1. DARWIN AND ALL THOSE IDEAS Dr Louis Heyse-Moore DM FRCP DHMSA ___________________________

2. Darwin’s ailments Throughout his adult life, Charles Darwin (1809-1882) suffered from chronic, debilitating ill health His doctors favoured nervous dyspepsia or suppressed gout as diagnoses His varied treatments afforded only temporary relief Dozens of diagnoses have since been suggested, none proven Charles Darwin 1854. Photo by Maull and Polyblank. National Portrait Gallery

3. Gout in the family Penelope née Foley = Charles Howard 1708-1748 1706-1771 Mary née Howard = Erasmus Darwin 1740-1770 1731-1802 Susannah née Wedgwood = Robert Darwin 1765-1817 1766-1848 Emma née Wedgwood = Charles Darwin 1808-1896 1809-1882 A drunkard, debauched and prone to gout (according to Erasmus Darwin ) ‘3 fits of gout in three successive years’. Resolved on stopping alcohol ‘My father has had a bad fit of gout together with a good deal of fever.’ (Charles Darwin) ‘Suppressed gout’ diagnosed by his physicians

4. Darwin’s Symptoms – a sample of 24 letters 1837-1865: 95 symptoms Desolate Dispirited Shattered condition Misery Thought of that time [Annie Darwin’s death] most painful Old thoughts would revive so vividly Often wished to see the grave Hysterical crying Nervous when E. leaves me This scene [a soldier's burial] deeply stirred whatever poetic fancy there was in me Amnesia Dissociation Flashbacks Avoidance places associated with trauma Difficulty concentrating Social withdrawal Rigid routine Rocking Treading on air Indifferent health Emma Darwin’s confinement knocked me up Sudden attack Good for nothing Bad all winter Unwell Bad enough Most think I am shamming Quite ill Sick boy Steadily going downhill Uncertain health Smallest exertion most irksome No spirits to do anything Want vigour Mental fatigue or rather excitement Weak Languid Excessively tired Not able to do anything Overtired with my work Good way from being a strong man Unable to write Cannot speak Cannot walk above half-mile Conversation or excitement tire me most Dying sensations I thought I was rapidly going the way of all flesh I hope my life may be very short Pain about the heart Uncomfortable palpitations Pulse 58- 62 or slower and like thread Periodical vomiting Stomach bad Speaking at the Linnaean Society brought on 24 hours vomiting Vegetable cells in the limpid fluid I throw up Bad amount of sickness Nausea Extreme spasmodic daily and nightly flatulence Extreme secretion of saliva with flatulence Vomit intensely acid, slimy (sometimes bitter) corrodes teeth Tongue crimson in morning intensely ulcerated Stomach constricted dragging Fundament – rash Cold stomach when sick Faint Half faint Slept too heavily Sleepless night Head often swimming Nervous system affected I felt as if my body was gone & only my head left Weakened my brain Head symptoms Seldom headach pins and needles vision. focus and black dots Fiery spokes Dark clouds Now constant lumbago My lips became suddenly so bad Dreadful numbness in my finger-ends Excessive irritation of skin Eczema Eruption all over legs Violent skin inflammation My hands are burning as if dipped in hell-fire Feet coldish Copious very palid (sic) urine Urine scanty (because do not drink) Pinkish sediment when cold Singing of ears Whizzing Sharpish shivery Slight shaking fit Hands tremulous 

5. Some proposed causes of Darwin’s illness Physical Causes Chronic neurasthenia of a severe grade (1901) Refractory anomaly of the eyes (1903) Mental overwork (1955) Brucellosis (1958) Chagas’ Disease (1959) Syndrome of narcolepsy and diabetic (functional) hyperinsulinism (1967) Arsenic and mercury poisoning (1971) Immune system dysfunction (1990) Hypoadrenalism and hypoglycaemia (1994) Systemic lupus erythematosus (1997) M é ni è re’s Disease (1997) Atopic eczema (2000) Systemic lactose intolerance (2005) Crohn’s Disease (2007 and 2014) Cyclical Vomiting Syndrome (2009) Helicobacter pylori infection (2011) MELAS syndrome (2013) Psychological causes Psychoanalytic interpretations (hostility to his father) (various dates) Anxiety neurosis (1918) ‘A mild form of depression’ (1959) Psychosomatic illness caused by the controversial nature of his evolutionary theory (1974) Hyperventilation syndrome (1990) Failure to grieve for his mother leading to depression (1990) Panic disorder with agoraphobia (1997) See handout

