Journal of the Royal Society of Medicine Volume 83 December 1990

Acute hyperventilation in literature: notes

M G H Bishop LDS MSc

on

797

four examples

Bulls Mill House, Hertford SG14 3NS

Keywords: hyperventilation; sleep; English literature

Recent articles"2 in this and other journals have drawn attention to the significance of hyperventilation and the unquiet mind. This paper records three descriptions in English Literature of hyperventilation associated with low spirits and waking from troubled sleep, a pattern not on the list of indicators given by Magarian in 19823 for the diagnosis of hyperventilation syndrome, although possibly appropriate. An alternative interpretation of Coleridge's poem Kubla Khan line 18 is also given. The literary quotes are given consecutively. The first, from Sir Kingsley Amis' The Old Devils of 19864, is a definitive description of the phenomenon. It is printed by kind permission ofthe author and the incident comes roughly halfway through the novel, so the reader is aware, as Sophie is not, of at least part of the cause of Charlie's distress. The second quote adds a literary twist to a concise and amusing description. It is taken with Mrs Nigel Dennis' permission from Nigel Dennis' disturbing and enjoyable novel Cards of Identity of 19665; The 'patient', a member of the Identity Club, is inventing the episode in order to deceive the doctor. The third example6 is the opening paragraph of a science fiction short story In Alien Flesh by Gregory Benford - Professor of Physics at the University of California. Later the author makes clear the reluctance of the protagonist to tell his companion what is troubling him, although in the end he does so and a curious tale unfolds - not for the squeamish.

The Old Devils - Kingsley Amis, 1986

.... she asked how Charlie was, rather less inquisitively than when she had asked after Gwen. "That bugger knocks it back like a fool," said Sophie without looking up. "Yes, I thought . . "I never realised how much he drank till the night he came home sober. A revelation, it was." "Not even nice at the time, I don't suppose." "What had happened that day I'll never know. Anyway it was a hell of a night after that. He made me sit up with him till he was asleep which wasn't till after two, and then it couldn't have been much after four he was cootched tight up to me, stiff as a board and breathing in and out, in and out as ifhe was doing it for a bet. And he wouldn't say what it was, what the matter was. I went on and on asking but he wouldn't say. Next day he was paralytic by six, Victor said."' Cards of Identity -Nigel Dennis, 1966 "'Begin, madam," said the doctor, raising a pair of dog-like eyes to hers. She responded by fixing on him the intense, horrified gaze of a revelationist. Her breast rose and fell rapidly. The words began to tumble from her mouth: "A sort of trembling, doctor, every morning when I wake up - as though I was somehow anticipating the worst.

At first, snug in my warm bed, I am puzzled - why, I ask myself dreamily, should I feel afraid? Suddenly it dawns on me - oh, heavens! this is morning and I am me! I am myself, and nothing I can do will mitigate the horror of this fact. This realization - which is too agonizing to describe - is followed by a 'Hah-hah-hah-hah' sort of panting, like that of a sheep caught by its horns in a thicket." "Omit sheep and thickets, madam, for God's sake!" cried the doctor, turning white. "We are not a Bible class."'

In Alien Flesh - Gregory Benford, 1988 - green surf lapping, chilling Reginri's hand jerked convulsively on the sheets. His eyes were closed. - silver coins gliding and turning in the speckled sky, eclipsing the sun The sheets were a clinging swamp. He twisted in their grip. - a chiming song, tinkling cool rivulets washing his skin He opened his eyes. A yellow blade of afternoon sunlight hung in the room, dust motes swimming through it. He panted in shallow gasps. Belej was standing beside the bed. "They came again, didn't they?" she said, almost whispering. "ye ... yes." His throat was tight and dry. "This can't go on, darling."'

The characteristic features of hyperventilation derived from the literary examples given, are shown below: Amis

Dennis Benford Present Present Present

Hyperventilation Waking from sleep Present Present Present Depression Present Present Present Drug abuse (inc alcohol) Present Absent Absent Reluctance to discuss Present Absent* Present *In the light ofthe other examples, such eagerness to discuss her plight as the Dennis character displays should perhaps have made the doctor suspect a Munchausen

Xanadu and hyperventilation Line 18: 'As if this earth in fast thick pants were breathing', in Samuel Taylor Coleridge's poem Kubla Khan7 sums up the acute hyperventilation of the three passages given above, although, in what is one of the most analysed poems in the English language, the interpretation is usually of a different nature. Coleridge was in ill health and distress of mind, and had taken a draught of opium before falling asleep, and, on waking, writing the poem. In these circumstances, and taking the work as a record of Coleridge's half-sleeping, half-waking dreams, inito which external stimuli make their way, the line, when interpreted in the context of hyperventilation, fits four of the five diagnostic features derived from the literary examples: these are acute hyperventilation, waking from sleep, depression and drug use. The fifth, reluctance to discuss, may be added by noting that

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Journal of the Royal Society of Medicine Volume 83 December 1990

Coleridge published the poem as a psychological curiosity at the prompting of Byron. The derivation of diagnostic features is not scientific no real case reports are given, so it is only valid to present this interpretation, and ofline 18 as literally but unconsciously descriptive, as opinion. Accordingly the poem is here given in full, with the comments by Coleridge which were printed, together with the editor's notes, in E H Coleridge's 1912 'The Complete Poetical Works'8. For a full assessment of Coleridge's mental state and lifestyle, Richard Holmes' 1989 biography is strongly recommended9.

