How the Rockettes Helped Shape Sleep Medicine

After seeing the Rockettes with my family last week, I was reminded of a story in Dr. William Dement’s classic book, The Promise of Sleep. Just after receiving his Ph.D., Dement moved to New York city to work at Mt. Sinai Hospital in the late 1950s. He and his wife found a large apartment on the Upper West Side of Manhattan, which doubled as a research lab. 

About 10 years earlier, Dement had been a medical student doing research in Chicago with Drs. Aserinsky and Kleitman, the discoverers of REM sleep. Up until then, Dr. Aserinsky refused to allow overnight sleep studies on women. Finally, he relented and allowed Dement to test his then girlfriend, as long as a chaperone was present. He found that a woman can also have periods of REM sleep. 

Sleep studies in women were very sparse in that era until Dement moved to New York City. He began to recruit women to be studied in his apartment, funded by a National Institute of Health (NIH) grant. One of the first people to respond to his ad was a Barnard student, who was also a dancer for the Rockettes. She in turn referred other fellow Rockettes, who were happy to get paid for sleeping. Dement describes a nightly stream of women in theatrical makeup, asking the doorman for Dr. Dement’s apartment. The next morning, the women would leave, sometimes along with an exhausted and unshaven Howie Roffwarg, a psychiatry resident at Columbia who monitored the nightly studies. 

As you can see, the Rockettes were instrumental in the basic understanding and development of sleep medicine.

Dement describes lots of other fascinating stories and details on the history of sleep medicine. Not only is his book worth reading, it will also give you a good basic understanding of sleep disorders in general.

Besides Dement’s book, what other books on sleep do you recommend? Please type in your answers below in the comments section.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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13 thoughts on “How the Rockettes Helped Shape Sleep Medicine

  1. The books I keep going back to are “Restless Nights: Understanding Snoring and Sleep Apnea” by: Peretz Lavie; “Deadly Sleep: Is Your Sleep Killing You?” by: “Mack D. Jones MD”; and “Sleep Interrupted” by: Steven Y. Park M.D. However most of my study time concerning sleep apnea and related conditions is spent in the research papers I find through such sites as PubMed, Google Scholar, and PLOS.

    While I very much appreciate the research that has been done by Dement and others I also realize that the compromises that were made to basic science in those days keeps us far away from knowing how people actually sleep in their own homes night after night. Please know that I do understand that he simply used what he had. Big bulky equipment, very expensive, and in need of the constant aid of a competent technician. But I am disappointed to see that the much advanced technology that we do have today has not been taken advantage of.

    I believe it would be easy to develop the equipment needed to do the critically needed long term studies IN THE HOME and so obtain the very basic data we need to understand what is actually happening with people as they naturally sleep. “In the lab” studies are not even close to valid indicators of how people sleep naturally. I do not sleep in a lab and know of no one who does.

    With the micro-circuitry of today along with the advances in materials I believe that the EEG could be facilitated by an automatically fitting hat less intrusive than a shower cap. Indeed something more like a set of headphones (without the headphones) would likely do to capture the signals they use in most polysomnograms. Perhaps the same “hat” could be somewhat expanded to grab the muscle movement signals near the eyes. All of the sensors can be made wireless and comfortable I do believe. The current pasts they use for good electrical contact need to be replaced with a much more human compatible “bio-gel” which the skin likes and that also washes off easily. And certainly there are many new “markers” we can be looking to (e.g. heart rate variability).

    Yes we absolutely need to move the studies into the home, use wireless sensors, make the system compatible with daily use without the need for “professional application” (that is applied by the user in his or her own home every night). And then we need to centralize the monitoring using the Internet or simply the recorded data. And we absolutely need such studies to run for many months or years looking at individuals and groups. Sleep is not the same any given night.

    I believe that sleep medicine is yet so ineffective because it flies so blind.

  2. There are some that believe that CPAP is so innocuous that it is best if CPAP was to be put OTC and people could just try it to see if it has any subjective benefit.
    The spectrum of “proposals” is wide.

  3. In your notion of performing more and more imperfect tests, what would you trust?
    EEG alone?
    EEG + EOG?
    EEG +EMG?
    EEG+EMG+EOG
    Non-EEG metrics of “sleep”

    Of course just throwing out technology to do something as nebulous as “sleep” has quite the spectrum of valid techniques.
    Why not just rely on the current bevy of watch-worn consumer devices?
    Are they good enough?
    Are they even measuring the same “sleep” as gold standard measures of sleep?
    Do we want to measure these new variables to some standardized metric, or will we also have to contend with varying degrees of proficiency in the technologies available to consumers?
    Polysomnography is standardized and that is why it has become the gold standard. Polysomnography affords the patient of a controlled environment. Remember they are coming to the physician COMPLAINING about their sleep that they are getting in the bedroom. Why do people think it is best to test them in this possibly troublesome environment with spouses/partners/pets, kids, neighbors, heating, noises etc, etc. that are not controlled. Polysomnography is a controlled test: Where it is given, how it is given, how it is scored.
    If the technology is non-consistent (watch-worn devices) then how can you pick apart that variability which is due to technology or the patient or the environment?

    Moving this into the home for “diagnostic testing” is repleat with un-voiced issues. Why test in an environment the patient is already complaining about?

    I don’t get it. It is NOT better.