6. Some published diagnostic hypotheses on Darwin’s illnesses: Chagas’ Disease (Adler 1959) Darwin reported in his South American Journal of 26 March 1835: ‘At night I experienced an attack (for it deserves no less a name)... of the great black bug of the pampas. It is most disgusting...’ A protozoal infection by Trypanosoma cruzi, carried by a bug, Triatoma infestans, affecting the gut and heart, common in South America Late manifestations such as a grossly swollen gut and dilated cardiomyopathy, do not fit with Darwin’s symptoms However, a chronic low-grade form can also occur Darwin, C.R. (1860a) Journal of Research During the Voyage of H.M.S. ‘Beagle.’ Edinburgh: T. Nelson & Sons. The Beagle

7. MELAS Syndrome (Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes) Caused by gene mutation in mitochondrial DNA. Maternal inheritance Darwin’s family had a history of chronic unexplained illnesses First described 1984 Rare multisystem disease with multiple symptoms Typically starts in childhood with muscle weakness and pain Headaches, extreme fatigue, vomiting, fits, strokes, dementia Survival is usually a few years from onset of symptoms A less severe form beginning in adulthood can occur Hayman JA. Darwin’s illness revisited. British Medical Journal 2009; 339: b4968 Hayman JA. Charles Darwin's mitochondria. Genetics 2013; 194: 21-5.

8. Crohn’s Disease On the 2nd April 2014, a Channel 4 documentary 'Dead Famous DNA' revealed that hairs from Darwin's beard had undergone DNA analysis, and showed 'twenty-one markers for Crohn's disease, five of them being diagnostic, including the major marker of chromosome 16.’ Half of Darwin’s DNA extracted. Genes associated with baldness, enhanced memory and thrill-seeking found but no other illnesses. Cross-matched with members Darwin’s family. This is the only hypothesis so far backed by clinical investigation. All the others depend on reported symptoms and signs. Orrego F, Quintana C. Darwin’s illness: a final diagnosis. Notes and Records of the Royal Society of London 2007; 61: 23-29. Jefferies M. Channel 4 documentary Dead Famous DNA revealed Charles Darwin suffered from Crohn's disease. The Daily Mirror, 1 April 2014, http://www.mirror.co.uk/tv/tv-news/dead- famous-dna-charles-darwin-3337775 Burrill B. Crohn (1884-1983): described Crohn’s disease in 1932 Crohn’s disease – left-sided colitis with typical cobblestone appearance

9. Hypothesis Charles Darwin suffered from chronic post-traumatic stress disorder (PTSD). This began as developmental trauma when his mother died and progressed in adult life to PTSD following further traumas Charles Darwin 1868 – photo Julia Margaret Cameron Edvard Munch – Death in the Sick Room

10. 1817: Catherine Wedgwood’s memories of her dying sister, Susannah Darwin It is impossible to have a worse account than I have to give you. The Dr. has not the slightest hope & her suffering is terrible. The pain indeed is gone that was her first illness, but she has such severe vomittings, & sickness that he says he does not think her sufferings much lessened... This evening she is worse...[Her daughters] are always with her... Her senses are as perfect as ever. From feebleness she can hardly speak. [Next morning] After a wretched night my poor sister yet lives, but the mortification is far advanced & must soon be fatal. Ref: Wedgwood, C. (1817) Letter to Josiah Wedgwood II. 14 July 1817. Wedgwood Archives 19835-27. Susannah (riding) and Catherine Wedgwood when younger – from a portrait of the Wedgwood family by George Stubbs c.1780

11. 1817: Darwin’s dissociation – a protective psychological state I had, as a very young boy, a strong taste for long solitary walks; but what I thought about I know not. I often became quite absorbed, and once, whilst returning to school on the summit of the old fortifications round Shrewsbury, which had been converted into a public foot-path with no parapet on one side, I walked off and fell to the ground, but the height was only seven or eight feet. Darwin C. The autobiography of Charles Darwin. E Barlow, ed. London: Collins, 1958: 25. Magritte ‘Mr Duffy lived a short distance from his body.’ James Joyce (1914) Dubliners

12. 1825: Alterations in arousal and reactivity However, Darwin was not entirely a helpless victim. When he was 16, he ‘became passionately fond of shooting... I remember killing my first snipe, and my excitement was so great that I had much difficulty in reloading my gun from the trembling of my hands.’ (Darwin 1958). Browne (1995) comments on: ‘The resulting bloodbath of animals – partridges, pigeons, rabbits, rats – which he killed with violent pleasure...’ Thomas Smythe (1825-1906) Duck shooting watercolour 1889.

