Vestibular migraine (VM) and Menière’s disease (MD) in the writings of Aretaeus of Cappadocia and in the Chinese book Huangdi Neijing

During a systematic search of the literature for ancient descriptions of fear of heights and seasickness in the Chinese Medical Classics and Greek antiquity, two reports of vertigo syndromes that strikingly resemble today’s definitions of vestibular migraine (VM) and Menière’s disease (MD) were discovered. These descriptions appeared in the book of Aretaeus of Cappadocia De causis et signis acutorum et chronicorum morborum and in Huangdi Neijing, the Yellow Thearch’s Classic of Internal Medicine, a book that lays the theoretical foundation for Chinese medicine.

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Aretaeus of Cappadocia

The Greek physician Aretaeus was born in Asia Minor, Cappadocia, at the end of the reign of the emperor Hadrian in the 2nd century AD. Eight books of his work contain extensive descriptions of the aetiology, features, and treatment of different diseases. Two were preserved: De causis et signis acutorum et chronicorum morborum and De therapia acutorum et chronicorum morborum. In the first of these he examines headache and differentiates, apparently for the first time, between different forms of headache: a chronic type (κεφαλαίη, cephalea), a brief type lasting up to several days (κεφαλαλγίη, cephalalgia), and heterocrania (ετεροκρανίη), which later evolved into ‘hemicranias’, from which our word ‘migraine’ is derived.

To the best of our knowledge no historical descriptions of VM have so far been published.

The term was first coined in 1999. In the meantime VM has become a well-recognised medical entity and the most frequent cause of a spontaneous episodic vertigo syndrome. It is also the most common cause of episodic vertigo and dizziness in children. A chameleon of sorts among the episodic vertigo syndromes, VM is characterised by the variety of its clinical manifestations, especially as regards its duration (from minutes to days) and severity.

in Book III in the chapter entitled ‘Περί κεφαλαίης’, ‘About headache’. Here he notes that hemi-headache can be accompanied by vertigo, and even movements of the eyes:

‘This type of headache is called heterocrania . . ..The face is distorted spasmodically, the eyes remain glassy and rigid like horns or move to and fro forcedly, and the patient is dizzy . . .’

In this chapter Aretaeus points to other symptoms accompanying VM such as the patients’ nausea, vomiting of black bile, and slumping down. They avoid light and feel relief when in the dark. Their sense of smell may be impaired, and they may even feel a weariness of life, ‘taedium vitae’.

In the next chapter, entitled ‘Περί σκοτωματικών’ or ‘About vertigo’, a physical state is mentioned in which darkness befogs the eyes, the head whirls, and the ears hear sounds of a river murmuring; this condition is called pioquka (skotoma), i.e. vertigo. Moreover, this symptom may arise from the head (in the sense of headache – cephalea), and subsequently a severe condition develops. One has to be careful when interpreting the word ‘scotoma’ since the vestibular organ was not known at the time and the word was also used to mean ‘to darken’ or ‘make dim-sighted’. The following attributes are used to describe the symptoms of scotoma:

‘. . . they sense a heaviness of the head and a pronounced darkening of the sense of sight; flying threads float before their eyes; they are aware of neither themselves nor those around them. And when the illness worsens, the forces that keep them upright become so weak that they crawl on the ground. They are overcome by a nausea and have to vomit watery, bilious, brightly yellow or black fluids’

The fundamental cause of scotoma is ascribed to dampness and cold.

If the disease progresses and becomes intractable, then it may lead to other diseases such as melancholy, which may be preceded by nausea due to black bile. The classical authors tried to explain the cause of diseases within the framework of the humoral theory of Empedokles and Aristoteles valid at the time: the four body fluids (χολή = yellow bile, φλέγηα = phlegm, μέλαινα χολή = black bile, αίμα = blood) were said to be out of balance. It was also used to explain the pathophysiology of seasickness.

Nowadays the pathophysiology of migraine aura is usually considered to be a transient cortical ‘spreading depression’. The symptoms of VM could be classified as brainstem aura in the sense of a non-cortical spreading depression.

