Once upon a time, before my wife, Jenny, and I got married and had our three children, I was a Catholic priest. On one occasion, I fell asleep during one of my own sermons, an accomplishment that is easier than it sounds.
I said Mass on Sunday evenings in a parish full of wonderful young families. I thought I was doing everyone a favor by keeping the sermon short, a discipline I achieved by sticking to topics I knew something about. Generally, my wisdom had petered out by the end of the third minute.
One day, after the service, a mother of three young boys took me to task for my brevity. The woman’s problem with me was practical. She put good money on the collection and wanted better value. Mass was her only chance on the weekend to have a rest, and by late Sunday afternoon, she was totally exhausted and facing the weekly prospect of getting the lunches cut, the boys to school, and herself to work the following morning. The sermon was her only chance for a bit of a nap. Would I mind stretching it out a bit longer? She’d be grateful if I could. She needed the rest. I said I would do what I could.
The great Irish satirist and author of Gulliver’s Travels, Jonathan Swift, was annoyed by people who fell asleep in church. He was an eminent churchman who made a career out of turning up his nose and being appalled. Swift divided the world into those who stayed home on Sunday to sleep there and those who went to church and slept there. He wrote a diatribe called On Sleeping in Church. It’s hard to imagine the topic raising a sweat these days. Swift wrote,
Of all misbehavior, none is comparable to those who come here to sleep. Opium is not so stupefying to many persons as an afternoon sermon. Perpetual custom hath so brought it about that the words of whatever preacher become only a sort of uniform sound at a distance, than which nothing is more effectual to lull the senses.
Swift had a point. I grew up hearing a story about a politician who used to come to our church. One time, he fell asleep during the service and began snoring loudly. His wife was embarrassed and dug him in the ribs to wake him up. Assuming he must have been sitting in the chamber, he immediately called out, “Hear! Hear!” The congregation was distracted because the priest had just begun to wonder aloud what words Jesus might have said to the deaf girl in that day’s gospel reading— and “Hear! Hear!” was not a bad suggestion. The problem was that the priest was not open to suggestions; all the questions in our church were rhetorical.
Sermons are not the only cause of untimely sleep. Speeches, meetings, PowerPoint presentations, and children’s ballet concerts can all have the same effect. The Internet has plenty of images of people who have fallen asleep at awkward moments, including a judge who dozed off during sensitive testimony in a trial for a violent crime. One poor anchorman fell asleep at his desk while on air. This may not mean it was a quiet news day. It could mean the opposite—that he was working too many hours, trying to keep up with the endless flow of wisdom that comes from the mouths of politicians and celebrities.
We inhabit a culture that keeps people on the brink of falling asleep and yet inhibits them from doing it properly. Swift wasn’t really concerned just about church. He was concerned about people who were too exhausted by what was happening on the surface of the world to keep an eye on its foundations.
Heaven knows what Jonathan Swift would have thought when I nodded off during the sermon I was delivering myself. This may be divulging a trade secret, but once a sermon gets beyond a couple of minutes, it reaches a delicate point at which the preacher has no idea what he or she is going to say next. In the Jesuit tradition of which I was a part, this point normally came much closer to the start of the sermon than the end. The Jesuit custom was to keep the sermon ticking until something popped into your head, a practice known as “relying on the spirit.” It was a risky way of going about things, especially when the most likely thing to pop into your head was either what you’d already said or what you’d soon wish you’d never said. Another strategy when stuck for an idea was to pause briefly and invite the congregation in a reassuring tone to reflect on what you had just been saying. This bought a bit of time to come up with something else. It was on one such occasion that, with my hands joined devoutly on the lectern, my head started to nod. My eyes closed. My breathing slowed and deepened. It was only when I bumped into the microphone that I woke myself up and noticed that the congregation was giggling. I remember thinking that I must have said something funny and wondered what it was.
