Dickens' "Fat Boy:" A Classic Case of What?
© Kerrin Leon White
But does Joe fit the modern concept of this disease? Let’s take a look at how Dickens depicted him.
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.
