Robert Lewis Stevenson (1850-1894) was one of the best-known authors of his day. He was a paradox; he traveled widely, yet was weak and sickly all of his life. He spent much of his life in bed or in a sickroom, yet he wrote wonderful adventures like Kidnapped and Treasure Island.

Even as a small child, he had chronic lung ailments, with frequent cough, breathing problems, and spitting up blood. Because of his frail condition, he rarely attended school and was taught by tutors at home. He recollected these early years in the well-known poem “Counterpane”,

When I was sick and lay a-bed, 
I had two pillows at my head, 
And all my toys beside me lay 
To keep me happy all the day….

As an adult, he reminisced about spending long days and nights in bed, often lulled to sleep by his father, who would sit at his bedside and weave imaginary conversations with ship captains, shopkeepers, and others. This fueled Stevenson’s imagination.

Remarkably thin, he had frequent health scares. There is no proof what his chronic illness was; doctors of the time assumed it was tuberculosis. After all, his mother had a chronic pulmonary ailment, believed to be tuberculosis, and during Stevenson’s lifetime, TB killed about a quarter of the adult population in Europe. Stevenson, like many TB sufferers, traveled widely, searching for purer air, the only treatment at the time. His travels took him throughout France, the Swiss Alps, a health resort on the English Channel, the US Adirondack Mountains and eventually, to the American west coast. Dry California air was good for him, and he recovered some of his health. He and his family spent several years sailing among the Pacific Island, and finally, settled in Samoa.

Perhaps it was not tuberculosis. While he was in a New York TB sanitarium in the Adirondacks, his sputum was tested; no TB bacteria were seen. This was a brand-new test, and we don’t know how accurate it was. Regardless, he continued to have frightening coughing fits and hemorrhages. He wrote, “I have written in hemorrhages . . . written torn by coughing . . . few are the days when I am not in some physical distress.” In fact, he named his hemorrhages “my old friend Bluidy Jack”.

There are speculations he may have had bronchiectasis. This is a chronic lung condition in which the architecture of the lungs becomes abnormal, with pouches that trap mucus. Bronchiectasis can be congenital or can develop after a severe lung infection. The most common symptoms are coughing up sputum, shortness of breath, and clubbing of fingers. Stevenson certainly had enough pulmonary infections to cause bronchiectasis, however, photographs and paintings of him do not show the fattened spade-like fingertips known as clubbing. Nevertheless, it remains a strong contender.

Another intriguing possibility is a rare disease, Hereditary Hemorrhagic Telangiectasia (Osler-Rendu-Weber Syndrome). HHT is an inherited condition in which there is a mutation in the genes that regulate the growth of blood vessels. People tend to develop clusters of complex spider veins, fragile blood vessels that rupture and bleed easily. Most spider veins are of cosmetic concern only, but in HHT, these weak-walled veins can grow in the lungs, liver, brain, stomach, and nasal passages. This would explain his chronic respiratory complaints, recurrent episodes of frightening bloody coughing, and his death, at age 44 years, of probable cerebral hemorrhage. It would also explain his mother’s apparent stroke, at age 38 years. HHT was only described a couple of years before Stevenson’s death, and was not widely understood, so it is not likely he would have been diagnosed with this during his lifetime, if indeed that is what he had.

There’s another clue; Stevenson was always unusually thin. Now, any chronic illness can lead to cachexia (thin, wasted body habitus), and this was typical in tuberculosis. In fact, the common name of TB was consumption, due to the belief that the body was being consumed by the illness. In John Singer Sargent’s famous painting of Stevenson, he is amazingly slim. Stevenson himself, upon the occasion of his wedding, described himself as “. . . a mere complication of cough and bones, much fitter for an emblem of mortality than a bridegroom.” The historian Henry James visited Stevenson in Samoa and wrote, “Imagine a man so thin and emaciated that he looked like a bundle of sticks in a bag….” A doctor who cared for him before his death was amazed at his frailty and thinness. “How can anybody write books with arms like that?” he asked.

I’m curious about the possibility of Cystic Fibrosis. People with Cystic Fibrosis have a genetic deficiency in the glands that make mucus and sweat. Because of this, thick sticky mucus builds up in lungs, and the digestive tract. This leads to persistent cough, frequent lung infections, inability to fully digest food, stunted growth, difficulty gaining weight and shortened lifespan. This disease would certainly explain his chronic cough, frequent infections, and cachexia.

Alas, we will never know, because he died long before there were definitive tests for these diseases. Despite his poor health, his mind and imagination went on wonderful trips, leaving us classic stories of adventures and excitement.