Snooze

When, my daughter Clare was ten, I was surprised how easily she memorized a good part of William Blake’s “The Tyger.” It’s a poem that tends to stick to the memory; its rhythm does half the work for you. I was delighted to see her mind chewing on the textures of strangely shaped words. Sleep helps to create memory; learning things by heart helps the memory build muscle:

Tyger! Tyger! Burning bright
In the forests of the night,
What immortal hand or eye
Could frame thy fearful symmetry?

The author, William Blake, might have been surprised to find his work between the covers of a Bedside Collection of Children’s Verse. His Songs of Innocence all have a dark tinge. Blake was uncomfortable with the materialistic explanations of the world that dominated the century in which he was born, the so-called Age of Enlightenment. He described it as a time when “the soul slept in beams of light,” meaning that too much understanding of one kind can allow deeper kinds of understanding to slumber. In an 1802 letter, Blake wrote some of his best-known words: “May God us keep / From single vision and Newton’s sleep.”

Blake often took aim at Isaac Newton, a man who did an extraordinary job of approximating the whole of the physical world to a small number of mechanical laws. For Blake, the world was simply not a machine. He painted Newton as a naked man in a cave, transfixed by his measurements and drawings. All around him is darkness, but his single focus doesn’t notice. He may as well be asleep.

Nevertheless, the sleep physician I met—Dr. John—had opened my eyes to the role of science in understanding sleep. There are indeed lots of things about sleep than can be measured and calibrated; my overnight sleep study had made this clear. Eventually, Dr. John sent me off to a chemist with a prescription for the CPAP machine, the device that would help me to breathe through the night by keeping my airway open. I hadn’t realized that snoring, the stuff of comedy, had been for me a sign of a nightly struggle to stay alive. I literally fought against suffocation for hours on end. No wonder I was tired. Yet the solution was simple and scientific.

The chemist to whom I was despatched knew a great deal about the history of sleep. He immediately launched into an entire mythology about these new CPAP machines and the Australian who invented them, Dr. Colin Sullivan. He said that Sullivan was a recluse and a millionaire— all because he had a single bright idea, out of the blue.

“Everyone was trying to discover what to do about sleep apnea,” the chemist told me. “One night, Sullivan was sitting in a Chinese restaurant in Marrickville. He was the last to leave, and they began to clean up the restaurant before he was finished. He noticed that the restaurant owner didn’t sweep up the grains of rice off the floor. Instead, he had reverse-wired a vacuum cleaner that he used to blow the rice out the back door. That was when Sullivan had his Archimedes moment. What he came up with was basically a reverse-wired vacuum cleaner to push air down your throat all night to let you breathe.” It was that device I was myself about to purchase.

I finally met Professor Colin Sullivan himself in September 2004. It turned out that almost nothing the chemist had told me was true. Sullivan had never been in a Chinese restaurant in Marrickville in his life, and he was far from a multimillionaire recluse. Intead, his office at Sydney University was still in the same unassuming room in the same building where he had devised the first CPAP machine almost twenty-five years before. He invited me to pay him a visit.

By the time we met, a million people around the world were using his invention, and it had become Australia’s second-largest medical export after the cochlear implant for hearing. And yet Sullivan’s office still didn’t have air conditioning. When I arrived, he was struggling to get the window open.

“It gets difficult to breathe in here,” he said.

It was breathing that brought Colin Sullivan into the area of sleep medicine, which, in the 1970s, was very much in its infancy. In many respects, it still is. Sullivan was drawn to medicine through physiology, the study of the more mechanical aspects of the human person, because it was the closest branch of medicine to engineering. His two elder brothers had both been engineers, and it seemed to be the family default position. His father had been an electrical fitter.

“My wife calls me a human engineer rather than a doctor because I tend to think mechanically. It’s only recently that I have begun to think of myself as an inventor,” Sullivan told me.

In the early seventies, Sullivan had embarked on his research under the supervision of David Read, after whom the sleep laboratory in which we were sitting is named. Read became interested in the tragic phenomenon of sudden infant death syndrome (SIDS) after friends had lost a baby in this way. The diagnosis was still in its early phase; SIDS had only been named as a distinct condition in 1969. Read began to explore the nature of breathing and sleep in infants. Over time, Sullivan moved on to asking separate questions about sleep in adults. He went to Canada and did research on what happens to the breathing of adults during sleep, using dogs fitted with masks to aid his research.

“We are pretty sure now that, in children, sleep drives the entire process of development,” he says. “In adults, it has more a function of maintenance.”

