Obstructive sleep apnoea syndrome: the first picture?
Authors: J Barry Ferriss
Journal: Journal of the Royal Society of Medicine (2009)

The obstructive sleep apnoea syndrome is a form of disordered breathing in which the upper airways close repeatedly during sleep.1 It is characterized by snoring, witnessed apnoeas and daytime sleepiness.1,2 A large neck and obesity are common, while other risk factors include ageing, the male sex and alcohol intake.1,2 The condition may carry an independent risk of stroke and death.3

The first modern description of obstructive sleep apnoea syndrome is credited to Burwell and colleagues just over half a century ago.4 However, Lavie5 and Bray6 have documented much earlier accounts, for example by Russell (1866), Broadbent (1877), and both Morison and Caton (1889). Following Caton's case report, Heath7 made reference to the sleepy fat boy in The Pickwick Papers by Charles Dickens, published in 1837.8 The eponymous description the Pickwickian Syndrome was proposed by Burwell et al.4

Francis Grose (1731–1791) was a well-known English antiquary and raconteur. He was a prolific illustrator of architectural remains and was among the earliest lexicographers to compile a dictionary of English slang.9,10 Grose was aptly named, being hugely obese. His father came from German-speaking Berne, in Switzerland. The family was also known as Grosse, which translates as big or large, suggesting a family background of adiposity.

Short as well as corpulent, he was said to be only five feet tall, while weighing 22 stone.11 These figures, though most likely inaccurate, would give a prodigious BMI of 60. Robert Burns called him ‘a fine, fat, fodgel wight, o'stature short, but genius bright’.12 He was described in the first edition of The National Biography as ‘a sort of antiquarian Falstaff’.

A satirical portrait, probably by a friend the Rev James Douglas, shows a corpulent thick-necked man asleep in a chair (Figure 1). The mouth is partially open, suggesting mouth breathing and possibly snoring. It is clear from an inscription underneath that he had dozed off at a gathering of the Society of Antiquaries. It seems he fell asleep often and was ‘a great eater and drinker and fond of sleep’.13 Gandon observed that Grose was subject to ‘salutary periods of repose’, but was cheerful and witty after these.14 Another friend, the Rev Mark Noble, compared him to Sancho Panza in his love of sleep.9



Figure 1

Portrait of Francis Grose. Etching attributed to Rev James Douglas, c. 1785. The British Museum



Francis Grose died suddenly in Dublin, at the age of 60 years. It is thought that he suffered a stroke.11,15

It seems credible that Francis Grose had the obstructive sleep apnoea syndrome. Nowadays the diagnosis is confirmed by overnight polysomnography or other sleep-related tests.1 Such investigations were not available in the past and hence the diagnosis must remain tentative. In support, his great obesity and somnolence are well established, while a hugely thick neck is confirmed in another portrait of Grose by Nathaniel Dance (National Portrait Gallery, London). Other supporting although non-specific features are his age, gender and fondness for alcohol. It is not possible now to obtain a history of witnessed apnoea, while the idea that he may be snoring in Douglas's sketch is of course conjecture.

The obstructive sleep apnoea syndrome may be an independent risk factor for hypertension16 and cardiovascular disease.17 Grose's putative obstructive sleep apnoea and obesity both would have increased his risk of hypertension, while the breathing dysfunction as well as raised blood pressure would enhance his chance of suffering a stroke.3,17

If the diagnosis is correct, it did not impair greatly his formidable intellect. Sleepiness seems more marked than cognitive dysfunction in obstructive sleep apnoea syndrome:18 the condition may have little impact on intelligence and verbal ability, although it adversely affects sustained attention.19 Despite his fondness for alcohol, his frequent lapses into sleep but absence of post sleep torpor would mitigate against sleepiness induced by alcohol alone. There are no reported episodes in his younger days to suggest a background of narcolepsy.

Artists often depicted medical conditions long before the particular entities were described clinically. It is plausible to suggest that, by chance, the etching is the first picture of the obstructive sleep apnoea syndrome. It precedes by a half century or more illustrations of the fat boy in various editions of The Pickwick Papers. It is remarkable that what was in all likelihood an informal sketch of Grose by a colleague and friend, remains such an elegant and medically interesting work.