Q J Med 2014; 107:945–946
doi:10.1093/qjmed/hcu159 Advance Access Publication 1 August 2014
Commentary
The vampire in medical perspective: myth or malady?
R.P.P.W.M. MAAS and P.J.G.M. VOETS
Address correspondence to R.P.P.W.M. Maas, Radboud University Nijmegen, Faculty of Medical Sciences,
Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands. Email: roderickmaas@student.ru.nl
Introduction
The vampire is a fascinating creature that has
captured man’s imagination ever since its first descriptions. Throughout the years and all over the
world it has been portrayed in various—sometimes
conflicting, but more often relatively similar—ways
in folklore, books and movies. Some well-known
examples are the Transylvanian count Dracula, the
sasabonsam from West African folklore and the
manananggal from the Philippines. The aversion to
garlic and sunlight and a victim’s similar fate after a
bite seem to be recurring elements.1,2 On closer inspection the physical and behavioral features of the
vampire show striking and intriguing similarities
with three relatively rare medical conditions discussed in this article: porphyria, rabies and pellagra.
Porphyria
The association between vampirism and porphyria is
probably the most famous one. Porphyria refers to a
group of disorders characterized by a defect in one of
the enzymes involved in the synthesis of heme. As a
consequence, accumulation of porphyrins (toxic
heme precursors) occurs in various organs, depending on the specific subtype.3 Although porphyria cutanea tarda and acute intermittent porphyria are the
most common forms, it is congenital erythropoietic
porphyria that is in particular associated with vampirism.1 This autosomal recessive disorder, also known
as Günther’s disease, is characterized by pronounced
photosensitivity and chronic hemolytic anemia.3
The classical aversion of the vampire to garlic may
be accounted for by the ability of certain compounds
of this bulbous plant to induce the heme degrading enzyme heme oxygenase-1,4 thereby further
exacerbating the anemia. Furthermore, in the presence of sunlight accumulated uroporphyrin I and
coproporphyrin I are able to donate electrons to
oxygen, resulting in the formation of reactive
oxygen species and severe skin damage.5 In addition,
secondary infections and bone resorption may
induce severe scarring and deformities of sunexposed body parts. Accumulation of toxic porphyrins not only occurs in skin, but also in bones and
teeth,3 giving rise to the characteristic erythrodontia
that may have readily been attributed to the drinking
of blood in former days. In this way, vampires might
theoretically replenish their heme stores and thus
partially correct the state of chronic anemia. Further
analysis, however, reveals the fraction of heme in the
circulation after oral intake to be negligible and craving to be absent among porphyria patients.1
Rabies
The association between vampirism and rabies was
first described in 1733.6 Three years after, the
French theologist Augustin Calmet wrote that
people who died from rabies had an increased
chance of ‘returning’ (as a vampire).7 Rabies is
caused by a lyssavirus that is transmitted through
animal saliva—usually after a bite of the with vampires associated bat, wolf or dog—and quickly
travels along the peripheral nervous system by retrograde axonal transport. After a phase with nonspecific, prodromal symptoms, such as fatigue and
periwound paresthesias, an encephalitic or (less frequently) paralytic illness develops. The encephalitic
or ‘furious’ form is clinically characterized by hydrophobia, muscle spasms, agitation, insomnia and
bizarre—beastly or hypersexual—behavior.8
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From the Radboud University Nijmegen, Faculty of Medical Sciences, Nijmegen, The Netherlands
946
R.P.P.W.M. Maas and P.J.G.M. Voets
coffin can simply be accounted for by the normal
decomposition process of the human body. For
instance, fresh blood around the mouth and a distended—‘satiated’—abdomen are often noted in the
deceased as a result of increased pressure due to
intestinal gas accumulation.2
Should we therefore conclude that a disease is an
insufficient explanation for the vampire myth? Not
necessarily. As mentioned earlier, various creatures
with similar appearance, abilities and behavior have
been described independently by different peoples
all over the world. Although this might be sheer coincidence, these similarities in depiction may point to
a common ‘source of inspiration’ which could very
well be a medical condition that is seen all around
the world. Most likely, other influences, such as indigenous animals or local beliefs and traditions, may
have colored the portrayals of the vampire from
region to region. In summary, although it would not
be justified to conclude that the vampire myth definitely has medical roots, there certainly are arguments
that at least partially favor this hypothesis.
Pellagra
Conflict of interest: None declared.
A deficiency of niacin and its precursor molecule,
the essential amino acid tryptophan, gives rise to the
so-called four D’s of pellagra: dermatitis, diarrhea,
dementia and, unless proper treatment is initiated,
death. Photosensitivity is a hallmark of this disorder
that is dermatologically characterized by erythema,
edema—and in long-established disease—hyperkeratosis and hyperpigmentation, most notably of
the neck (‘Casal’s necklace’) and dorsal surfaces of
the hand.10 Furthermore, erythematous glossitis is
often present and it is not hard to imagine the link
between this symptom and fangs, dripping with
blood.11 Insomnia and aggression could provide
an explanation for the behavior of the vampire.
Lastly, due to scarce resources in former days, nutrient deficiency would seem an epidemiologically
plausible explanation for the vampire myth.
Conclusion
In the previous sections, we have described similarities between three relatively rare medical conditions and the characteristics of vampires, as they
are described in folklore and the more contemporary books and movies. Although porphyria, rabies
and pellagra each provide some sort of medical justification for the vampire myth, none of these diseases seems to present a conclusive explanation for
the sum of properties and phenomena. Furthermore,
it seems likely that some of the vampire’s features
that were observed in a corpse after opening the
References
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There are several links between hydrophobia and
vampires. Streaming water is one of the apotropaia
or repellent substances and, according to folklore,
the chance of transforming into a vampire could
be decreased by sprinkling water on the coffin of
the deceased.2 Hydrophobia is characterized by
severe laryngeal muscle spasms in response to drinking or even seeing water, often accompanied by
coughing up blood and exposing the teeth. Even
one’s own reflection could trigger laryngeal
spasms, which might explain the vampire’s fear of
mirrors.2 The beastly biting behavior of the infected
patient, a means to transmit the virus, could explain
how vampirism was transmitted from one person to
another. Both this behavior and the insomnia which
could explain the vampire’s nightly escapades, are
the result of dysregulation of the limbic system, an
important and early site of neuronal damage and
inflammation in furious rabies.9 Finally, as opposed
to the rare forms of porphyria, rabies was a relatively
common condition in former times.