Ironically, after thirty years in the field, Sullivan is now more interested in childhood sleep and especially fetal sleep than ever before, developing techniques for studying it. He was trying to ascertain if there were clues in childhood, especially in childhood breathing and snoring, that might provide pointers for the later onset of serious conditions such as sleep apnea. He wondered if they could be headed off before they developed and did damage. He points out that it was once common to remove large tonsils from children.

“These kids often presented as sickly, and we used to rip out their tonsils at the drop of a hat,” he explains. “Their snoring was interrupting their sleep and suppressing their growth hormone. After the procedure, they’d often have a growth spurt.”

He went on to explain that babies can spend eighteen to twenty hours a day asleep. Most of that sleep is REM sleep, which is that part of sleep where the brain stimulates itself. But fetal sleep is even more predominately REM sleep. So what’s going on?

“We know that by eighteen weeks, the fetus starts to perform the motions of breathing, even though it doesn’t need to,” Sullivan explains. “It gets all the oxygen and nutrients it needs through the placenta. In its last four or five months, the fetus looks like it is breathing a lot of the time, and this requires a good deal of energy, so there must be some point. What we know is that the fetus learns and practices three key activities while it is asleep: breathing, sucking, and swallowing. These are critical to survival at birth. They are learned during fetal sleep. So, like adult sleep, it isn’t exactly down time. It is key learning time.”

Colin stood up and reached to the top shelf of a bulging cupboard and pulled down a box in which he started rummaging, picking over pieces like it was a box of oddments in a garage sale. These were the first masks that had ever been used for CPAP machines; it was a little box of medical history. They were ugly and cumbersome. There were plaster-of-paris molds in the box as well, masks taken from the faces of early patients. They had all been made by hand and fitted to each patient individually. In the early days, they had to be stuck on every night with glue and then prised off in the morning. It was a hell of a business. But the people who were prepared to sleep with these hideous gadgets stuck to their faces were in dire straits. They were people for whom the most natural thing in the world—breathing—did not come naturally, at least not in bed.

To Lucy Costas, a young science graduate, Sullivan was an entertaining lecturer who, according to her, was “a bit of an iconoclast” who “didn’t kowtow to the medical hierarchy.” When Costas began working with Sullivan and his team in 1979, she had newly returned from overseas with her husband. Not sure of life’s next direction, her eye happened to fall on a job advertisement in the paper that wasn’t quite what she was looking for but that she thought might do for now. She soon found herself in a new world.

Costas remembers hearing about a particular patient from the moment she’d first arrived. He was in his fifties, had been a heavy smoker, and was overweight. He was what is sometimes known as a “blue bloater,” a condition in which the body begins to tolerate low blood oxygen levels and high levels of CO₂. As a result, he had developed a blue physical appearance. And yet studies showed that there was actually nothing wrong with his diaphram; his rib cage was expanding and contracting as it was supposed to, so his breathing apparatus ought to have been doing a better job. But there was little airflow at his nose and mouth during sleep.

Medical science had believed that such a problem must be neurological; it had to be that the brain wasn’t communicating properly. Sullivan and his team, however, clarified the issue. The problem was really the collapse of the upper airway; the mine shaft was blocked near the surface.

“Up until that point,” says Costas, “respiratory medicine didn’t involve the throat. It basically ended at the neck.”

Initially, Sullivan had thought that patients with this condition were few and far between, and that he’d have to go looking for them. He wondered if he’d find five a year.

But they came looking for him.

Just as he had done in Canada, Sullivan used dogs fitted with masks to help him understand breathing and sleep. He used German shorthaired pointers because they were placid, easy to train, and had short hair, which made life easier when it came to keeping equipment clean.

One day in 1980, Sullivan was visited by a man who had been scheduled to undergo a tracheotomy. The man was in his early forties, had a young family, and had reached such a level of dysfunction—being scarcely able to stay awake at all—that he was willing to undergo the extreme procedure. Needless to say, he was not looking forward to it. He was visiting Sullivan because he was volunteering some “before” and “after” studies to measure the procedure’s effectiveness, but during the process, he kept asking Sullivan if there were any alternative at all to having a tube permanently sticking out of his throat, as he would have with the tracheostomy.

Sullivan didn’t have any ideas and then, all of a sudden, inspiration struck. Sullivan thought of the German pointers and an idea popped into his head.

By 4:00 AM the next morning, he could hardly believe what he had seen.

“It was incredible,” Sullivan says now. “The first experiment just worked like a charm. We turned on the blower and this guy went straight into REM sleep and stayed there for two and a half hours. You never see that. A REM cycle might be forty-five minutes.”

Lucy Costas says she remembers the excitement the following day. Sullivan was already telling people that they needed to have their findings published as soon as possible. Before long, five patients had similar experiences and were reporting dramatically improved daytime alertness.

