Sleep apnoea and Dickens

Hannah Devlin reported for The Guardian of 16 May 2018:

“Fat boy Joe, the messenger in The Pickwick Papers, is “always asleep… he goes on errands fast asleep, and snores as he waits at table”.

The chubby servant’s constant snoozing becomes a running joke in Dickens’ first novel, but the character also served as an unlikely inspiration for a breakthrough in sleep science. 

After observing similar symptoms in an obese poker player who fell asleep holding a winning hand, in 1956 American doctors named “Pickwickian syndrome” – now known as obesity hypoventilation syndome – in which severe obesity causes breathing problems that lead to daytime sleepiness.

The example is one of several highlighted in a new exhibition Charles Dickens: Man of Science where the author’s forensic descriptions of illness anticipate or even inspire later advances in medicine…”

From: Kryger M. “Charles Dickens: impact on medicine and society”. J Clin Sleep Med (2012):

“…The symptoms described were so striking that physicians speculated that Dickens was describing a syndrome that had not made its way into the medical literature. For example, the “fat boy” was mentioned in the context of sleepiness and obesity by Sir William Osler, in Principles and Practice of Medicine. On the 100thanniversary of the publication of Pickwick Papers, there were speculations about what disease the fat boy might have had. Over the years endocrine disorders (hypopituitarism, hypothyroidism), hypothalamic disorders, and Prader-Willi Syndrome have been postulated. (It is unlikely that Joe had Prader-Willi syndrome in which hypogonadism is prominent; Joe did have an interest in the opposite sex.)

In 1956, in what may have been the most widely cited single case report, (which we would now call an anecdote), the term “Pickwickian syndrome” entered the medical lexicon. Burwell and colleagues, did not, however, get it right. They described the case of an obese gentleman who fell asleep holding a winning hand of cards in poker. The patient was found to be hypoventilating during the daytime, and he had the features of right heart failure. The hypothesis raised in this case report was that abnormal chemical drives to breathe caused hypoventilation, and that the resultant hypercapnia was responsible for the daytime sleepiness. It only became apparent about a decade later, when researchers studied sleeping patients that the sleepiness was, in fact, caused by repetitive episodes of apnea during sleep which caused multiple awakenings. With time, it also was found that patients with sleep breathing disorders may have normal drives to breathe, without hypercapnia or right heart failure, and that Charles Dickens had described a subset of sleep breathing disorders which is still called by many the Pickwickian syndrome, or more recently, the obesity hypoventilation syndrome. Thus, it is not an exaggeration to say that Charles Dickens played a pivotal role in the development of the field of sleep medicine.

It is now known that sleep breathing disorders affect somewhere between five and ten percent of the population and that it is likely that some important historical figures including at least one US President (William Howard Taft) had a sleep breathing disorder…”

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