The Slumbering Masses: Sleep, Medicine, and Modern American Life

1. The Rise of American Sleep Medicine: Diagnosing and Misdiagnosing Sleep

27 1 .................. The Rise of American Sleep Medicine Diagnosing and Misdiagnosing Sleep Definitions of sleep were plentiful in the nineteenth century. For instance, Henry Lyman begins his Insomnia and Other Disorders of Sleep, “Natural sleep is that condition of physiological repose in which the molecular movements of the brain are no longer fully and clearly projected upon the field of consciousness.” Lyman was adding precision to William Hammond’s definition, which he proposed in his Sleep and Its Derangements: “The immediate cause of sleep is a diminution of the quantity of blood circulating in the vessels of the brain, and . . . the exciting cause of periodical and natural sleep is the necessity which exists that the loss of substance which the brain has undergone, during its state of greatest activity, should be restored.” Hammond, in his turn, was adding to Robert Macnish’s definition of sleep, which appeared in the first modern monograph on sleep, The Philosophy of Sleep. Macnish writes, “Sleep is the intermediate state between wakefulness and death: wakefulness being regarded as the active state of all the animal and intellectual functions, and death as that of their total suspension.” Compare this with Donald Laird’s 1930s discussion of why humans sleep, approximately a century later: “Why people sleep may never be known. And what sleep is may never be satisfactorily stated. Sleep, in these respects, is like life itself, of which it plays so important a part; the biologist cannot tell what life is, but this does not prevent the physician from saving it and prolonging it.” One of the characteristics of contemporary conceptions Rise of American Sleep Medicine 28 of sleep is that it is inscrutable, that it remains a mystery to even those whose medical practice focuses on the remedy of its disorders. Contemporary sleep medicine was invented in the 1950s. The beginning date of modern sleep medicine can be easily identified: it occurred when physicians created the category of what was then referred to as “Pickwickian syndrome,” named for a character in a Charles Dickens novel, but has been called obstructive sleep apnea since the 1960s. Ten years later, William Dement began to work earnestly on understanding narcolepsy, and his efforts at the Stanford Sleep Disorder Center helped to move sleep medicine further toward disciplinary consolidation. In the late 1970s and early 1980s a host of other sleep-related disorders came to be nosologically defined, and by the end of the 1990s, with the wider availability of pharmaceuticals and prosthetic treatments, sleep medicine was a wellde fined subdiscipline of American medicine. The existence of a recognized subdiscipline means many things: institutional and financial support, annual meetings and academic journals, advocacy and ethical review boards, and the need to expand the capabilities of the discipline further. Whereas this attention to sleep within medicine happened in relatively piecemeal fashion from the 1950s through the 1980s, by the beginning of the 1990s, it was intensifying. In this chapter, I examine two formations: the contemporary sleep clinic and its workings, and the rise of sleep medicine in the United States, from the 1930s through the turn of the twenty-first century . In telling this history, I am interested in the ways that normal sleep has been defined implicitly through defining pathological sleep. Sleep has come to be known not by what it is but by what it is not. Sleep has long been defined by its negative status (it is not wakefulness , nor is it coma or death), and this negative status allows for an interpretive flexibility in the clinical understanding of sleep and its variations. This ambiguity allows negotiation within sleep medicine and science, changing the objective nature of sleep, and also allows for the expansion of sleep’s importance in its increasing association with other concerns. Building upon the analysis of sleep’s definition, I describe the sleep clinic where I conducted my fieldwork and focus on two cases of clinical misdiagnosis , in which physicians at other clinics, as a result of expansion in the discipline, diagnosed patients as having sleep disorders they did not have, and the later rediagnosis of these patients by the physicians with whom I conducted my fieldwork. I use these vignettes to explore how 29 Rise of American Sleep Medicine the rise of sleep medicine, with seemingly easy treatments and straightforward nosologic categories, has led to a rise of misdiagnosis and...