Doctors now have many more diagnoses and treatments, and we now want to know what Annie was suffering from and what she died of. A medical history can be drawn up for her from the notes and letters that survive, but the information is difficult to interpret because many of the words used were vague and there is almost no clinical detail. To find out what could be said about the illness, I gave all the clues to four experienced physicians and medical historians for their advice. Looking at the pattern throughout the months after the time when Annie “first failed,” they agreed that she probably died of tuberculosis, which was known at the time as consumption, phthisis or simply “decline.” The early symptoms were characteristically non-specific and intermittent—discomfort, wakefulness and tiredness, but the change in Annie’s health by the end of October 1850 must have been marked as it was worrying enough for Emma to take her twice to London to see Dr. Holland. Annie had a low fever in October and a barking cough from December. The crisis in early April may have been triggered by her ’flu in mid-March, or an infection she caught in Malvern. Tuberculosis then took hold of her body, weakened as it was by the infection. The disease may have struck Annie finally in the abdomen causing tuberculous peritonitis, or in its generalised “miliary” form infecting the blood and leading to meningo-encephalitis, the vomiting and fatal coma. Few who fell victim to tuberculosis before adolescence developed the racking consumptive cough with blood-stained phlegm. Severe damage to the lungs occurred more often in young women and men.
Tuberculosis is caused by a slow-working bacillus, Mycobacterium tuberculosis, which can be picked up in infected milk or passed from person to person through the air when the carrier coughs. Many people who acquire the infection never suffer any active disease. Others are rapidly affected, and some develop the symptoms after a period of dormancy. The disease is said to be Protean; besides the commonest form which wrecks the lungs, other forms attack the intestines, the lining of the brain, the lymph glands, the spine, other bones, the kidneys and genitals. The bacillus was first identified as the cause of the disease by the German bacteriologist Dr. Robert Koch in 1882. The most obvious pathological signs had always been the tubercles—white fatty deposits which were often found in areas of infection. Tubercles were also found in slaughtered cows and other animals, especially the monkeys and apes who so often sickened and died in the zoos and menageries.
In the 1840s and 1850s there were deep fears of consumption in almost every household. Dr. Thomas Yeoman, a physician in north London, wrote in 1848: “Consumption, Decline or Phthisis, is the plague-spot of our climate; amongst diseases it is the most frequent and the most fatal; it is the destroying angel who claims a fourth of all who die.” He wrote about the fears of the disease, “Does the individual exist who has not some special interest in every attempt to arrest its ravages? Is there a family without anxiety, lest some loved relative or connection should fall a victim to its ruthless arm?” It struck both rich and poor without favour. “Consumption steadily and surely pursues its way, and desolation of heart, of home, of hope, follow in its path.”
Nothing was known at the time about the causes of the disease and there was no effective cure. The leading authority on the condition and its treatment was Sir James Clark, who had published his Treatise on Pulmonary Consumption in 1835. He was physician to Princess Victoria at the time; Charles had consulted him in 1838 about his illness, and he treated the pianist Frédéric Chopin when he was suffering from consumption in London in 1848. Clark estimated that a third of all deaths in England arose from tuberculous diseases, and noted that a physician at the Hôpital des Enfants Malades in Paris had reported in 1824 that five out of six children who died in the hospital were found at autopsy to be “more or less tuberculous.”
Clark described a number of forms in which the illness might appear. The one closest to Annie’s symptoms he called “latent or occult.” It was particularly common in delicate young persons; it was marked by fever and night sweats, and it could continue without any more specific symptoms for some time. Any cough was rarely accompanied by expectoration with traces of blood until late in the disease. Dr.Yeoman wrote that the earliest symptoms were often “so obscure or doubtful that consumption . . . cannot be detected with certainty. We should always suspect the presence of consumption when we . . . find a cough continuing for some length of time, inducing increasing debility and emaciation.” Another physician, Dr. Richard Cotton, wrote: “In childhood . . . the child is peevish, irritable, and indisposed to exertion; and, in general appearance, is evidently labouring under some deep-rooted malady, which, at no very distant time, will exhibit itself either as phthisis or some other form of tubercular disease.”
