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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
  1. John A Hayman, associate professor
  1. 1Department of Anatomy and Developmental Biology, Monash University, Clayton, Melbourne, Victoria 3800, Australia
  1. hayman{at}johnhayman.net

    It is 200 years since the naturalist Charles Darwin was born. It is therefore an appropriate time to establish the nature of the illness that he endured throughout adulthood and to refute the many fanciful proffered diagnoses, both physical and psychological, or psychoanalytical.

    Darwin on board HMS Beagle

    Throughout his adult life Darwin endured a chronic, relapsing illness. This was present even before he sailed on HMS Beagle in 1831:

    • I was also troubled with palpitations and pain about the heart, and like many a young ignorant man, especially one with a smattering of medical knowledge, was convinced that I had heart-disease. I did not consult any doctor, as I fully expected to hear the verdict that I was not fit for the voyage, and I was resolved to go at all hazards1

    Sea sickness was a major problem for Darwin, to the extent that he was incapacitated for days at a time. On 30 December 1831 and again in January, he recorded his feelings in a diary (box).

    Extract on seasickness from Darwin’s diary

    • Dec 30th At noon Lat. 43, South of Cape Finisterre & across the famous Bay of Biscay: wretchedly out of spirits & very sick. I often said before starting, that I had no doubt I should frequently repent of the whole undertaking, little did I think with what fervour I should do so. I can scarcely conceive any more miserable state, than when such dark & gloomy thoughts are haunting the mind as have to day pursued me

    • January 1 (1832) The new year to my jaundiced senses bore a most gloomy appearance. In the morning almost a calm, but a long swell on the sea. In the evening it blew a stiff breeze against us. This & three following days were ones of great & unceasing suffering.

    • Monday 2nd Heavy weather. I very nearly fainted from exhaustion2

    Darwin’s seasickness was clearly more severe than that normally experienced and lasted throughout the voyage. He was sick for days, even under relatively mild conditions. To his sister Susan he wrote:

    • For the last four months I have not slept more than one night in the Beagle; today took all my things on board meaning to stay–But I am writing this on shore; and what do you think is the reason? . . . Sea sickness3

    Darwin’s continuing illness

    Darwin’s sickness continued after the voyage. His illness was characterised by episodes of nausea, vomiting, intermittent abdominal pain, weakness, and lethargy and often associated with headache, dizziness (“swimming of the head”), visual disturbances, and palpitations. At times he complained of “inordinate flatulence” and diarrhoea:

    • I am weak enough today, but think I am improving. My attack was very sudden: it came on with fiery spokes and & dark clouds before my eyes; then sharpish shivery & rather bad not very bad sickness. I got up yesterday about 2 & about 7. I felt rather faint & had a slight shaking fit & little vomiting then slept too heavily; so today I am languid and stomach bad, but do not think I shall have any more shivering & I care for nothing else4

    Darwin also had eczema and had several attacks of boils. Interestingly, when his eczema erupted his main illness remitted, and remission also occurred during attacks of “rheumatism.” Emma Darwin, his wife, wrote:

    • He has had a better week with much less sickness owing to a tightness of the chest & excema. The excema alas is gone & was hardly enough to affect him much but I am glad it is still lurking about him5

    The episodes of sickness were at times completely disabling and Darwin was confined to his sofa in a constant nauseated state for days—even weeks—at a time. He was aware that the episodes could be initiated by excitement or stress, even by pleasurable events. In a letter to his old shipmate Philip King he wrote:

    • I grieve to say that my health is so indifferent, I cannot stand seeing at present anyone here. Twice lately I could not resist seeing old friends . . . & the excitement made me so ill afterwards that I have been advised not to do so again. I am well enough in the mornings and when I keep quiet

    Again, a month later, writing to Thomas Rivers, a nurseryman specialising in the cultivation of fruit trees, he stated:

    • I suffer severely from ill-health of a very peculiar kind, which prevents me from all mental excitement, which is always followed by spasmotic sickness, and I do not think I could stand conversation with you, which to me would be so full of enjoyment6

    Darwin went through many different treatments, without lasting improvement from any. The most famous of these was Dr James Gully’s cold water treatment, at his clinic in Malvern, Worcestershire. Darwin may well have gained some relief from this treatment, which would explain why he persisted with it for six months. Such relief may, however, have been due as much to the boredom of the place as to the prescribed therapy.

    • I am rather weary of my present inactive life & the Water Cure has the most extraordinary effect in producing indolence & stagnation of mind; I cd not have believed it possible7

    Proffered diagnoses

    The nature of Darwin’s illness has been the subject of much and very varied speculation. Psychological diagnoses offered include hypochondria, neurasthenia, panic disorders, and agoraphobia. Psychoanalysts have put Darwin’s illness down to “repressed anger towards his father,” nervousness about his relationship with his wife, and guilt over conflict with his earlier religious beliefs.8 Darwin was no hypochondriac or neurasthenic; he fought against his illness and struggled to work even when he was severely unwell. He did have anxiety but this may well have been engendered by his illness rather than being the cause of it. In later years he became almost a recluse for the good reason that travel, social contact, and meetings could trigger an attack.