(This wasn’t the first time that I had amused a congregation when I thought I was being serious. Soon after I was ordained, I was asked to preside at a service on Good Friday, the day Christians ponder the death of Jesus on the cross, hardly the happiest moment in human history. I wanted to make the point that the message of Jesus was hard to reduce to a few choice slogans. Unfortunately, what I said was that Jesus was a hard man to nail down.)
At least now I had a bit more experience under my belt: it appeared that I could give a sermon in my sleep.
The incident was part of a bigger picture. I wasn’t just falling asleep during my own sermons; I was falling asleep anywhere and everywhere. I would go to bed early, get up as late as possible, and yet, by ten o’clock in the morning, there was nothing I wanted more than to go back to bed. After lunch, I’d crawl under my desk at work and grab some shut-eye. It was getting harder and harder to stay awake. At the same time, my snoring was getting worse and worse. I could make a monastery sound like a factory. I was like the Giant in Jack and the Beanstalk who rocked the entire castle with his snoring.
I underwent my first sleep study in January 1997 at the age of thirty-six. The cheerful technicians stuck a suite of electrodes to my scalp, chest, and legs and put a band around my chest to measure my breathing. They also put a microphone somewhere to record my snoring. (This, I presumed, was how they made sound effects for disaster movies.) The electrodes were all connected to an electroencephalogram (EEG) machine, which traces brainwaves, drawing a picture of what the brain is doing during sleep; this computer was kept outside in a command booth. Then, trussed up like a turkey at Thanksgiving, I was asked to get as good a night’s sleep as possible. I knew at once that this was a ridiculous request. I wasn’t going to sleep a wink. Nobody had advised me to bring my teddy bear.
When I got the results, I discovered it had taken me nine minutes to fall asleep, an interval known as sleep latency. Even in the comfort of your own bed, if you fall asleep in less than ten minutes it’s an indication of sleep deprivation.
There were more results as well. The following morning the technicians came in with big smiles and said that they had big news to tell me.
“Oh,” I asked warily. “What’s that?”
“We can’t tell you.”
“How come?”
“You have to see the doctor in a couple of weeks.”
“The suspense will kill me.”
It wasn’t suspense that was going to kill me. It was sleep, or at least what was happening in my sleep. When I turned up for my appointment with the doctor early on the day after a public holiday, his waiting room was packed, suggesting I was not the only person in the world with problems. Meeting the doctor, John, was one of those experiences—a bit like what I imagine it is to discover that your partner has been having an affair for years—when you realize that you have known very little about a major part of your own life. John produced an impressive little pile of printouts, technically known as a polysomnogram, that were generated during my night in the sleep lab. He started circling parts of them with a magnificent black Mont Blanc fountain pen that I began to covet.
“How do you think you slept in the lab?” he asked.
“All things considered, not too bad,” I replied.
“Were you aware of waking in the night?”
“No, I reckon I slept right through.”
“Undisturbed?”
“Totally undisturbed.”
He was writing all this down with his Mont Blanc. He then put the cap on the pen with a small flourish, indicating it was time for him to stop listening and start speaking.
“Actually,” he said, “you woke up 287 times.”
I found this hard to believe. Perhaps he’d mixed up my results with those of a young mother somewhere. The Mont Blanc reappeared and circled the key statistic, to impress upon me that 287 was a very big number and not to be joked about. I noticed the pen had a broad nib, the type that requires skill to wield without making a mess, altogether a very nice writing instrument. I wished we could talk about that.
“You slept for a total of five hours and forty-nine minutes. This means you were waking up on average forty-nine times an hour or, in other words, almost every minute.”
“What about the snoring?”
“This is related to the waking. I’ll explain how that works in a minute. We were recording you at well over eighty decibels, which is the same as traffic noise or shouting. Normal conversation is sixty decibels; hearing damage starts at ninety decibels. You weren’t far short of that. It was quite a racket, I believe.”
“Wow.”
“Yes, ‘wow’ indeed.”