It is a mark of how little was understood about the disease that no one established the critical point that it was infectious or how the condition was passed on. A few doctors had claimed it was infectious, but Clark argued strongly against them, and his view was widely accepted at the time. He and many others believed that the condition could arise in any person. Many suggestions were made about factors that might trigger it. Dr. Gully was among those who believed that it had its origins in poor digestion. There was also general agreement that the condition could be inherited. Dr. Yeoman wrote: “Many persons acquire a predisposition to consumption from their parents, although the latter may attain an advanced age without evincing any symptoms of pulmonary disorder.” The parents need not themselves be consumptive. “Bad general health in one generation is frequently converted into tuberculous disease in the succeeding one.”
Clark suggested that parents could protect their children from the disease by careful upbringing with fresh air and exercise, but insisted that once the disease had taken hold, it was fatal. “No physician acquainted with the morbid anatomy of Tuberculous consumption, can for a moment indulge the hope that we shall ever be able to cure what is usually termed ‘confirmed consumption.’ ” By the 1840s and 1850s, his view that the disease was fatal was the accepted medical opinion.
Against this background, to say firmly that a child was consumptive was a sentence of death, and the force of the judgement had a deep effect on what people were prepared to admit to themselves and say to others about the possibility. Some young women dwelt on the idea. Harriet Martineau wrote in later life: “I romanced internally about early death till it was too late to die early.” For most others, the possibility was a lurking fear to be kept out of mind as long as possible. Describing the early stages of the disease, Dr. Cotton noted a common pattern of denial. “From some cause, for which no good reason can be assigned, there is a slow but marked diminution of bodily vigour, compelling the individual to abandon many of his accustomed pursuits; the spirits, nevertheless, are good, and not only is the idea of consumption never entertained, but any allusion to it is at once ridiculed. So general, indeed, is this hopeful condition,—this almost instinctive blindness to the real cause of distress, that in its absence, however suspicious certain symptoms appear, these may, with much probability of accuracy, be pronounced unconnected with phthisis. The complexion is, at the same time, pallid or sallow; the expression is that of care united with animation; the features are somewhat sharpened; the movements of the body are hurried and anxious; the mental condition is irritated and capricious; whilst every act betrays an effort, sometimes instinctive, and at others voluntary, to conceal the presence of the disease.”
Another physician, Dr. Henry Hillier, wrote insistently about the need for extreme caution in giving a clinical opinion. “The extreme prevalence of consumption in this country, the very insidious nature of the symptoms which mark its positive existence, its undoubted hereditary tendency, the various complications with other diseases which attend its development, and the very uncertain means we possess of staying its progress, renders it the imperative duty of every physician, no matter how celebrated his professional reputation, to pause ere he gives a positive opinion that his patient is the subject of consumption, a disease from which there is little chance
of recovery, and which must sooner or later prove destructive to life.”
Because there was no known cure for the condition, no hospital in London would admit consumptive patients until the Hospital for Consumption and Diseases of the Chest—now the Royal Brompton Hospital—was opened in 1842. It had two aims, to provide care for those poor victims of the disease to whom all other hospitals’ doors were “irrevocably closed,” and to learn what it could from them about the disease. “Pain and suffering must be alleviated; the agonies of disease must be mitigated and soothed: but we hope for more; we hope that here discerning and patient minds, investigating the progress of a fearful complaint in all its gradations, and narrowly observing the results of different remedies, will discover the best mode of treatment; and that from this Institution rays of light will be dispersed, not only through our country, but we might fain hope through the whole civilised world.” An appeal for funds was widely supported, and Charles was one of many people hoping for progress in medical understanding and care who made contributions. The hospital staff were soon treating hundreds of patients, but the disease would not yield its secrets.
