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Vasovagal attacks Thomas Lewis published his observations upon faint- ing attacks in 1918,' suggesting that "accurate obser- vations upon the cardiovascular system during the faints of which young men and women of nervous dis- position are the subjects have not as yet been obtained, or obtained have not been recorded." Such descrip- tions were available to Lewis, although not in the sci- entific literature. The following extracts include an early account by Diderot and analyses of the warning symptoms by Jane Austen, George Eliot, Wilkie Collins, and Arnold Bennett. Dostoyevsky mistakenly assumed the loss of posture to be precipitate rather than gradual. Dickens believed faints to be virtually a female prerogative-indeed of the twenty or so descriptions in his novels, all but one are female, the exception, in Oliver Twist, having had a previous event that suggested epilepsy was the more likely diagnosis. Dickens assumed that faints were either a response to a physical insult, or a deliberate manipulation on the part of the sufferer. The witnessing of blood-letting can be a potent trigger as Flaubert's account of a "double faint" testifies. Authors have also touched on the management of syncope in some cases with a touching belief in the efficacy of vinegar, but in others with awareness of the value of the horizontal posture. Cardiac syncope can be difficult to distinguish from vasovagal attacks, though in some cases, symptoms such as palpitations suggest the possibility, as with Captain Wybrow in Scenes of clerical life. D Diderot, 1796, The nun I moved towards the superior with my arms held out in supplication and my body leaning backwards, swoon- ing. I fell, but it was not a heavy fall. In such fainting fits when one's strength abandons one, the limbs seem to give way and as it were fold up unawares; nature, unable to hold up, seems to try to collapse gently. I lost consciousness and the sense of feeling, and merely heard confused and distant voices buzzing round me; whether it was real speech or a singing in my ears, I could make out nothing but this continual buzzing. J'ane Austen, 1811, Sense and Sensibility Marianne, now looking dreadfully white, and unable to stand, sunk onto her chair, and Elinor, expecting every moment to see her faint, tried to screen her from the observation of others, while reviving her with lavender water. Charles Dickens, 1837-9, Oliver Twist "... turned his hands in his hair; and, with a loud scream, rolled grovelling upon the floor, his eyes fixed, and the foam covering his lips." Charles Dickens, 1839, Nicholas Nickleby "Miss Petowker was at length supported in a condition of much exhaustion to the first floor, where she no sooner encountered the youthful bridegroom than she fainted with great decorum." Gustave Flaubert, 1856-7, Madame Bovary So Bovary sent for a bandage and basin, which he asked Justin to hold. "Don't be afraid, my man" he said to the already white-faced villager. "No, no, go ahead!" the man answered. And he held out his brawny arm with a touch of bravado. At the prick of the lancet the blood spurted out and splashed against the mirror. "Nearer with the basin!" Charles exclaimed. "Lookee!" said the peasant. "It's like a young fountain flowing! What red blood I've got. Should be a good sign, eh?" "Sometimes", the Officer of Health remarked, "they don't feel anything at first: the syncope occurs after- wards, especially with strong chaps like this". Instantly the yokel let go of the lancet-case which he had been twirling in his fingers: a jerk of his shoulders snapped the back of his chair: his cap fell to the floor. "I thought as much", said Bovary, putting his fin- gers over the vein. The basin began to wobble in Justin's hands. He quaked at the knees. His face went white. "Emma!" Charles called out, "Emma!" She was down the stairs in a flash "Vinegar!" he cried. "Good Lord, two at once!" George Eliot, 1858, Scenes of clerical life By jove, what a rate my heart is galloping at! These confounded palpitations get worse instead of better ... Still he might only have fainted; it might only be a fit. Sir Christopher knelt down, unfastened the cravat, unfastened the waistcoat, and laid his hand on the heart. It might be syncope; it might not-it could not be death. No! that thought must be kept far off. George Eliot, 1859, Adam Bede "Look there! She's fainting" said the landlady, hasten- ing to support Hetty, who had lost her miserable con- sciousness and looked like a beautiful corpse. Wilkie Collins, 1861, The dead secret She staggered desperately, a few paces further, and reached the first row of doors that opened on the land- ing. There nature sank exhausted: her knees gave way under her-her breath, her sight, her hearing all seemed to fail her together at the same instant-and she dropped down senseless on the floor at the head of the stairs. Fedor Dostoyevsky, 1871, The devils But she suddenly uttered a scream and fell full length on the floor in a faint. I can still hear the thud of her fall as her head hit the carpet. Arnold Bennett, 1904, Teresa of Watling Street Never raise the head of a person who has lost con- sciousness, he said coldly, it is dangerous. Teresa will recover in a few minutes. This swoon is due only to the shock and strain of the last few minutes. Arnold Bennett, 1911, Hilda Lessways She felt dizzy... the door of Sarah's wardrobe was ajar, and, in the mirror of it, Hilda could see herself obscurely, a black-robed strange young woman, with untidy hair and white cheeks and huge dark, staring heavy eyes, with pouches beneath them. The image wavered in the mirror. She thought: "Here it is again, this awful feeling! Surely I am not going to faint!?" G D PERKIN Regional Neurosciences Centre, Charing Cross Hospital, London W6 8RF, UK 1 Cotton TF, Lewis T. Observations upon fainting attacks due to inhibitory cardiac impulses. Heart 1918-20;7: 23-4. NEUROLOGY IN LITERATURE 789 o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://jn n p .b m j.co m / J N e u ro l N e u ro su rg P sych ia try: first p u b lish e d a s 1 0 .1 1 3 6 /jn n p .5 7 .7 .7 8 9 o n 1 Ju ly 1 9 9 4 . D o w n lo a d e d fro m http://jnnp.bmj.com/