  4. One of the basic principles of science is that your test method must not change what is being tested. To the extent that it does your test is not valid.

    For example if you wanted to measure the temperature of some potato salad in your refrigerator, well now, they may have a much more accurate thermometer in a laboratory somewhere and also a very nice refrigerator, but tests made from the refrigerator in that laboratory in no way represent what is happening in your refrigerator at home. And it is the food from your home refrigerator that will actually affect your health.

    So we still have no idea of how people sleep in their own home in their own bed night after night.

    I am not talking about just part of the polysomnogram. I am talking about developing new equipment that can be self administered and worn night after night in the persons own home to bring the polysomnogram fully into the home long term.

    Only when this is accomplished well we know how people sleep in their own home in their own bed night after night.

    I believe that sleep medicine performs so poorly because flies so blind.

  5. Tod, your analogy is incorrect. The salad dressings are not sleep. We do not think salad dressing spoils differently in different refrigerators if kept at the same temp. Your logic is faulty.

    Polysomnography helped define sleep. The stages of sleep and the architecture of nightly sleep. You would have no idea what is happening at home if not to measure it against a gold standard “ruler” which is the polysomnographic definition.
    Just wanting to bash polysomnography because it is not a ubiquitous procedure is peurile. The Gold standard findings have to serve any new science that can afford nightly “sleep” recordings. one must start from somewhere. A first step to such a new easy to apply (bw you are not the first to desire this) is to get everyone involved in the manufacture of consumer based sleep devices to be speaking the same language. This meeting on Thursday at CES in Las Vegas is a big start.
    http://www.cesweb.org/Conference/Conference-Tracks/Technology-Lifestyle/LIFEST07_Measuring-Sleep-with-CEA-and-NSF.aspx
    “CEA has partnered with the National Sleep Foundation to define common performance requirements and core sleep metrics for wearable sleep monitors. These standards will define common terminology. Learn about CEA standards activities related to health and fitness wearables.”

    Only when the devices available to the public are validated against known measures can they then have rationale basis for what they claim. Otherwise who knows what any one device is truly measuring. There are devices that touch the body and ones that do not. Are they actually measuring sleep similarly?

    To lament that polysomnography has not reached every one of the millions that has OSA, let alone the 10’s of millions that have some sleep disorder is not cause to throw the baby out with the bathwater.

  6. First of all special thanks for mentioning Dr. Dement’s book, “The Promise of Sleep”. I am finding it a useful and wonderfully enlightening read.

    Concerning the polysomnogram I have no desire to throw the baby out. Simply we need for the baby to grow up. That starts with doing real science which must see the measurements taken in the true native environment of the sleeper. In their own home in their own bed. The only way.

  7. Tod and Claude,

    Thanks for contributing an interesting discussion. I agree that future sleep study technology must be compared with formal PSGs, but at the same time, we need to take advantage of technological advances to redefine how we measure sleep. The formal PSG was developed with the technology of the 50s and 60s. If we could start fresh and develop the ideal sleep study, I’m sure that we can have minimal leads and intrusiveness that Todd talked about.

    For example, the original PSG used oral thermistor, which is very old technology. But because all of our normative data is based on this technology, we continue to use it while scoring. Even the concept of the AHI is very outdated. I don’t care much about the AHI anymore. I frequently find people who obstruct dozens of times every hour with tiny airways and an AHI of 0.

    I’ve also had many patients complain to me that the sleep study was the worst night of sleep ever. Ideally, there should be no intrusive leads or monitors on your body while you sleep. You should also be allowed to sleep in your own bed, in your normal sleep position. I think that with advancing technology we will be able to accomplish this task, but we also need to change our scoring systems to accommodate for these new technologies.

    One comment about changing the outcome of what we can measure: During last year’s sleep meeting in Minneapolis, I was given a sample home unit to try at my hotel. It was your typical level 3 home unit. What I found was that the nasal cannula caused my nose to get so stuffy that I couldn’t sleep at all. It also caused a number of more apneas than what I was expecting. This is in line with studies showing that nasal congestion alone can sometimes aggravate apneas, but more importantly, causes partial obstructions that produces sleep fragmentation and poor sleep quality.

  8. Steven,
    I too have had the desire to move the field forward. In 1990 I started publishing on a simple, unitary, single EEG channel algorithm for a new sleep/wake metric. http://www.z-eeg.com It is open-sourced as I informed the attendees in Germany in 2005.
    http://www.sleep-wake.com/z-ratio_Presentation.ppt
    http://www.zomnography.swf
    We cannot just jump to new technology without having to reinvent the total wheel,spoke, and axle.
    We can jump to new technologies by leveraging our knowledge of the old technologies. not…throw the baby out with the bathwater.

  9. Thanks again Dr. Park for the book recommendation. I have the audible version but will also purchase probably a used book to start using the “sleep camp” notes to improve my own sleep.

    I think we do best come to admit to ourselves that not knowing how we sleep in our own beds in our own houses night after night also means that we do not know enough about sleep to say we understand it. Let alone treat it. The “baby” was never fully formed. That is where we are. Doing the basic research in a truly scientific way is the only cure for this lack. The tainted data that we have gathered needs to fall away and a new understanding based upon good method needs to come to be.

    We need to start over and learn to do sleep testing from the ground up.