Charles Dickens had given a vivid impression of ordinary people’s understanding of the slow onset of consumption in his novel Nicholas Nickleby, which appeared in 1838-39. “There is a dread disease which so prepares its victim, as it were, for death; which so refines it of its grosser aspect, and throws around familiar looks unearthly indications of the coming change—a dread disease, in which the struggle between soul and body is so gradual, quiet, and solemn, and the result so sure, that day by day and grain by grain, the mortal part wastes and withers away, so that the spirit grows light and sanguine with its lightening load and feeling immortality at hand, deems it but a new term of mortal life—a disease in which death and life are so strangely blended, that death takes the glow and hue of life, and life the gaunt and grisly form of death—a disease which medicine never cured, wealth warded off, or poverty could boast exemption from—which sometimes moves in giant strides, and sometimes at a tardy sluggish pace, but, slow or quick, is ever sure and certain.” Dickens was familiar with the pattern of denial. When Nicholas noticed that his friend Smike was growing ill, he took him to a physician “with some faint reference in his own mind to this disorder, though he would by no means admit it, even to himself.” The physician avoided commitment. “There was no cause for immediate alarm, he said. There were no present symptoms which could be deemed conclusive.”
The Christian Remembrancer, an Anglican periodical, felt that Dickens was trying to romanticise the disease and found his approach objectionable. It commented: “We have great doubts about the propriety of this incessant working up our feelings by pictures of consumption. It is hardly fair. The subject is, to half the families of England, too fraught with painful reality to be thus introduced in a work of amusement, and amid dreamy sentiment. It suggests reminiscences at once too agonising and too sacred to make it admissible in fiction. Like the death to which, in all its manifold varieties, it surely, whether slowly and inch by inch, or with impetuous torrent-like rapidity, conducts its prey, consumption is a thing too terribly real to be fitly sported with.” The writer urged realism. “Let our thoughts about death be always as practical as death is actual and certain.”
But, as the Christian Remembrancer itself recognised, there was no avoiding the truth. Everyone had relatives, friends or neighbours who had been killed by tuberculosis. In writing about it in the way that he did, Dickens cannot have believed that his readers would forget what they knew about the fear and wasting pain involved. He and others dramatised the disease because so many of its victims were young people; they could feel it working in their bodies and see their death approaching at an uncertain pace for months or years; they had all too much time to dwell on what lay ahead for them. The “good death” of the evangelical and other traditions was a way to draw something of lasting value from the suffering. There was no denying or avoiding the long-drawn-out and cruel pain of the illness beneath the devout hopes.
Charles and Emma both read Nicholas Nickleby, and knew many other books for children and adults in which young people died slowly of consumption. In the books that Charles borrowed from the London Library for Annie in her last winter, there were two set-pieces: the illness and death of Ben the young shepherd in William Howitt’s Boy’s Country Book, and of Lady Eleanor in The Earl’s Daughter by Elizabeth Sewell. The disease also claimed two of the main characters in Elizabeth Wetherell’s The Wide, Wide World, the novel about the American child with a writing case which Emma read to her grandchildren. The book is now mocked by many for its sanctimonious tearfulness, and it seems strange at first that Emma, with her extreme reticence and distrust of emotional display, should have read it. But it was a melodrama like those which she had loved as a young woman at the theatre in London. The young heroine, Ellen Montgomery, cried and wept in different ways in different situations, and quite as often it was the suppression or utter lack of tears which expressed her emotion.
