BIL snores. Is he Pickwickian?

My brother in law (BIL) has joined the jobless - the vortex of sub-prime debacle has sunk the hedge fund he managed. But please don’t pity him: he is without a job but not without money. Unlike a side-street plebeian, this Wall Street prince stays rich even when unemployed.

BIL - though ailing from derivatives deprivation - is now blessed with free time to reflect on the genesis of the hedge fund collapse. He thinks he suffers from sleep apnea; he snores at night and feels exhausted when awake. He blames this daytime undue somnolence for his blunders in trading.

Sleep apnea made its debut in medical literature in 1956. Dr C S Burwell and his colleagues told the story of an ever-sleepy 51 years old obese businessman who measured 5 ft 5 inches and weighed 260 Lbs. During a game of poker - with three aces and two kings in his hand - the businessman missed the prime chance to make a killing. The reason: he had fallen asleep! Dr Burwell titled the article, ‘Extreme Obesity Associated with Alveolar Hypoventilation: A Pickwickian Syndrome’.

‘Pickwickian’ refers to ‘The Pickwick Papers’ where in 1837, Charles Dickens introduced a gluttonous, “wonderfully fat boy” Joe, who had a hard time staying awake. He stood at the door after repetitive knocking “ upright his eyes closed as if in sleep” with looks of “calmness and repose.” Questioned thrice, he did not answer, but “nodded once and seemed ----- to snore.” Then he “suddenly opened his eyes, winked several times, sneezed once, and raised his hand as if to repeat the knocking.”

Dr Burwell - with retrospective analysis – diagnosed ‘fat Joe’ and the somnolent obese businessman suffering from obesity-hypoventilation, which is now called sleep apnea. Joe still continues to live in the medical literature as the original embodiment of the Pickwickian Syndrome.

BIL thinks, he is the clone-reincarnation of fat boy Joe. Like him, BIL is also portly, short and overweight; his round head sits atop his stout neck; a cigarette often dangles from his wet lips and he finds the poker game goof akin to his hedge fund fiasco.

He wonders, “Do I have Pickwickian Syndrome?”

So, BIL goes for a check up - a sleep apnea study. BIL spends one night in the sleep lab, wired to gadgets, which monitor his blood oxygen, respiratory pattern, blood pressure, pulse and brain electrical activity.

During sleep, the muscles inside his throat relax and collapse into the air passage, which is already narrow due to his stout neck. The air cannot flow through the obstructed airway and his breathing stops for a moment (apnea), which plummets his blood oxygen. The oxygen-deprived brain startles and awakens him for a moment; the muscles at the back of his throat tense up, which opens the breathing passage allowing air to rush through. He breathes again. The gushing air vibrates the floppy throat muscles, broadcasting a sonorous snore. He falls asleep only to stop breathing again. He repeats this cycle of stops-and-starts, about 27 times every hour during the night.

BIL does not remember the sleeping-awakening cycles, but the video monitors, focused on him, capture his snoring, tossing and turning. A sleep-deprived night leaves him exhausted the next day.

The sleep lab verdict follows quickly: BIL does have sleep apnea. He is not alone. One in fifteen or 6.6 percent Americans have sleep apnea. Most are overweight mid age males, though skinny ones and women are not exempt. One in fifty snore through life undiagnosed – at work, while driving or in public places.

Now, the bear news: many years of sleep apnea are likely to give BIL high blood pressure and heart failure. He also has higher chances of suffering from a paralytic stroke.

And the bull news: sleep apnea is treatable and simple interventions yield satisfactory results. BIL can, once more, enjoy a restful sleep at night and profitable derivatives during day.

What should BIL do?

He should stop smoking and avoid alcohol. (Alcohol relaxes the throat muscles, enhancing the obstruction.) He should loose weight. His Body Mass Index or BMI is 33, which classifies him as obese; if it were over 40, he would be morbidly obese. (BMI is weight in kilograms divided by the square of height in meters. A Belgian statistician, Adolph Quetelet, who was friend of Charles Dickens, first described this concept in 1869 and called it Quetelet index.)

He should sleep on his side and may use a mouth appliance to keep his throat open. BIL may have to use a CPAP (continuous positive airway pressure) machine, which forces air under pressure into his obstructed airway. If these methods don’t help, he may have to undergo surgery, where the surgeon will remove the triangular floppy muscle hanging form the roof of his throat (uvula and soft palate) and also some of the surrounding tissue, to widen his airway.

BIL, in his insuppressible bullish manner, is determined to get his trading prowess back. No more daytime slumber! The night in the sleep lab convinced BIL of his infirmity. “See, I told you I am Pickwickian.”

BIL: the answer is yes and no. You do have sleep apnea but you may not have the Pickwickian Syndrome; the two may not be the same disease.

You remember, Dickens describing the nonstop knock at the door at the Pickwick mansion, which prompted the opening of the door leading to discovery of a “wonderfully fat boy” standing “upright” and “in sleep”. Some experts tell us that people suffering from sleep apnea do not fall asleep during vigorous action like incessant knocking. If Joe did fall asleep, he would not be standing but would have dropped to the floor with flaccid muscles. His snore would be loud and not ‘feeble”. Joe probably exhibited a different sleep disorder: narcolepsy.

BIL still insists in washing off his guilt. “ But, you do agree that sleep deprivation was the cause my poor judgment and hedge fund collapse?”

Dear BIL, the cause of your bungled trading was not apnea-when-asleep but avarice-when- awake. You are less like Joe from Dickens and more like Malcolm from Macbeth:

“With this there grows
In my most ill-composed affection such
A stanchless avarice that, were I king,
I should cut off the nobles for their lands,
Desire his jewels and this other's house:
And my more-having would be as a sauce
To make me hunger more; that I should forge
Quarrels unjust against the good and loyal,
Destroying them for wealth.”