Márquez, by Juan Vicente Fernández de la Gala.