13. 1825: Flashbacks ‘I also attended on two occasions the operating theatre in the hospital... and saw two very bad operations, one on a child, but I rushed away before they were completed. Nor did I ever attend again, for hardly any inducement would have been strong enough to make me do so... The two cases fairly haunted me for many a long year.’(CD) He was left with ‘a [permanent] morbid horror of the sight or even the word blood’ (according to his son, George Darwin) Unknown artist. Amputation, Old St Thomas’s Hospital. 1775. Royal College of Surgeons

14. His illness begins 1838 Episodes of being ‘unwell’ 1839 Marries Emma Wedgwood December 1839 vomiting and flatulence begin 27 December 1839 his son, William, born March 1840 resigns from position as secretary of Geological Society because of ill health The Darwins’ first house (No. 12 on left), Upper Gower Street, London

15. The death of Annie Darwin, 1851, aged 10 years, in Malvern Annie’s illness, though fluctuating daily, and despite the water cure, advanced inexorably and Darwin’s letters to Emma chart his emotional peaks and troughs. Annie developed severe diarrhoea. ‘As she lay writhing helplessly, his own stomach gave way, and he ran from the room, convulsed and retching.’ Her death certificate: ‘Bilious fever with typhoid character.’ Two more of his children later died in childhood. Desmond, A. & Moore, J. Darwin, 1991, p.383

16. Origins The research on and conceptualisation, writing and publication of The Origin of Species was to cause Darwin much mental anguish over many years Already vulnerable from his past traumas, he was prey to chronic symptoms of psychological distress His mood and symptoms usually improved when he took the Water Cure and ceased working on his book Charles Darwin’s study, Down House

17. Alfred Russel Wallace – an unexpected and unwelcome catalyst 18 June 1858 – Darwin receives an essay ‘On the Tendency of Varieties to Depart Indefinitely from the Original Type,’ from Wallace writing from Malay. Darwin comments ‘he could not have made a better short abstract’ (of the theory of evolution) Darwin is horrified. His decades of unpublished research have been overtaken. Alfred Russel Wallace and his friend Frederick Geach February 1862, Singapore Malay Archipelago – the scene of Wallace’s natural history expeditions

18. 1858 Emotional storm clouds Origins has been pre-empted Darwin wrestles with his conscience on priority of publication He agrees to a joint presentation at the Linnean Society Etty, his daughter, is seriously ill with diphtheria as is her nurse Charles Waring, his baby son ‘backward in walking and talking’ dies of scarlet fever and his nurse contracts the same illness There are fears (soon justified) of an outbreak of scarlet fever in the village Charles and Emma move their children to a safe location Darwin stays at home, ‘grief-stricken and ill’ He and Emma bury their son while the Linnean meeting is in progress This absence was to be a repeating pattern over the years at future meetings 1857 Charles Waring Darwin (b 1856) and Emma. He is thought to have had Down’s Syndrome Henrietta Darwin

19. 1859 Publication of The Origin of Species First edition. Natural History Museum, London

20. 1860 – The British Association Debate, Oxford TH Huxley, Darwin’s bulldog JD Hooker Bishop Samuel Wilberforce, Bishop of Oxford ‘Soapy Sam’ The famous debate in which Huxley and Hooker passionately defended evolution and Wilberforce spoke against it. Darwin was not present. He was away taking the Water Cure at the time

21. Darwin’s medical note to Dr Chapman, 20 May 1865 University of Virginia Library, Albert and Shirley Small Special Collections Library, Darwin Evolution Collection (3314)

22. Darwin’s symptoms, DSM-IV-TR and PTSD Darwin’s symptoms fit the Diagnostic and Statistical Manual of Psychological Diseases (DSM IV- TR) criteria for PTSD: 1. Traumatic events 2. Emotionally distressing memories 3. Avoidant behaviour 4. Alterations in arousal and reactivity 5. Chronic illness

23. PTSD and other diagnoses PTSDPhysical diagnosis PTSD Physical diagnosis

24. Differing concepts Pierre-André Brouillet. Clinical lesson at La Salpêtrière Hospital, Paris. c.1887.(Museé d’Histoire de la Médecine, Paris). Hysteria Charcot lecturing on the hysteric, Blanche Wittman

25. Differing concepts William Simpson. (1823-1889). Embarkation of the sick at Balaclava. Crimean War (1853-1856) War Irritable Heart Soldier’s heart Da Costa’s Syndrome (American Civil War) ‘Nostalgia’ in soldiers (Dr Johannes Hoffer, Swiss, 1678) ‘Estar roto’ = To be broken (Spanish)

26. Dr James Manby Gully (1808-1883) Tudor House, Dr Gully’s water cure establishment – opened 1842

27. The Regime Dr Gully’s regime 'was based on the idea that all chronic disorders were caused by a faulty supply of blood to the viscera and the application of cold water to the skin would return the circulation to normal and alleviate the condition.’ Browne, J. ‘Spas and sensibilities: Darwin at Malvern’. Medical History 1990;34 suppl S10:102-113 Cartoon by Spy. Dr James Gully. Vanity Fair. (5 th August 1876)