There were some important things I needed to understand. The 287 interruptions to my sleep were called apneas, a word of Greek origin that means the cessation of breathing, and I had a condition called obstructive sleep apnea, which, in those days, was not well known. That situation has changed dramatically in recent years, as the ailment has reached epidemic proportions in well-fed countries. Sleep apnea is a condition that more commonly afflicts men, although their partners also suffer. It does affect women themselves as well, although it is one of the few maladies for which men are more likely to go looking for help, usually with considerable urging from home. Dr. Christopher Worsnop, a sleep physician, explains that the classic interview with a couple goes like this:
Doctor: “Do you snore?”
Man: “She says that I do.”
Doctor: “Does she snore?”
Man: “She says that she doesn’t.”
Being overweight is a significant risk factor. As a luggage handler once said, I had a bad case.
Sleep apnea is in large measure the result of a design fault in the upper airway. The human throat is a floppy tube, something that distinguishes us from all other species, which have rigid throats, a situation that is thought to have come about because of the human need to speak. While you are asleep, your tongue and soft palate, which is the fleshy part at the top rear of your mouth, relax and your throat collapses. Your uvula, which is the bit that hangs over your tongue like a stalactite and which you can see when you gargle, also flops in the way, as do your tonsils. As a result of so much slack behavior behind your teeth, the passage of air to your lungs may be blocked, especially if you’ve had a bit of alcohol or if your throat is narrow. Why might your throat be narrow? Perhaps you’re a bit chubby: the body stores fat in visible places and also invisible ones such as the walls of the throat. On the other hand, it might just be a matter of luck. People with jutting jaws are more likely to have open throats and hence be less susceptible to snoring and sleep apnea. Dr. Worsnop points out that superheroes such as Superman and Batman are often drawn with strong jutting jaws, a feature that, since the time we lived in caves, has been seen as attractive to women. I personally think the reason women may be attracted to jutting jaws may have nothing to do with jutting biceps or jutting anything else; it simply makes it less likely that they will have to put up with snoring.
If your throat falls in on itself or becomes obstructed, the level of oxygen in your blood decreases and the amount of poisonous CO2 rises. If something didn’t happen at this stage, you’d suffocate. But luckily the increase of CO2, decrease of O2, and the work of various receptors in the throat, lungs, and chest all send a message to the brain that it needs to wake up and the brain obliges. The brain does a lot of things for you without even letting you know. It’s good like that. The loud spluttering, strangling, gargling noise that passes as snoring is actually your attempt to push the palate and tonsils out of the way, open the throat, and clear the airway. The noise sounds desperate, and it is. You are struggling for life and you don’t even know. Untreated sleep apnea is a killer; the main way it kills people is when they fall asleep driving. If you don’t actually choke, it may put pressure on the cardiovascular system. Even if you avoid these pitfalls, you wake up exhausted, as someone who has been disturbed 287 times in a night has every right to be.
“Would this be happening every night?”
John picked up the pen and held it between his two forefingers like the rod of judgment.
“Yes. Every single night of your life. You’re lucky we found out. It was five minutes to midnight for you.”
I must have looked shocked.
“Don’t worry,” he said. “I love the old Cold War language.”
Had I been talking with John twenty years earlier, his options would have been limited. I could have tried sleeping on my stomach, an old-fashioned idea that can make a difference because it allows the soft tissue in the upper airway to fall forward and make less of a nuisance of itself. The advice given to snoring blokes in a bygone age of putting a tennis ball in a sock and pinning the sock to the back of their pyjama top is not just an old wives’ tale. Another idea is to put on a bra backward and put tennis balls in the cups, a form of evening wear that can be confusing to a partner in the middle of the night.
Upping the ante, he could have suggested a tracheotomy, an operation that puts a little hole (a tracheostomy) in your throat below the site of the blockage. This hole is then left open at night, like a window, to let some air in; but it is not a sightly addition to the physiognomy, as it makes a person look a bit like a bassoon. The air bypasses the collapsible throat but in so doing also bypasses the vocal cords, so you can only speak during the day by inserting a plug into the hole. A further and yet more drastic option may have been an uvulopalatopharyngoplasty, a word that required nothing less than the services of a Mont Blanc fountain pen to get itself onto a piece of scrap paper so that I could contemplate it with all its vowels.
