Feature Christmas 2009: Diagnosis

Darwin’s illness revisited

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4968 (Published 14 December 2009) Cite this as: BMJ 2009;339:b4968

Re: A clinical case study to further this discussion

I am grateful to Christopher Kent for his comments on my article and
his
most interesting survey. Darwin’s complaints have been eloquently
described
as ‘polymorphous symptomatology’. Even today, patients presenting with
this range of symptoms to their General Medical Practitioner or Family
Physician are likely to come away with a prescription for a minor
tranquilizer, advice as to how to avoid stress, and perhaps even a
psychiatric referral. The disease that affected Darwin, with its wide
range of
bizarre symptoms, is not well known.

Darwin vomited several hours after meals, which is a characteristic
of the
Cyclical Vomiting Syndrome. Darwin to Hooker (Feb 1864): ‘it rarely comes
on till 2-3 hours after eating, so that I seldom through up food …
otherwise
I shd have been dead, for during a month I vomited after every meal &
several times most nights’.[1] His wife Emma reported: ‘His good symptoms
are losing no flesh & having a good appetite so that I fully hope that
in time
he will regain his usual standard of health which is not saying much for
him’.[2] Although Darwin lost no food he did lose fluid and electrolyte,
losses that would have resulted in increased ACTH (and MSH) production
and his later pigmentation. Increased ACTH production is recorded in CVS
patients during episodes but this does not continue as patients now
generally receive prompt replacement therapy.[3]

Other symptoms experienced by Darwin match and match exactly those of

many patients with CVS. ‘Flatulence’ (‘fits of flatulence’), in this
context
referring to burping or belching, was one of Darwin’s most distressing and

persistent symptoms, with noxious gas expelled from the stomach. Francis,
Darwin’s third son, recorded: ‘He (Charles, Francis’ father) suffered from

“fits of flatulence”, coughing up from his stomach acid, bitter, fetid
odours’.[4] A patient today writes: ‘I never would have thought to
associate
my smelly burps and hiccoughing to this. I will clear a room belching. Or
as
my husband so delightfully puts it – “blister the paint on the wall”.’[5]

Darwin consulted many different doctors and tried many different
treatments; Bence Jones was not the only physician to receive financial
benefit from Darwin’s illness. Darwin complained that Dr Edmund Smith, at
Ilkley –– ‘constantly gives me the impression, as if he cared very much
for
the Fee & very little for the patient’.

CVS is probably more common than it is diagnosed; many patients have
relatively minor symptoms and outgrow these (but may develop migraine) in
later life. Other patients have the ‘full hand’ and are greatly
incapacitated. It
is to be hoped that more effective therapy will be developed for this
distressing disorder, therapy that was not available to Darwin.

References:

1. Darwin, C., Letter 4412 to J D Hooker. Darwin Correspondence
Project,
1864. 12(56).

2. Darwin, E., Letter 4355 to W D Fox. Darwin Correspondence Project,

1863. 11(690).

3. Nakazato, Y., N. Tamura, and K. Shimazu, An adult case of cyclic
vomiting syndrome successfully responding to valproic acid. J Neurol,
2008.
255: p. 934-935.

4. Darwin, F., The Life and Letters of Charles Darwin. Vol. 1. 1888,
New
York: Appleton.

5. Cyclic Vomiting Syndrome Association. Forums 2009 [cited 2009;
http://cvsa.websitetoolbox.com/].

Competing interests:
None declared

Competing interests: No competing interests

09 January 2010
John A Hayman
Pathologist
Department of Anatomy and Cell Biology, Monash University, VIC, 3800