Elizabeth Wetherell wrote in rich detail about Ellen’s life in a small town in New York State, and dwelt eloquently on her hesitant but growing faith in God, but she never named the illness which killed Ellen’s mother and her closest friend Alice, and she wrote nothing about any physical symptoms. Yet the hints and silences left no doubt, and Ellen showed the familiar pattern of denial. When Alice revealed her condition, Ellen could not believe what she had told her. “To her mind it seemed an evil too great to happen; it could not be! . . . ‘But have you seen somebody?—have you asked somebody?’ said Ellen,—‘some doctor?’ ‘I have seen, and I have asked,’ said Alice; ‘it was not necessary, but I have done both. They think as I do.’ ‘But those Thirlwall doctors—’ ‘Not them; I did not apply to them. I saw an excellent physician at Randolph, the last time I went to Ventnor.’ ‘And he said—’ ‘As I have told you.’ Ellen’s countenance fell—fell.” Later, Alice’s father responded in the same way. “It was impossible at first to make Mr. Humphreys believe that Alice was right in her notion about her health. The greatness of the evil was such that his mind refused to receive it, much as Ellen’s had done.” In Emma’s copy of the book, these passages are marked with a straggling pencil line.
There is no hint in the Darwin family papers of a belief that Annie might have had consumption, but it was almost certainly the main unspoken fear. Emma’s brother-in-law, Charles Langton, had lost nine brothers and sisters from the disease, and himself suffered an attack in 1833 which alarmed the Wedgwoods and the Darwins. Charles’s father had judged that cousin Allen Wedgwood who had christened Annie at Maer was consumptive; Emma’s sister Elizabeth had a severe spinal deformity which may have been due to tuberculosis, and there was a belief in the family that Charles’s brother Erasmus had tuberculous damage to one lung. Herbert Mayo’s Philosophy of Living which Charles read in the late 1830s described a kind of child who was likely to become consumptive. Among the points believed to be characteristic was that the child’s mind was “quick, forward, intelligent, [and] touched with a high degree of sensibility and gentleness.”
The water treatment which Dr. Gully prescribed for Annie may also have been devised as a regime suitable for the early stages of consumption. Dr. Yeoman wrote: “Water is one of the best prophylactics of disease that beneficent nature has provided for us, and in the malady now under consideration, when judiciously employed, is of considerable utility.” Dr. Gully followed Sir James Clark in his belief that there was no cure for “confirmed consumption,” but suggested that the water cure might be effective in its early stages. He wrote in The Water Cure in Chronic Disease that he was “convinced, that the judicious use of the water treatment reduces the harassing evils of consumption, the hectic, sweatings, bad sleep, and languor, and prolongs existence to some extent.” “Is it not gain to be spared even a little of the stupor of opiates, the exhaustion of bad sleep and sweatings, which are the ‘heavy day on day’ of patients in consumption? . . . th
ese can be in great measure avoided, notwithstanding the unceasing onward progress of the miserable malady.”
The nature of all diseases was a mystery to Charles, but he had to take account of death by disease at a number of points in his thinking about natural life and human origins. In 1838, he had noted how hydrophobia, cowpox and many other diseases were shared between man and animals, and saw the point as “proof of common origin of man.” He returned to the theme many years later in The Descent of Man, mentioning that humans shared consumption with monkeys, and suggesting that the two-way communication of diseases between man and animals “proves close similarities of tissue and blood far more plainly than does comparison under the best microscope.”
The strength of heredity was a central strand in his thinking from before his marriage until the end of his life. He wrote about his grandfather Erasmus that he “fully recognised the truth and importance of the principle of inheritance in disease,” and he paid particular attention to it himself. In a note he made in 1838, he used the point to illustrate his fundamental insight into the lack of direction or purpose in the processes of variation and inheritance. “It should be observed that transmission bears no relation to utility of change. Hence harelips [are] hereditary, [and] disease.” Thirty years later, in The Variation of Animals and Plants Under Domestication, he wrote: “Unfortunately it matters not, as far as inheritance is concerned, how injurious a quality or structure may be if compatible with life. No one can read the many treatises on hereditary disease and doubt this.” He cited consumption alongside epilepsy, asthma and cancer as examples.
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