“Don’t worry,” said John. “It is normally just called a UPPP.”
A UPPP involves the removal of the tonsils as well as a serious trim for the soft palate, the uvula, and the pharyngeal arches, whatever they are. John wasn’t recommending this form of major surgery. It tended to be very painful and was by no means guaranteed of success. Like a vasectomy, it isn’t a procedure you can do yourself.
But luckily there was something that had become available of more recent times. It was called CPAP (continuous positive airway pressure) and was the brainchild of a professor in Sydney named Colin Sullivan, of whom John spoke with awe. Sullivan had come up with a clever solution to a problem that had baffled the boffins for ages. While others were dabbling in such elaborate ideas as injecting silicon into the soft palate to stiffen it up so that it maintained its condition during sleep, Sullivan realized that the upper airway is a bit like a door that keeps banging shut in the night. It just needs somebody willing to stand with a foot in the door. Sullivan theorized that what was required was a machine that would use simple air pressure to splint open the airway; the machine would fit into a mask, and the mask would sit over the nose of the patient. It was a simple but ingenius mechanical solution to a problem for which others had sought surgical, pharmacological, and even psychological solutions. Colin Sullivan’s bright idea has saved tens of thousands of lives.
I returned to the sleep laboratory to experiment with CPAP, and the results were remarkable. John explained to me that sleep has distinct stages, each stage marked by a certain type of brain activity; the function or purpose of each stage has long been the subject of argument and conjecture. These stages rotate through the night in cycles of approximately ninety minutes; five cycles is a good night’s sleep for most people. The fifth stage, which begins an hour or more into a night’s sleep, is in a class of its own and is so unique and mysterious that it is often known as paradoxical sleep, meaning it is a time when the body looks asleep and the brain looks awake. It is called REM sleep, and it is compeltely different from the other four stages, which are known as non-REM, or NREM, sleep. Stages three and four have a particular importance and are known as slow wave sleep. Many sleep researchers don’t divide the states of human wakefulness into sleeping and waking. They divide them into three separate categories: waking, NREM sleep, and REM sleep.
Like many people with sleep apnea, I was missing out on stages three and four sleep, the time in which growth hormone is released, a substance that uses small doses to achieve a long list of useful results. I was more than just tired. I was sick.
“You also have periodic leg movements.” John Mont-Blanced this new problem onto page two of the polysomnogram. “This means your legs are moving all night long, kicking. You spend the night walking without going anywhere.”
“Why?”
“Well, it’s one of a number of sleep disorders in which people do rhythmic things during the night. Bruxism is another one. Teeth-grinding, in other words. It’s most common in children and more common in adult women than adult men. We think these sorts of disorders may be some kind of release mechanism.”
“I probably need the exercise.”
“You’re lucky you’re a priest. At least nobody else is going to get kicked in the night.”
He produced a cheap ballpoint that he kept for writing on a prescription pad on which carbon copies where required and wrote a prescription for a drug called pergolide (sold as Permax), usually given to people with Parkinson’s disease to control their shaking. Permax was to become embroiled in controversy a few years later and was withdrawn from the market, angrily pursued by a group of people who blamed it for causing compulsive behavior such as gambling. It was also held responsible for heart-valve problems in people with Parkinson’s. John didn’t know that at the time. He just thought it might cause nausea, like motion sickness, a strange side effect for something that prevented motion.
“There’s more to sleep than meets the eye,” I said. “I never realized.”
“Well, most of it happens in the dark, so it doesn’t meet the eye, which is why it’s been one of the last frontiers of medical research.”
Over time, John elaborated. He told me that many people think sleep is a passive state.
“It’s not like that at all. I think of it as the night shift coming in. The plant doesn’t close down. There are all sorts of active processes going on that need to happen overnight.”
