By Dickens

The first reports in medical literature of what is now called obstructive sleep apnoea only date from around 1965. However the clinical picture of this condition has long been recognised as a character trait, without an understanding of the disease process.

If you are a Charles Dickens enthusiast you may have heard of his 1836 publication The Posthumous Papers of the Pickwick Club (better know as The Pickwick papers). Written for publication as a serial, The Pickwick Paper’s main character is Mr. Samuel Pickwick who establishes the Pickwick Club. Along with three other “Pickwickians”” he undertakes coach journeys through the remote English countryside in order to discover more about life. The writings describe their adventures and the many distinctive characters they meet.

One of these characters is Joe the “fat boy” who consumes great quantities of food and constantly falls asleep in any situation at any time of the day. Joe’s sleep problem is the origin of the medical term Pickwickian Syndrome which ultimately led to the description of Obstructive Sleep Apnoea.

It was famous early 20th century physician William Osler, a prolific author and collector of books, who first coined the term Pickwickian Syndrome. He must have been a fan of Dickens (as a practical joker the humour probably appealed to him). Osler forwent his aim to be an Anglican Minister to pursue his interest in Medicine and one of his greatest contributions was the establishment of medical residency where medical students learn from seeing and talking to patients. Osler lent his name to a number of diseases and symptoms, as well as having buildings named after him.

Wikipedia cites that “the early reports of OSA in medical literature describe individuals who were very severely affected, often presenting with severe hypoxaemia, hypercapnia and congestive heart failure. Tracheostomy was the recommended treatment and although it could be lifesaving, postoperative complications in the stoma were frequent in these very obese and short- necked individuals”.

Pickwickian Syndrome is better known under the descriptive term Obesity Hypoventilation Syndrome (OHS). OHS is a form of sleep disordered breathing which is defined as the combination of obesity (body mass index above 30 kg/m2), hypoxia (falling oxygen levels in blood) during sleep and hypercapnia (increased blood carbon dioxide levels) during the day, resulting from hypoventilation (excessively slow or shallow breathing). Two subtypes are recognized, depending on the nature of disordered breathing detected on further investigations. Most people with obesity hypoventilation syndrome have concurrent obstructive sleep apnoea - around 90% in fact. This is confirmed by the occurrence of 5 or more episodes of apneoa, hypopnea or respiratory-related arousals per hour (high apnea-hypopnea index) during sleep. "Sleep hypoventilation syndrome" accounts for the other 10%. This requires a rise of CO2 levels by 10 mmHg (1.3 kPa) after sleep compared to awake measurements and overnight drops in oxygen levels without simultaneous apnoea or hypopnoea.

Weight loss (diet, exercise, medication, surgery) is the most important treatment of OHS. CPAP alone is effective in more than 50% of people with OHS. For severe low oxygen levels Bi PAP or O2 therapy may be required or as a last resort a tracheotomy (with or without mechanical ventilation) – just like back when.

So even if it was only in the 1960s that various discoveries were made that led to the distinction between obstructive sleep apnea and sleep hypoventilation, one hundred and thirty years earlier, Dickens’ would have based his portrayal of Joe the “fat boy” on an observation he had made of someone with OHS, even if he didn’t know that.

Irene