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.
Sullivan suggested that he could fit a mask to the patient and hook it up to a machine that looked like a reverse vacuum cleaner, similar to one which had been used on babies considered in danger of SIDS. And so, at 9:45 PM one night in 1980, having come in for yet another all-nighter, Sullivan trusted his wild instincts and fitted the mask.
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 l
ife 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.”
When I was a child, I often found myself unable to sleep. I used to lie awake and listen to the way the world spoke at night: cats prowling, birds nesting, dogs barking, windows rattling, doors creaking, wind blowing, rain falling, mosquitoes buzzing. It was only the mosquitoes that disturbed me, because I hated getting bitten and itching all night. The other sounds were amplified by stillness. I was never more a creature than at night, because that was when I listened to voices that weren’t human. They didn’t nag, instruct, advise, or warn. Nor did they express affection, praise, affirmation, or encouragement. In other words, they were different from the human voices in my life. They didn’t make any claim on me, either positive or negative. I still love that aspect of night. It’s when humans get to leave center stage and be part of the chorus.
There was not one reason why I was such a poor sleeper. But there are likely many factors that have played a part in my nocturnal habits. First, there were the mosquitoes. I shared a room with my brother, and the mosquitoes seemed to prefer me; they would torture me all night long. But there was also the fire: On five separate occasions before I turned nine, fire ravaged through the valley behind our house and we had to evacuate in a hurry. At least twice we were in our pajamas when we were rushed out the door. (Then Mum sent us back for our dressing gowns. We may have burnt to a cinder, but at least we’d have been decent. Mum subsequently became a great advocate of flame retardant nightwear, which was hardly a comfort.) Fire often recurred in my dreams; I would sometimes wake and smell for smoke.
In a lifetime of change—growing up, becoming a priest, leaving the Jesuit order after twenty-one years and getting married and starting a family—my issue with sleep was one of the main constants in my life. The year 2004 found me living with my new wife, Jenny, in the tiny town of Gunning, Australia, population just five hundred. By that point, I’d been through the process of diagnosis of sleep apnea, bought a breathing machine, and been fitted for a mask. In the whole of this process, getting a mask that stays in place, doesn’t allow air to escape, and doesn’t cause blisters is the most arduous part.
I’d been using the mask for a while by the time Jenny and I got together, so I was now quite accustomed to sleeping with a large device on my face. I was, however, quite worried how Jenny would take to it. A breathing mask is hardly the most alluring item of intimate apparel. The alternative, I explained to Jenny, was the equivalent of sleeping beside an idling V12 engine. Without this ingenious invention, the product of exhaustive research in the style of Thomas Edison, we’d need not just separate rooms but probably separate houses.
Jenny was so good at overlooking the mask that before long we were expecting our first child, Benedict.
The local doctor in Gunning had a plaque hanging over one of her patient chairs with a message replicated from a time when electric light was still attached to the apron strings of its creator. It read this room is equipped with edison electric light, and it assured the reader that there was no need to put a match to the light and that electricity has no harmful effects. nor does it effect soundness of sleep.
I was studying these words with furrowed brow as our doctor told us, for the second time in two years, that Jenny should make an appointment to see the obstetrician. I studied them again when we returned to the doctor and told her that the obstetrician had squeezed some jelly on Jenny’s belly, dug around in the jelly with something that was connected to a computer, and soon discovered that Jenny was expecting twins.
“That means two babies,” I had responded, dumbstruck.
The obstetrician replied that, yes, she did know what twins meant. She had read about it in med school.
The obstetrician looked at me strangely and then glanced at Jenny with pity. Twins were good news. A difficult husband was not so good. There were a lot of hearts beating in that little room, which was just as well because mine had stopped for a moment.
