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The Study of Human Sleep: a Historical Perspective Thorax: First Published As 10.1136/Thx.53.2008.S2 on 1 October 1998 S2 Thorax 1998;53(Suppl 3):S2–7 The study of human sleep: a historical perspective Thorax: first published as 10.1136/thx.53.2008.S2 on 1 October 1998. Downloaded from William C Dement Since this is an historic meeting which will brains of animals in 1875. The early descrip- address one of the most important clinical tions of the diVerences between brain wave issues in the field of sleep medicine, it is appro- patterns in awake and sleeping human beings priate to examine how we arrived at this by Hans Berger in 1929 only served to further moment. Accordingly, I will present a brief fix the notion of sleep as an inactive or “idling” review of the history of sleep medicine. I have state. addressed this topic on several previous occasions.1–3 In my view the history of sleep Phase 2: 1952–1970 medicine can be divided into five clearly Phase 2 was ushered in by the observation in demarcated phases. These are listed in table 1. 1952 that binocularly synchronous rapid eye movements occurred during sleep.4 This obser- Phase 1: before 1952 vation and data demonstrating an association I have designated the first phase, to some extent between the occurrence of rapid eye move- with tongue in cheek, as “prehistoric”. This ments and the occurrence of dreaming finally reflects the relative lack of scientific experimen- stimulated an intense interest in the study of tation involving sleep over the first half of the sleep for its own sake. 20th century and before. The subject of dreams The years after World War II saw the and dream interpretation probably received the unchallenged dominance of psychoanalysis in most attention. A great deal of the early sleep American psychiatry, and Sigmund Freud’s literature reported observations on sleep habits writings about dream interpretation and the and sleep characteristics in the service of com- underlying theoretical psychological structure paring and contrasting the data reciprocally to of “id” and “ego” made dreaming a central data describing the waking state. During this issue of unparalleled significance. In this “prehistoric” period nearly every biomedical atmosphere one can appreciate the excitement scientist assumed that sleep occurred when generated by the demonstration of a physi- sensory stimulation continuously bombarding ological marker for the occurrence of the brain during the day was rendered insuY- dreaming.5 The first complete descriptive cient to maintain a waking level of brain activity journey through the night in human beings— by the occurrence of the darkness and silence of that is, continuously recording brain wave night. patterns and eye movement activity throughout http://thorax.bmj.com/ It seems reasonable that this perspective, an entire night—was carried out in the labora- often called the “passive process theory”, tory of Nathaniel Kleitman at the University of would have made the study of sleep seem rela- Chicago. tively uninteresting. The notion that sleep was My personal excitement and interest in the the brain “turned oV” led to the erroneous newly discovered phenomenon of rapid eye conclusion that sleep could be regarded as an movements (REMs) was certainly not shared entirely homogenous state, and that a single by others. I toiled alone for about five years, observation could be generalised to the entire studying as many individual subjects as possi- sleep period. Finally, there was no tradition of ble to demonstrate the universality of the on October 2, 2021 by guest. Protected copyright. staying up at night to carry out scientific occurrence of REMs during sleep, the repeti- research except, of course, for astronomy. tive occurrence of distinct periods of sleep with There are some “prehistoric” scientific land- which REMs were associated, and finally the marks that are worth noting but which basic sleep cycle and characteristic all-night occurred far too early to be exploited by the sleep stage architecture.67It was probably not field of sleep medicine. For example, Jean until I demonstrated the REM deprivation/ Jacques d’Ortous deMairan demonstrated the compensation phenomenon in a study8 pub- persistence of circadian rhythms in the absence lished as The eVect of dream deprivation in 1960 of environmental cues in 1729. Jean Baptiste that other investigators began to investigate all- Edouard Gellineau published his landmark night sleep. The “pressure” that developed as description of the narcolepsy syndrome in REM sleep was prevented from occurring was 1880. The Scottish physiologist, Richard widely regarded as evidence supporting Caton, demonstrated electrical rhythms in the Freud’s theory that dreaming functioned as a Table 1 History of sleep medicine Phase 1 Prehistoric Stanford Sleep Phase 2 1952–1970 Exploring sleep; discovery of REM; journey through the night Disorders Clinic and Phase 3 1971–1980 Extending medical practice to include the sleeping patient; understanding the Research Center, determinants of daytime alertness Stanford University, Phase 4 