‘The object that presented itself to the eyes of the astonished clerk, was a boy – a wonderfully fat boy – habited as a serving lad, standing upright on the mat, with his eyes closed as if in sleep ... “Sleep!” said the old gentleman, “he’s always asleep. Goes on errands fast asleep, and snores as he waits at table.”’1
I always enjoyed reading Dickens as a teenager. Once immersed in the fabric of his stories, my imagination could then run wild. Dickens was a great observer of human nature, utilising ‘humour, satire, exaggeration and in-depth analysis of psychology’ to convey the broad fabric of human life in 19th century London.2 Perhaps it is no surprise, as Dickens is considered the greatest writer in the English language since Shakespeare.2 Both writers were able to accurately describe particular behaviours of human population subgroups, sometimes long before they were investigated and categorised by medical investigators and clinicians.
The sleep disturbance described by Dickens was not considered in the medical literature to any extent until 40 years later in 1877, when Broadbent wrote in the Lancet:3
‘When a person, especially advanced in years, is lying on his back in heavy sleep and snoring loudly, it very commonly happens that every now and then the inspiration fails to overcome the resistance in the pharynx of which stretor or snoring is the audible sign, and there will be perfect silence through two, three or four respiratory periods, in which there are ineffectual chest movements; finally, air enters with a loud snort, after which there are several compensatory deep inspirations before the breathing settles down to its usual rhythm.’
Little subsequent progress was made until almost 80 years later, when a paper was published in the American Journal of Medicine, where, in honour of Charles Dickens, the term Pickwickian Syndrome was proposed to describe this condition.4 Even then, interest continued to grow rather slowly until the 1970s when the term sleep apnoea was first coined5 and, subsequently, when Sullivan first described the effectiveness of continuous positive airway pressure (CPAP) in 1981.6
As a medical student a generation ago, sleep apnoea was not on the radar. Only in more recent times, as sleep medicine became mainstream, with formal training and accreditation, has there been an effective referral path for general practitioners to follow when seeking relief for this group of patients. Interestingly, the programs were initially adult-oriented until recently with the arrival of paediatric sleep specialists. As this is a relatively new field, the paper by Nixon and Davey7 will provide a valuable update on the current state of understanding and management.
The evolution of paediatric sleep apnoea since Dickens’ time is an interesting counterpoint to the management of paediatric wheeze. Whereas the former was late in maturing, wheeze is in a post-mature phase and much of the dogmatism of more distant times (such as one wheeze equals lifetime asthma) has been overturned by new evidence. The distinctions between wheeze and asthma are perhaps more pronounced now than for many years. Fortunately, the paper by Oo and Le Souëf8 will help guide readers through the latest evidence.
Perhaps paediatric migraine lies somewhere between sleep apnoea and wheeze. Only in recent years has a clear and unequivocal focus on the pain relief needs of children finally arrived. Yet, the specific management of migraine has also become more focused and less dogmatic with the influx of the latest evidence. The paper by Sixsmith and Starr9 will help to provide a detailed, evidence-based discussion of the current state of play.
The development of evidence-based medicine has been consequent on careful examination of the evidence. But before studies can occur, careful observation of the human condition is required to accurately delineate the syndromes to study – those human characteristics that help define the illness pattern. Hence, no more feeling guilty when you curl up with a powerful novel. Spending more time relaxing with the latest fiction might just presage the next medical discovery.