28. 1849 Dr Gully’s diagnosis Nervous Dyspepsia Excessive intellectual endeavour ‘The digestive organs irritated the brain and spinal cord and these in turn irritated the stomach’ Browne, J. ‘Spas and sensibilities: Darwin at Malvern’. Medical History 1990;34 suppl S10:102-113 1837 – Darwin’s B notebook on Transmutation of species, p. 36, ‘I think...’ and first drawing of evolutionary tree

29. The lamp or perspiration bath I am heated by Spirit lamp till I stream with perspiration, & am then suddenly rubbed violently with towels dripping with cold water: have two cold feet-baths, & wear a wet compress all day on my stomach. Darwin, C.R. (1849) Letter 1236 to Hooker, J.D., 28 March 1849. Darwin Correspondence Database, http://www.darwinproject.ac.uk/entr y-1236 http://www.darwinproject.ac.uk/entr y-1236 Priessnetz’s hydrotherapy cure, Grafenberg, Germany, Corset Wrap c. 1860.

30. 1865 Spinal Ice Bags ‘I have had a shocking month with much sickness & have done nothing: I am now trying, at first with strong hope, now with weak hope, D r. Chapman's ice- bags along the spine, which at least is comfortable.’ Letter to JD Hooker, June 1 st 1865 ‘Papa had a good day yesterday in & out & to the sand walk. No effect from ice. Certainly no bad effect.’ Letter from Emma Darwin to Henrietta, 1 June 1865

31. Darwin and electrotherapy November 1845: he tries ‘passing a galvanic stream through my insides from a small-plate battery.’ (Galvanism) ‘I have been unusually well.’ October 1851: he writes in his Diary of Health of using ‘electric Chains attc’ [attached] waist,’ and ‘do [ditto] neck’. These did nothing for him. Colp 2008 2 June 1869: Darwin writing to SP Engleheart: ‘… have you heard any credible account of good being derived in dyspepsia & nervous weakness from “Pulvermachers Volta-Electric Chain bands”… [is it] quackery & lies, or wd it be worth trying as an experiment?’ He did not follow this up. Pulvermacher’s galvano-electric chain belt Pulvermacher’s chain charged by being drawn through vinegar

32. Doctors’ prescriptions A visit by Dr William Jenner 20 March 1864 ‘No organic mischief’. He would ‘some day’ get over his vomiting His regimen: Reduced intake fluids Combinations of antacids – chalk, lime water, carbonate of magnesia, carbonate of ammonia Colchicum Podophyllin Taraxacum Bismuth 15 May: ‘I have now been more than a month without sickness’ Medicine chest of Sir James Reid (1849-1923), personal physician to Queen Victoria Sir William Jenner (1815-1898) c. 1860

33. Possible mechanisms for Darwin’s temporary improvements The placebo effect The benefits of exercise on depression in the Water Cure An adrenaline high from immersions in cold water Massage in the guise of towel rubbing A break from his intellectual labours

34. Darwin’s illness in his social context He was persistent in looking for cures He was prepared to try cures that were unpleasant, time-consuming, unorthodox and expensive in his search for health He followed health fashions such as the Water Cure and galvanism His treatments were those available to a well-off Victorian gentleman His PTSD was an exemplar of what was happening to thousands of others in England at the time His was a continuing struggle between his personal emotions and his scientific studies: the contrast between the boy with depression and the study of the facial muscles of emotion. A boy with depression from CD ‘The Expression of the Emotions in Man and Animals.’ The muscles of the face, from the same book

35. 19 th April 1882 – Darwin’s death

36. My thanks to the Society of Apothecaries: this talk was based on a dissertation written for the DHMSA exam _________________________________________________________ FURTHER READING Browne, J. ‘Spas and sensibilities: Darwin at Malvern.’ Medical History 1990;34 suppl. S10: 102-113 Colp R Jr. Darwin’s Illness. Gainesville, Fla.: University Press of Florida. 2008. Desmond A, Moore J. Darwin. London: Michael Joseph. 1991 Heyse-Moore, LH. ‘Darwin’s illnesses: the role of post-traumatic stress disorder.’ Journal Medical Biography. In press. Levine, P. Waking the Tiger: Healing Trauma. Berkeley, California: North Atlantic Books. 1997 The Darwin Correspondence Project (his correspondence available on-line): http://www.darwinproject.ac.uk/ http://www.darwinproject.ac.uk/