1981–1990 New treatments; expanding and organising sleep medicine; operational and public policy implications Palo Alto, California Phase 5 1991–2000 Bringing the diagnosis and treatment of sleep disorders into the mainstream of society 94303, USA and the health care system W C Dement The study of human sleep: a historical perspective S3 “safety valve” for the release of instinctual Center was well known for its research studies energy. During the 1960s many investigators of narcolepsy, the Sleep Clinic received many Thorax: first published as 10.1136/thx.53.2008.S2 on 1 October 1998. Downloaded from participated in a detailed and quantitative referrals of putative narcoleptics from all over description of human and animal sleep includ- the United States. It will be no surprise that the ing changes related to diVerent stages of devel- excessive daytime sleepiness of the majority of opment. Perhaps the major advance was the these individuals was due to obstructive sleep concept of the duality of sleep—that is, sleep apnoea. Literally within a few months, it was consists of two entirely diVerent organismic completely obvious to us that the diagnosis and states, REM sleep and non-REM sleep. Added treatment of obstructive sleep apnoea (OSA) to this was the elucidation of the brain stem would be a very important item in the future of control of sleep states including the neural sleep medicine. Furthermore, most of the OSA mechanisms of active motor inhibition during victims seen at Stanford in those early days REM sleep. were very far advanced and we were extremely Obstructive sleep apnoea was discovered in impressed by the severity of the clinical Europe in 1965 by two separate groups, complications. The case history of our first Gastant et al 9 and Jung and Kuhlo.10 Kuhlo et al patient who received a tracheostomy and the are credited with performing the first tracheo- consequent reversal of severe hypertension is stomy with the intention of bypassing airway described in detail elsewhere.14 obstruction that occurred during sleep in the By November 1972 we had organised our upper airway of these very obese patients.11 The voluminous new clinical knowledge and were observations a decade earlier that led to the able to begin teaching others. A clinical description of the “Pickwickian syndrome”12 discipline can only be said to exist if it included the misattribution that the associated represents an organised body of knowledge, daytime somnolence was caused by hypercap- and if this body of knowledge can be effectively nia. It is not clear what would have happened if taught. Accordingly, the first sleep medicine an Italian neurologist, Elio Lugaresi, had not continuing medical education exercise that become very interested in obstructive sleep took place on 29 November 1972 can be desig- apnoea which he called “hypersomnia with nated as the birthday of the field of sleep periodic breathing”. He pursued the problem medicine. A replica of the original brochure with unusual zeal, although he did not publish announcing a clinical course on “Sleep his seminal study13 documenting an association between snoring and hypertension until 1975. Phase 3: 1971–1980 The beginning of phase 3 occurred when Stan- ford sleep researchers formally extended the practice of medicine to include the sleeping patient. There was a wise physician who once http://thorax.bmj.com/ said: “The practice of medicine ends when the patient falls asleep”. His intention was to draw attention to an important gap in medical prac- tice. However, it is my impression that the dis- enfranchisement of the sleeping patient grew out of the general attitude that sleep repre- sented a boundary that physicians should not cross. In other words, the practice of medicine should end when the patient falls asleep. on October 2, 2021 by guest. Protected copyright. The Stanford University Sleep Disorders Clinic for the diagnosis and treatment of patients with sleep problems was launched in the summer of 1970. We had studied several patients with Pickwickian syndrome and noted the periodic breathing. However, our major clinical interest was managing patients with nar- colepsy and developing diagnostic and treat- ment approaches for individuals complaining of insomnia. In the summer of 1971 Dr Vincent Zarcone and I attended the First International Congress of the APSS in Bruges, Belgium where we recruited Dr Christian Guilleminault to join us at Stanford. He arrived in January 1972 and immediately insisted we pay more attention to sleep disordered breathing. Although we were charging patients for our services, our early survival depended almost entirely on research grants. Early in 1972 the recording of respiratory and cardiac variables as part of the all-night sleep test (later to be Figure 1 A replica of the original brochure announcing a called “polysomnography”) became routine. clinical course on “Sleep Disorders: a New Clinical Since the Stanford University Sleep Disorders Discipline”. S4 Dement Disorders: a New Clinical Discipline” is and sleep disorders, particularly obstructive displayed in fig 1.
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