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.
Teachers tell stories about sleep, same as most people. Sometimes they are stories about all-nighters required to complete reports or mark papers. I would attribute some of my worst errors of judgment in the classroom to fatigue, although even the most alert people can still be foolish.
I recall speaking to a sixteen-year-old student whom I had been teaching philosophy for the whole semester. I was grumpy with him. He seemed disengaged and withdrawn, not making much contribution to a class that required students to chew on their ideas in public. I had taken a phone from him several times; each time it was like asking him to leave his mother. The problem was that I could not for the life of me remember his name. I was mortified, and he was rightly indignant. I used the wrong name. His breath shortened with impatience. I apologized. But still the name would not come. I didn’t mention that I had been up at 1:00 AM trying to make sense of his assignment. He didn’t mention that he was probably sacrificing sleep to his phone. Two tired people will never have much space for each other. Exhaustion can rant and rave and sometimes stamp its foot; it is seldom a good listener.
Philosophy is that rare thing, a necessary luxury. Plato thought that it belonged to the hours of the day when everyone was wide awake. In his time, that meant dawn. In our time, it’s hard to imagine when that might be.
Other teachers tell very different stories about sleep. Martin Kelly has been a teacher since 1973. For the past twenty-five years, he has worked exclusively with young students who have been unable to find a home in what you might call traditional schools. These are often damaged children, kids who have coped with more in fifteen years than other people do in fifty. It can be difficult to gain their trust and create stability in their lives, but Martin is one of those self-effacing people whose quiet exterior belies a profound commitment. He is employed in one of the flexible learning centers under the auspices of Edmund Rice Education Australia. Martin’s work is mostly in urban environments, on the sprawling edges of cities where supports and services are often slow to keep up with population growth. His world is different from mine. He tells me about a parent-teacher interview in which the child discussed was in some disciplinary trouble. This boy, call him Johnny, was using his phone too much. So maybe, in some ways, our worlds do have similarities.
“I spoke to the mother,” he says.
“How did she respond?”
“She was annoyed with him. She said she was going to cut back his dope allowance.”
He also speaks of twelve-year-old girls being given bottles of Jim Beam for their birthday.
“It’s a cliché to say they grow up quick. But really, they don’t get the chance to grow up properly.”
On a number of occasions over the years, Martin has come across students who need to sleep with their shoes on. This is a powerful image. The kids need to be ready to escape from domestic violence in the middle of the night. Somebody—usually a man, often drunk or drug addled, more often than not the product of a similar childhood to the one being inflicted on the next generation—will turn up ready to do god knows what. The kids are expecting this; they don’t even untie their laces. They flee as fast as they can. Sometimes their mother is with them; sometimes not.
Martin also speaks about finding kids in the middle of the night walking the streets. They will be in small groups, often families, an older one shepherding the others. They will have the blankets wrapped around their shoulders that they grabbed as they ran out the door, narrowly in front of the gale that is pursuing them.
“You can measure the chaos of their lives in terms of the chaos of their sleep,” he says.
One of the basic signs of a coherent life is the knowledge of where you are going to sleep. To function as a human person, you also need an orderly idea of when you are going to sleep, but the where comes first.
In Martin’s neck of the woods, many young people live transient lives. They often bunk somewhere in crowded homes. He has heard horrendous stories of young girls who share beds with older men simply in order to find some privacy, two square meters to call their own for a few hours.
Sleep can be a window on a dark world in every sense.
The children I teach generally know where they are going to sleep. But this doesn’t always mean they are well rested. Sociologist Hugh Macka
y, author of The Good Life, has conducted extensive research into the question of what makes people happy, and it’s not what you think it might be. Instead of money or freedom or family, Mackay’s discovery was that the key to happiness is self-discipline. It seems self-control is a far more secure foundation for happiness than self-belief. In his book The Good Life, Mackay writes:
We may be sacrificing the very thing that will lead to the deepest sense of satisfaction: self-respect based on self-control. There is no shortcut to that and no amount of self-control will get us there.
As young people negotiate the woods of adolescence, the discovery of self-discipline is fascinating to observe and even to help foster. For some it comes more naturally than others, but a lot of young people are helped through a period of angst, uncertainty, and self-doubt by having a structure in their lives on which they can rely and in which they feel safe. Knowing when it’s time to put out the light is the most simple and underrated part of this. A day, like a sensible meal, needs to have a clear beginning and a clear end. The times for sleeping and rising are among the boundaries that young people, as they mature, need to establish for themselves. Many rites of passage are justly celebrated. These include the first date, the first kiss, the first breakup, the first paycheck, and the first time behind the wheel of a car. But ideally, before all these, comes the important transition from parents telling you when to go to bed to making that decision for yourself and sticking to it. Finding order in a single day is as much part of the task of adolescence as finding order in the entire world.
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