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Sleep Disorders - Dickens' "Fat Boy:" A Classic Case of What?
Home > Applied sciences > Medicine and health > Diseases
Author: Kerrin Leon White
Published on: August 25, 2000
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Charles Dickens (1812-1870) populated his compendious work with a throng of memorable characters, one of whom has won him a place in the annals of medicine. He accomplished this with the figure of a fat, sleepy servant boy named Joe, who made one brief entrance in Chapter 54 of The Pickwick Papers (1837). This comic caricature survived in medical lore as a classic case of sleep apnea, “the Pickwickian Syndrome.”
But does Joe fit the modern concept of this disease? Let’s take a look at how Dickens depicted him.
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[fatboy-1.gif] A clamor of incessant knocking besieged Mr. Pickwick’s lodgings. Once opened, the doorway revealed a “wonderfully fat boy” who stood “upright. his eyes closed as if in sleep,” his expression one of “calmness and repose Asked his business, he said nothing, but “nodded once, and seemed . . .to snore feebly,” immobile through three repetitions of the question. Then, as the door was about to close on him, he “suddenly opened his eyes, winked several times, sneezed once, and raised his hand as if to repeat the knocking.”
In the present, 163 years later, we recognize that many people with sleep apnea fall asleep in inappropriate situations—in a theater, at the dinner table, even while driving.
However, we do not expect to see a person with sleep apnea falling asleep while knocking violently on a door. If he did, the overall muscular relaxation of sleep would cause him to collapse, or at least to sway conspicuously. Sleep onset during vigorous activity might occur in a person with narcolepsy. Likewise, the dissociation of sleep elements—intact postural muscle tension despite loss of awareness—suggests something akin to narcolepsy, or perhaps a petit mal seizure.
Note also that, while snoring is typical of a person with sleep apnea, it is usually stentorian, not a scarcely audible murmur!
The extraordinary obesity of the boy--whom Dickens describes as fatter than a carnival freak-- defines him as much as his sleepiness. Although we now recognize an association between overweight and sleep apnea, we also realize the association is not obligatory. Here we perceive the early emergence of a stereotype that has subsequently contributed to failure to consider the diagnosis of sleep apnea in individuals without obesity.
We learn that Joe’s master told him to knock without stopping until answered, so that he would not fall while waiting for the occupants to answer the door.. Alas, the master’s familiarity with his servant fails to encompass the realization that he can easily fall asleep in the midst of knocking. We can forgive Dickens such a small inconsistency.
After other characters converse for several pages, Joe, asleep again, attracted renewed attention. He had to carry a message. He arrived, sleeping once more, but awakened when the carriage stopped, “giving himself a good shake to stir up his faculties,” apparently without complete success. He unwittingly, without knocking, burst into a scene of physical affection that evoked at the same time “an interjection” from the boy, a scream from ladies, and an oath from a gentleman.
Joe, “terrified,” could scarcely speak, while the occupants made exclamations of “wretched creature” and “stupid creature,” and commanded him to leave the incriminating scene. Still, during “some minutes” of discussion among the others, he fell asleep yet again. The others having decided to bribe Joe into secrecy awakened him with kind words and five shillings.
His “perception being slow,” Joe first reacted with puzzlement, then grinned, giving “a horse-laugh. . .for the first and only time in his existence.”
What this means in terms of Joe’s usual state of mind remains unclear. We might suspect depression, common in sleep disorders, except for his unexpectedly mischievous behavior that follows.
Invited to share a meal, Joe betrayed his gluttony, showing “rapture” at the variety of dishes on the table. Then he paused before eating to express admiration of one lady1s appearance, and flirt briefly with the other—a gallantry that provoked their reproof.
As the ladies prepared to leave, Joe “stretched out his arms to ravish a kiss; but, as it required no great agility to elude him, his fair enslaver had vanished before he closed them again; upon which the apathetic youth ate a pound or so of steak with a sentimental countenance, and fell fast asleep.”
This picture of a voracious satyr amuses, but should strike the one reading with medical interest as incongruous with that of a real sufferer from sleep apnea. The overweight that often occurs with sleep apnea has scant relation to monstrous appetites. Reduced activity due to sleepiness, the futile effort to stay awake by eating or drinking, and the hormonal changes resulting from disrupted sleep--all appear to contribute. Moreover, far from being hypersexual, such people often suffer impaired potency and libido. Joe1s inappropriately amorous behavior, though explicable in the context of the ladies’ own wily dealings, does not represent anything typical of men with sleep apnea. The same applies to his tomfoolery that follows.
In the presence of all the characters except the suitor of the previous scene, Mr. Snodgrass, Joe showed off his conspiratorial complicity with the ladies--with “smirks, and grins, and winks.” Later he poked a “sharp instrument” into Mr. Pickwick’s leg, to gain his attention. They others thought him intoxicated or “deranged.” He had reacted with alarm to his unexpected discovery of Mr. Snodgrass in the adjacent bedroom.
Thereafter a happy ending to the chapter omits further mention of Joe, who departs from the novel into medical fame.
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So, what disease does Joe have? Sleep apnea? Narcolepsy? He more closely resembles the latter, but the real answer is: Joe has no known disease. His author has merely drawn him to gain the reader’s attention and amusement. Dickens has no interest in accurate portrayal of a medical condition scarcely known at the time. As in all works of fiction, characters need only convince the reader enough of their possible existence to maintain suspension of disbelief; otherwise they need conform to no principles of diagnosis. There is nothing to require that a character like Joe exists in reality.
Yet the problem here is not that Dickens failed to depict in accurate detail an actual disease. It is that doctors, taken with his artful prose, should use a fictional model for a real condition. Moreover, the error goes beyond the confusion of fiction and reality, to encompass the use of “classic cases” to define diseases of many types.
When a disease is first described, often as a report of one or a few cases, that picture by virtue of its primacy tends to become “classic,” which means that it establishes the defining features of the disorder.
In actuality, as we later gain knowledge of the broad range of manifestations possible for any systemic disease, and the wide variety of people it can affect, we also come to realize that the classic case represents a singular type, neither the paradigm nor the modal pattern. Nevertheless, a “cartoon” picture of the disease carries forward in the minds of diagnosticians, to form our stereotype image of how a person with that diagnosis should look. Like most stereotypes, this proves fallacious. Moreover, it deprives people who fail to fit the pigeonhole—for example, a skinny person with sleep apnea—to get the deserved evaluation.
Let me conclude with one more example. In epidemiological studies, men with sleep apnea outnumber women, perhaps by 2:1. However, many studies that specify no selection of subjects to exclude women, describe subject samples devoid of women, or with far fewer women that prevalence studies would lead us to expect. Since such study samples usually derive from clinical populations, their skewed samples point to the relative neglect of people who fail to fit the “Pickwickian” or other stereotypes—a failing that affects a large proportion of people with this widely undiagnosed and untreated disease.