Jenny and I had plenty of time on the long drive back home to our town to talk things over. The obstetrician had gone though a long list of agonies that could lie ahead. Jenny was told she had a high possibility, even probability, of miscarriage, and if the babies held on to their slender thread, there were other possibilities that were also labeled as risks. By the time we had had something to eat and had passed the last street light of the city, it was already 9:30 and we were safely under cover of dark. It was then that we could both admit that we’d hate to lose either of these tiny creatures. No matter what was involved, we wanted them to come and live with us. I think the night sky of our country town had something to do with that, for big things seldom seem so big when you can see the stars. It doesn’t always feel the same way in the city, a place where darkness has to be artificially created. It has no night sky to keep things in perspective. You can thank Edison for that.
We returned to our local doctor who, other than Edison Electric Light, didn’t have a great deal of gadgetry in her surgery, not even a computer. When we were expecting Benny, the obstetrician would tool around with her ultrasound and tell us that the baby’s length was precisely 14.5 centimeters. She would join her thumbs over Jenny’s belly, reach around with her little fingers, then hold her hands against an old wooden ruler and tell us that the baby was approximately 14.5 centimeters. We were looking forward to surprising her with our news about the twins.
“Oh, I thought so,” she said when we told her. She showed us the record where she had written, five weeks after conception, “Probably twins.” She had made an educated guess based on Jenny’s size.
“That means two babies,” I added, still wondering if there was perhaps a little-known technical definition of the word that might involve fewer nappies and more sleep.
“I know,” she said softly. “Yes, two babies.” She must have gone to the same med school as the obstetrician. “You’ll find that’s quite a lot of babies,” she said.
There were practical considerations to think about while we were expecting our twins. One was that Benedict, now aged sixteen months, was already bringing sweetness and light into our lives. Perhaps a bit too much light. He was progressing wonderfully, a prodigy in every area of accomplishment, a child to make the young Mozart look like a hack. He had already surpassed his old man in both wisdom and maturity. There was only one problem: The meaning of the phrase “a good night’s sleep” eluded him completely. Almost as soon as the obstetrician found two heartbeats in Jenny’s tummy, the prospect of two more sleepless babies entered our minds. The fact that we would soon have to find a bigger house seemed like a mere detail in comparison.
Soon afterward, Jenny’s mother, Coralie, came to visit, and we took advantage of her vast experience as a babysitter to go to the movies. We looked in the paper and found there was a 10:15 PM showing at the theater down the road. We live on a long road. Times were, in another life, when going to the movies was no big deal for either of us. We both went a lot back then. It was something you could do on your own without fear of b
eing pitied by some couples or envied by others; in those days, a 10:15 PM movie was where we were most likely to run into friends with whom we’d go to supper afterward and drink strong coffee. Sleep was a resource we could just squander. Now the nearest movie house was thirty miles away and a 10:15 PM session felt decadent.
There were numerous advantages to living in a small town. Gunning now had a population of 504, although most afternoons, you’d wonder where they all were. It wasn’t long before we were telling our neighbors and friends that, once the twins arrived, our little family would constitute 1 percent of the population. There would have to be 80,000 of us to have the same demographic impact in New York, and it’s hard to find an apartment that size in Manhattan. A town that never sleeps is, of course, one that never wakes either. Our village didn’t have this problem. It dozed on and off in its patched pajamas, stirring every now and then to remark that things weren’t what they used to be. I was looking forward to days ahead when our 1 percent could swing a close vote on some crucial municipal issue, such as the size of garbage bins or pool opening hours.
The other advantage of living beyond earshot of a city is that Jenny and I got a lot of time to talk in the car. We left Benny still wide-awake with his grandma to give ourselves time to get to the late screening.
“What’s the name of the movie?” Jenny asked on the way.
“Sorry. I didn’t check.”
“I just hope it’s not too noisy. I need the sleep.”
Our talk soon turned to Benny and how we were going to get him to go to bed more willingly. We had tried everything the books and some well-meaning strangers told us; none of it worked. The latest advice we’d been given urged us to establish a clear and calm bedtime routine, something like a ritual, so that Benny would learn to recognize signals that the day was ready to close for business and he might kindly now make his way to the exit. If the ritual included quiet things he enjoyed, such as reading books and saying good night to his numerous teddies, then, we were led to believe, we would find that Benny welcomed the end of the day. Benny might not welcome it, but we certainly would.
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