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Obesity Hypoventilation Syndrome (OHS)
(wikipedia) The name Pickwickian came up after 119 years, when in 1956 Dr. C.S. Burwell and colleagues published a medical case report titled “Extreme Obesity Associated With Alveolar Hypoventilation a Pickwickian Syndrome.” After quoting Dickens’s description of the fat boy the authors went on to describe their patient, a 51-year-old business executive who stood 5 feet 5 inches and weighed over 260 pounds (118 kg): (He) entered the hospital because of obesity, fatigue and somnolence…The patient was accustomed to eating well but did not gain weight progressively until about one year before admission…As the patient gained weight his symptoms appeared and became worse..he had often fallen asleep while carrying on his daily routine…on several occasions he suffered brief episodes of syncope (fainting) Persistent edema of the ankles developed… Finally an experience which indicated the severity of his disability led him to seek hospital care. The patient was accustomed to playing poker once a week and on this crucial occasion he was dealt a hand of three aces and two kings. According to Hoyle this hand is called a “full house.” Because he had dropped off to sleep he failed to take advantage of this opportunity. [Italics original]. A few days later he entered…hospital.  References * Bicklemann AG, Burwell CS, Robin ED, Whaley RD (1956). “Extreme obesity associated with alveolar hypoventilation; a Pickwickian syndrome”. Am. J. Med. 21 (5): 811-8. PMID 13362309.
PrintEmail Taft and Pickwick Previous Page Next Page In This Article Abstract and Introduction Materials and Methods Taft’s Professional Life Taft’s Adult Health Into Middle Age: 1874 to 1903 Taft’s Health as Secretary of War: 1904 to 1908 Taft’s Health as President: 1909 to 1913 Taft’s Health after the Presidency: 1913 to 1930 Did Taft Have Sleep Apnea? Was Taft Disabled? Medical Science, Taft, and the Physicians Was Taft Impaired? Taft’s Place in History Figures References Did Taft Have Sleep Apnea? Taft had three major risk factors for OSA :he was male, severely obese, and had a “short. . . generous” neck.[39(p28)] His size-54 pajamas had a neck size of 19 inches. His body habitus exhibited central obesity (Fig 4). Click to zoom Figure 4. (click image to zoom) Taft in 1908. Courtesy of the Library of Congress. Taft had two signs of OSA: excessive daytime somnolence and snoring. He may also have been polycythemic: his face was described as “ruddy”[13(p161)] and “florid.”[6(p159),9,39(p28)] Systemic hypertension is a known complication of OSA, albeit common in the general population. Most importantly, Taft’s somnolence correlated with his weight. Taft’s remarkable weight loss after the presidency produced an equally remarkable improvement in his somnolence, blood pressure and, likely, survival. In October 1910, President Taft was 53 years old, weighed 330 pounds, and snored. With these data, the model of Viner et al predicts a 97% chance that Taft had sleep apnea, defined as an apnea-hypopnea index > 10/h. The nature of Taft’s sleeping difficulty in 1913 is unclear. Although OSA may masquerade as insomnia, heart failure is another possibility, given Taft’s “weak heart” and “panting for breath at every step.” Sleep disturbances such as orthopnea, paroxysmal nocturnal dyspnea, Cheyne-Stokes respiration, and central sleep apnea are associated with heart failure. Any combination of hypertension, obesity, and OSA could have caused heart failure. The reasons for his transiently decreased somnolence in June 1909 are unclear; there are reports of exercise without weight loss improving sleep apnea. Taft lacked the cardinal manifestations of two other syndromes causing excessive daytime somnolence: periodic leg movements of sleep and narcolepsy. A third cause, the obesity hypoventilation syndrome (OHS), cannot be excluded without blood gas measurements. Most patients with OHS have sleep apneas, but the defining feature is hypoventilation while awake and asleep. Taft lacked other signs of OHS, such as cyanosis[6(p839)] and pedal edema.[6(p789)] OHS has been known as the “Pickwickian syndrome” since 1956. Before (and after) the noso-logic separation of OSA from OHS in 1965,69,70 it was common to call any sleepy obese patient “Pickwickian.” Biographers have entertained whether Taft had Pickwickian syndrome,[39(p126),71] but more strongly hold that a psychological need to escape anxiety and strife caused his sleepiness.[39(p126),44] This seems unlikely because Taft’s somnolence was initially distressing, was involuntary, correlated better with his weight than his happiness, and was so profound that other psychopathology would likely have been manifest. Thus, I conclude that OSA is the most probable explanation for Taft’s hypersomnolence. Except for periods associated with successful dieting (1906 to mid-1908, and perhaps briefly in 1909), he was likely afflicted from approximately 1900, when he started gaining weight in the Philippines, into 1913, when he started his post-presidency weight loss. He appears to have become symptomatic at approximately 300 lb. Based on Taft’s history of falling asleep during tasks requiring active attention, such as card playing and signing documents, he would be classified as having severe OSA syndrome.