Huangdi Neijing

Huangdi Neijing has two parts, the ‘Lingshu’ and the ‘Suwen’, both dating back to somewhere between the 2nd century BC and the 2nd century AD. The book presents the fundamental principles of Chinese medicine and provides lively descriptions of vertigo in different situations, e.g. at heights. The Yellow Thearch, Huang Di, is considered a cultural hero who bestowed the gift of medicine on the Chinese people. The book is mostly written in the form of dialogues between Huang Di and his physicians. One vertigo syndrome described in this book resembles MD.

The full picture of MD was first described by Prosper Menière’ in 1861; it is the second most frequent cause of peripheral vestibular vertigo. MD is characterised by recurrent attacks of vertigo lasting minutes to hours with unilateral hearing loss, tinnitus and a feeling of fullness in one ear.

The Chinese character ’dizziness’ (xuan) is used to define a malfunction of the eyes in one of the ancient dictionaries (Shuowen Jiezi) dating from the 1st century. The character has a semantic indicator for ’eye‘ on the left side and the phonetic character ‘xuan’ on the right side. The latter stands not only for the semantic field dark, black, darkness, unsureness but also suggests how the character is pronounced. It thus evokes an image of how it becomes dark before the eyes during dizziness. Later the character stood for different types of dizziness, which were never clearly differentiated. Dizziness is interpreted to be an optical phenomenon and thus a malfunction of the eyes which is evident in the most important character for dizziness. Already in the 4th century BC the eyes were associated with the liver and its function in Chinese medicine. In the Huangdi Neijing Suwen is written: ‘[diseases with] wind [that causes] tumbling and dizziness belong without exception to the liver’. In all cases involving optical phenomena, the liver is immediately considered the cause.

Chinese thinking connected climatic phenomena, cardinal directions, and calendric constellations with the actions of specific forces in the world and in the human body. Based on such systematic correspondences, this form of quasi-scientific, rational Chinese medical theory is called a medicine of correspondences. Dizziness was associated with the element/phase wood, wind, the liver, and the eyes. The brain (in our modern meaning) is also associated with the phenomenon of dizziness. It is interesting that otherwise the brain virtually plays no role in traditional Chinese medicine: It is not one of the six yin (zang) nor one of the six yang organs (fu). More often it is described as a storage organ of a substance called and translated as ‘marrow’, which is equated with the spinal cord. Thus, in one of the oldest and most fundamental texts of Chinese medical theory there is nevertheless a conceptual connection of the brain with the phenomenon of dizziness. This suggests there was anatomical knowledge of a connection between the brain and the eyes, but not with the ears. It is interesting that this theoretical ‘eye connection’, which was apparently based on anatomy, was not thematised in later works. In general the anatomy of the human body was never, with very rare exceptions, investigated in China. In the Chinese view the flawless operation of bodily function is closely connected with all parts of the body receiving an adequate supply of specific body substances, such as blood and the vital force Qi. Various subdivisions included essences (jing), blood (xue) and Qi, conceived as implementations or various aggregate conditions of the same life force Qi. Assertions are made about the significance of the body substances in connection with dizziness. The only functional link between brain, eyes, and ears is related to hearing symptoms:

‘If Qi is insufficient above, the brain is not sufficiently filled by it, the ears suffer a ringing noise, the head is bent low by it, the eyes [experience] dizziness’.

Here the brain is to be understood as the ‘sea of marrow’, i.e. the storage site of the marrow – a substance of the body. Thus, dizziness occurs with tinnitus and an imbalance of the head due to deficient Qi in the head. The following citation from the chapter ‘Discussion of the sea’ refers to the same subject matter:

‘If the sea of marrow is not sufficiently filled, the brain begins rotating around, the ears ringing, the calves/shins suffer from sour pains and the veil-dizziness (xuanmao) appears, the eyes can see nothing and passivity and hypersomnia occur’.

This combination of a ringing in the ears and dizziness is similar to the current diagnostic criteria for MD, but the pathophysiological explanations differ from our current views.

(Source: “Descriptions of vestibular migraine and Menière’s disease in Greek and Chinese antiquity”, by Doreen Huppert and Thomas Brandt)

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Research-Selection for NovoScriptorium: Maximus E. Niles

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