    Suggested physical diagnoses include maladies such as Meniere’s disease (due to middle ear damage from game shooting), arsenic poisoning (from prescribed drugs),9 and Chagas’ disease resulting from an insect bite during his sojourn in South America.8 These diagnoses have all been disallowed for good reasons. Darwin never had deafness; nausea and vomiting rather than tinnitus were his main symptoms. Arsenic (Fowler’s solution) was prescribed for a variety of complaints and Darwin may have taken it as a young man for eczema. There is, however, no evidence that he received large amounts of arsenic. Darwin’s symptoms were episodic, and between episodes he could feel entirely well. Chagas’ disease is rejected for several reasons; exposure was too brief and Darwin had symptoms before he sailed. His tolerance of exercise was good and despite being examined by several eminent doctors he showed no evidence of organic disease.10

    Speculation aside, we do know much about Darwin’s illness. It was chronic but intermittent (initially he had periods of sickness alternating with periods of being well). Episodes of sickness could be initiated by stress or overwork, even by pleasurable events, and they could last for days or weeks and were at times completely disabling. The illness was not fatal; it was present probably for at least 50 years and became less severe in old age (he died at 73 with symptoms of cardiac ischaemia and heart failure). He had no internal physical abnormalities.10 The illness did not impair his fertility; as well as being the father of modern biology he fathered 10 children, all conceived during his long period of ill health.

    The diagnosis

    Darwin’s symptoms are those of cyclical vomiting syndrome.11 Although this is primarily a disease of children it may persist into adulthood or may appear for the first time in adulthood.12 The disease is related to classic migraine and abdominal migraine but is also linked to abnormalities of mitochondrial DNA,13 14 with mutations in the MTTL1 gene.15 This disease is neither well known nor well recognised, particularly in adults, although it was first described in the English literature in 1882.16

    People with cyclical vomiting syndrome experience abdominal, circulatory, and cerebral symptoms, including headaches and anxiety. Symptoms overlap with those of classic and abdominal migraine, except for a lack of aura. Affected people may experience some or all of these symptoms, with each individual having similar symptoms with each episode. Over time, however, progression or change may occur in the most prominent feature, and episodes may coalesce. Many people report severe motion sickness, and this may be associated with a full episode.

    Episodes of illness may be divided into three phases—prodromal, emetic, and recovery—often with definite triggering events. Symptoms in the prodromal phase include fatigue, palpitations, and sweating. The emetic phase may consist of continuous nausea, with vomiting two to 20 times an hour. In most people this is associated with severe abdominal pain. Episodes may last one or two days or up to a week.

    Many people with cyclical vomiting syndrome have eczema that may be related to various food allergies. The eczema is a form of atopic dermatitis—Darwin was diagnosed posthumously as having atopic dermatitis.17 Affected people harbour staphylococci in their skin and often have recurrent skin infections.18 Many of the people in the reported series had transient alleviation of symptoms by taking baths or showers, although these, unlike Dr Gully’s hydrotherapy, were mostly with warm water. Many patients report a link between episodes and excitement, even pleasurable excitement, as did Darwin. Being in an institution where there was dull routine may have helped Darwin recover from months of sickness as much as the cold water therapy.

    Darwin’s mother Susannah died with abdominal pain when he was 8. As a child she had vomiting and boils, experienced motion sickness, had excessive sickness during pregnancies, and “was never quite well.”19 Her younger brother Tom had similar symptoms, with headaches, abdominal pains, and motion sickness. A sister, Sarah, considered that Charles and his uncle Tom had the same illness.20 Evidence of a matrilineal inheritance pattern is good, consistent with an abnormality of mitochondrial DNA.

    Conclusion

    Darwin’s symptoms may be explained by the diagnosis of cyclical vomiting syndrome, with secondary complications such as atopic dermatitis with staphylococcal infections, dental decay, oesophageal tears, and skin pigmentation (figure). He had a severe form of this illness with periods of coalescence of episodes. His was a well defined but not well known inborn illness; he did not primarily have hypochondriasis, neurasthenia, agoraphobia, or any of the strange psychoanalytically derived maladies that have been proposed.

    Figure1

    Darwin in 1881, the year before he died, showing tanning of the face and hand, abnormal for an Anglo-Saxon who spent most of his time indoors. The tanning was a physiological response to increased production of adrenocorticotrophic hormone or melanocyte stimulating hormone. Painting by John Collier for the Linnean Society. Reproduced with permission of the Linnean Society, London (www.linnean.org)

    Darwin was not aware of mitochondria or of genes and genetic mutations but he was very aware of random variations within species. This was the keystone for his theory of the “survival of the fittest,” the driving mechanism of evolution. His personal inherited genetic variation made him substantially “less fit,” but his survival prospects were greatly increased by his driving intellect; loyal colleagues; devoted wife, family, and household servants; and personal wealth.

    Notes

    Cite this as: BMJ 2009;339:b4968

    Footnotes

    • The Complete Work of Charles Darwin Online (John van Wyhe ed), (http://darwin-online.org.uk) and the Darwin Correspondence Project, containing 5000 of Darwin’s letters online (www.darwinproject.ac.uk) are the source of abundant original material. John Bertram and Dave Souza read the original draft and made suggestions.

    • Funding: None.

    • Competing interests: None declared.

    References

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