In a patient showing a typical pickwickian syndrome a study was made of respiratory functions and arterial gasometry, with polygraphic registrations carried out during the day and at night in an attempt to evaluate sleep, respiration, blood oxyhaemoglobin and CO2 concentration of the expiratory air.
It was demonstrated that, at the onset of an authentic pickwickian syndrome, the symptomatology may be confined to obesity and diurnal drowsing episodes of the type described by Dickens in his novel. This means that the permanent alveolar hypoventilation regarded by some authors as an indispensable feature of the syndrome,
In the patient under discussion, the numerous episodes of diurnal slumber which characterized his condition and occurred while the blood oxyhaemoglobin saturation and alveolar CO2 concentration were entirely normal, cannot be explained on the basis of hypoxia and hypercapnia as suggested by a majority of authors. One must resort to other hypotheses, bearing in mind that the one does not necessarily exclude the other.
A first hypothesis suggests that the subject drowses during the day as a result of a primary disturbance of centres in the brain stem which regulate wakefulness and sleep by a mechanism not yet understood. According to this hypothesis, we are confronted with some sort of narcolepsy.
A second hypothesis holds that the subject drowses during the day because he does not sleep sufficiently at night as a result of an exaggeration of the physiological phenomenon of hypnic hypoventilation. Nocturnal polygraphic registrations disclosed respiratory pauses which occurred in the initial phase of sleep, quite apart from hypotonia of the muscles of the floor of the mouth, so rapid and pronounced that the tongue moves back and causes the obstructive apnoea responsible for a hypoxia which arouses the subject, who returns to sleep after a short while. The cyclic repetition of arousal and slumber reduces nocturnal sleep to 2–3 h a night. This loss of nocturnal sleep is held responsible for the diurnal somnolence. Unfortunately the subject's diurnal sleep is disturbed even more than his nocturnal sleep because the slightest slumber immediately produces episodes of central or obstructive apnoea.
Regardless of the respective values of these two hypotheses, the authors are convinced that the majority of individuals suffering from the pickwickian syndrome drowse during the day and sleep badly at night because of a primary disturbance in the wakefulness-sleep regulation which as such is based on their obesity. This affords an obvious explanation of the established fact that the only way to suppress hypnic disturbances in pickwickian patients is to have them lose weight.