“So why do we sleep anyway?”
John drew a deep breath. “Well,” he said. “It’s not like there’s one explanation. It depends who you ask.”
If you ask an anthropologist, human sleep evolved to keep our ancestors safely in their caves at night away from nocturnal predators. If you ask a neurophysiologist, sleep is when a lot of neurochemicals get replenished; in other words, it is when the brain eats. If you ask a physician, sleep has a metabolic function; it’s when a lot of tissue repair takes place. If you ask a psychiatrist, it’s all about memory consolidation and the reprocessing of information, and dreams have a role in this. If you ask a developmental physiologist, sleep may be a remnant of our fetal existence and could be a hangover of circuit-testing in the fetus when dreams and dreamlike activity are important for helping a brain discover what it can do and teaching it how to do its job. Most fetal sleep is REM sleep, the type in which the brain is really pumping. The percentage of REM sleep diminishes over a lifetime. If you ask an adolescent pediatrician, you will discover than in the months before puberty, the pituary gland is working double time during sleep to get the process started.
I interrupted him.” What about you? What do you think it’s for?”
“I think it performs all these functions.”
“Really.”
“And more besides.”
The long and short of it is that no one fully understands why we sleep, but everyone agrees that sleep is both vital and universal. Fish, amphibians, and reptiles don’t have REM sleep. Birds and mammals do. So it could be that REM sleep is a sign of having got further up the evolutionary ladder. Nevertheless, it appears that even insects have inactive and active periods, much like a sleep/wake cycle, although lab technicians have found it difficult to get those electrodes onto the brains of bees.
John wrote down the name of a chemist who sold the kind of CPAP machine I required, as well as the pressure at which the machine would need to be set. I didn’t notice what pen he used. I was too busy looking at where I had to go next.
The best part of two decades later, in the early days of 2017, I caught up with John again. Both our lives had moved along in surprising ways, and his rooms now had a commanding view of St. Patrick’s Cathedral in Melbourne. We shared a laugh about the ways in which the cathedral had been helping people to sleep for longer than he had. I asked him about the latest news from the world of sleep medicine.
“The biggest change is in the area of awareness,” John said. “Everyone knows about sleep now.”
I wasn’t surprised to hear this. There was hardly a day when sleep wasn’t in the news in some way, shape, or form. It was even beginning to compete with restaurant reviews as a topic for lifestyle discussion.
“People now see sleep as a component of wellness. They used to talk of the importance of diet and exercise. Now they talk about diet, exercise, and sleep.”
Every year, John tries to attend the meeting of the American Academy of Sleep Medicine, which takes place in cities such as Boston and Denver and attracts more than six thousand registrants. These are just some of the hardcore professionals in the field.
John went on to describe how his practice had developed. “Seventy percent of our patients who have sleep apnea have one or more other sleep issues. We focus just as much on them. We have seen strange sleep behaviors such as parasomnias and even what we call sexsomnias feature in a number of legal cases.”
These are situations in which people do things while asleep that they wouldn’t dream of, so to speak, in normal life.
John continued, “Judges will now accept the fact that a patient has a parasomnia but may not necessarily accept that as a defense for a crime committed in the night.”
Sleep still keeps John awake at night. After twenty-five years in the game, he is clearly still buzzing with news from the frontiers of research. He speaks, for example, about new understandings of the role of orexin (also called hypocretin), a neuropeptide, in regulating our sleep/wake function. This has had major implications for the treatment of narcolepsy and the creation of new drugs that are continually arriving on the market. There is an entire new class of drug called DORAs, meaning dual orexin receptor antagonist.
“There are multiple competing DORAs coming through. Those drugs are worth a lot of money,” John says. “A lot of money.”
This prompts me to mention the problems I had with Permax, the mischievous drug I had been taking for restless legs. John listens sympathetically. “Twelve of our patients who were using Permax lost a total of $12 million through gambling,” he says candidly. When it comes to sleep, he treats drugs with extreme caution.