So it was that on page 862 of the Lancet of April 18, 1981, written by the team of Colin Sullivan, Faiq Issa, Michael Berthon-Jones, and Lorraine Eves, there appeared an article modestly entitled “Reversal of Obstructive Sleep Apnea by Continuous Positive Airway Pressure Applied Through the Nares.” (The nares are nostrils. The Lancet expects you to know that already.) The article pointed out that five patients who, without CPAP, had virtually no stage three or stage four sleep improved instantly once they tried it. It concluded that “the inherent simplicity and safety suggest that home use will be possible.”

That last line should have been lit up with dollar signs. The publication in the open forum of the Lancet meant that it was now open season for anyone to turn the reverse vacuum cleaner into cash. The Lancet has an assiduous readership of both medical professionals and business people, two groups that are by no means mutually exclusive.

There were hurdles to get over yet. One was getting the medical fraternity to accept a simple solution, especially one emanating from Australia. Another was creating a machine that was user-friendly; the early ones were so big and loud that they had to be installed outside the bedroom and special pipes were required to bring in the air in the way an aquaduct brings water from a damn. Other issues involved finding a way for the airflow to increase gradually to the desired level, so the patient could get to sleep before it reached full force. But far and away the biggest challenge was designing a mask that people could use comfortably.

Twenty-five years after Sullivan’s discovery, ResMed—the company that began from Sullivan’s work—occupies a vast site on the side of a freeway in Bella Vista, one of the western suburbs of Sydney. The ResMed plant looks more like a university than a factory. Near the entrance is the Healthy Sleep Center, outside which lie beds of lavender, an ancient ally of sleep; their presence lends a slight air of the esoteric to a place with a business edge. At the bottom of a gentle slope is the Innovations Building, which will eventually house three hundred engineers. Every room has access to the balcony that overlooks the Stream of Ideas, an artificial river that runs through the center of the site. Many of the battalion of engineers at ResMed are involved in creating the perfect sleep mask, a task that is more complicated than it sounds.

On the other side of the property is the factory itself. Within twenty-five years of Sullivan’s first experiments, they were making two thousand CPAP machines and fifteen thousand masks every day—mostly for export and mostly to the United States, where ResMed competes fiercely with another company called Respironics, which does much the same thing for a similar share of the market. Only 3 percent of ResMed’s trade is local.

The company’s “core competency” is making masks from Silastic, a word that was manufactured by gluing together silicon and plastic. Twenty-six molding machines (soon to be thirty) churn out masks day and night. Every few months, a new development in mask technology comes into effect, usually a precise refinement making them quieter or less obtrusive or more flexible. Masks cost between $200 and $300 and need to be replaced regularly. I have a collection of my own discarded masks from the last decade: each one a small advance on the previous model, each one a bit more expensive. It’s like a sleep mask graveyard.

After thirty years, Sullivan said that he still spent half his time thinking about the meaning and purpose of sleep.

“So why do we sleep?” I ask him.

“It’s hard to know,” Sullivan says. “We would have a better idea if we could observe what happened to people who didn’t sleep. But it’s hardly an ethical thing to deprive people of sleep.”

“You must have some idea why we sleep,” I say.

“It’s like asking why we eat,” Sullivan says. “The answer goes in so many directions all at the same time.”

A pioneer in the area of sleep medicine, William Dement, is famous for his response to the same question. When asked “What is sleep?” Dement replied simply, “What is wakefulness?”

Waking, of course, can have traumas of its own. The fairy tales never tell you that: Briar Rose (if you like the brothers Grimm) or Sleeping Beauty (if you prefer either Charles Perrault or Walt Disney) wakes after one hundred years and everything’s gorgeous. The prince finds his way through the thicket of thorns, plants the kiss we’ve been waiting for, and everyone in the castle rises and shines and gets on with life as if nothing has happened. Even the cook, who fell asleep as he was about to hit the scullery boy, gets to land his punch. The only misgiving is in Perrault’s 18th-century version, in which the prince notices that Sleeping Beauty is wearing the fashion of his great-grandmother’s era and that her collar is too high—but she is so beautiful, and no doubt well rested, that he loves her anyway.

Lucy Costas continued working for many years in the area of sleep apnea, patiently fitting mostly jowly men to the masks that put the wind back in their sails. She thinks back to one of the very first CPAP patients, someone who found waking from his long years of slumber a difficult experience. He awoke in a world that was not the world in which he had fallen asleep. Things had changed. It had been years since he’d been alert enough to notice.

“I often wonder what became of him,” says Lucy. “He didn’t continue with his treatment.”

Apparently, the journey back from his long hibernation was too hard.

“As far as I recall,” Lucy says, “he chose to go back to sleep.”