Kubla Khan or, a Vision in a Dream. A Fragment [A] The following fragment is here published at the request of a poet of great and deserved celebrity (Lord Byron), and, as far as The Author's own opinions are concerned, rather as a psychological curiosity, than on the ground of any supposed poetic merits. In the summer of the year 1797 [B], the Author, then in ill health, had retired to a lonely farm-house between Porlock and Linton, on the Exmoor confines of Somerset and Devonshire. In consequence of a slight indisposition, an anodyne had been prescribed, from the effects of which he fell asleep in his chair at the moment that he was reading the following sentence, or words of the same substance, in 'Purchas's Pilgrimage': 'Here the Khan Kubla commanded a palace to be built, and a stately garden thereunto. And thus ten miles of fertile ground were inclosed with a wall.' The Author continued for about three hours in a profound sleep, at least in the external senses, during which time he has the most vivid confidence, that he could not have composed less than from two to three hundred lines; if that indeed can be called composition in which all the images rose up before him as things, with a parallel production of the correspondent expressions, without any sensation or consciousness of effort. On awaking he appeared to himself to have a distinct recollection of the whole, and taking his pen, ink, and paper, instantly and eagerly wrote down the lines that are here preserved. At this moment he was unfortunately called out by a person on business from Porlock, and detained by him above an hour, and on his return to his room, found, to his no small surprise and mortification, that though he still retained some vague and dim recollection of the general purport ofthe vision, yet, with the exception of some eight or ten scattered lines and images, all the rest had passed away like the images on the surface of a stream into which a stone has been cast, but, alas! without the after restoration of the latter! Yet from the still surviving recollection in his mind, the Author has frequently purposed to finish for himself what, had been originally, as it were, given to him. But the tomorrow is yet to come. As a contrast to this vision, I have annexed a fragment of a very different character [C], describing with equal fidelity the dream of pain and disease.

Kubla Khan - Samuel T Coleridge, 1798 In Xanadu did Kubla Khan A stately pleasure-dome decree: Where Alph, the sacred river, ran Through caverns measureless to man Down to a sunless sea. So twice five miles of fertile ground With walls and towers were girdled round: And there were gardens bright with sinuous rills Where blossomed many an incense-bearing tree; And here were forests ancient as the hills, Enfolding sunny spots of greenery. But oh! that deep romantic chasm which slanted Down the green hill athwart a cedarn cover! A savage place! as holy and enchanted

As e'er beneath a waning moon was haunted By woman wailing for her demon-lover! And from this chasm, with ceaseless turmoil seething, As if this earth in fast thick pants were breathing, A mighty fountain momently was forced! Amid whose swift half-intermitted burst Huge fragments vaulted like rebounding hail, Or chaffy grain beneath the thresher's flail: And 'mid these dancing rocks at once and ever It flung up momently the sacred river. Five miles meandering with a mazy motion Through wood and dale the sacred river ran, Then reached the caverns measureless to man, And sunk in tumult to a lifeless ocean: And 'mid this tumult Kubla heard from far Ancestral voices prophesying war! The shadow of the dome of pleasure Floated midway on the waves; Where was heard the mingled measure From the fountain and the caves. It was a miracle of rare device, A sunny pleasure-dome with caves of ice! A damsel with a dulcimer In a vision once I saw: It was an Abyssinian maid, And on her dulcimer she played, Singing of Mount Abora. Could I revive within me Her symphony and song, To such a deep delight 'twould win me, That with music loud and long, I would build that dome in air, That sunny dome! those caves of ice! And all who heard should see them there, And all should cry, Beware! Beware! His flashing eyes, his floating hair! Weave a circle round him thrice, And close your eyes with holy dread, For he on honey-dew hath fed, And drunk the milk of Paradise.

Editor's notes - E H Coleridge, 1912 [A] First published together with 'Christabel' and 'The Pains of Sleep', 1816. [B] There can be little doubt that Coleridge should have written 'the summer of 1798'. In an unpublished MS note dated November 3, 1810, he connects the retirement between 'Linton and Porlock' and a recourse to opium with his quarrel with Charles Lloyd, and consequent distress of mind. That quarrel was at its height in May 1798. He alludes to distress of mind arising from 'calumny and ingratitude from men who have been fostered in the bosom of my confidence'. [C] The Pains of Sleep (not reproduced here). References 1 Lum LC. Hyperventilation syndromes in medicine and psychiatry - a review. JR Soc Med 1987;80:229-231 2 Nixon PGF, Freeman LJ. The 'think test': a further technique to elicit hyperventilation. J R Soc Med 1988;81:277-9 3 Magarian GJ. Hyperventilation syndromes. Infrequently recognised common expressions of anxiety and stress.

Medicine 1982;61:219-336 4 Amis K. The old devils. London: Hutchinson, 1986:206 5 Dennis N. Cards of identity. London: Wiedenfeld & Nicholson, 1955 (also Penguin Modern Classics, 1966:57) 6 Benlford G. In alien flesh. London: Victor Gollancz, 1988:3 7 Coleridge ST. Kubla Khan 'A Vision in a Dream', 1778 (first published 1812) 8 Coleridge EH, ed. The complete poetical works. Oxford

University Press, 1912; reprinted 1957:295-7 9 Coleridge EH, ed. The complete poetical works. Oxford university Press, 1912; reprinted 1957:295-7 (Accepted 21 May 1990)