Feature Christmas 2009: Diagnosis

Darwin’s illness revisited

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4968 (Published 14 December 2009) Cite this as: BMJ 2009;339:b4968

Darwin and Meniere revisited

Many diagnoses of Darwin’s illness have been offered in the previous
responses, but Meniere Spectrum Disorder can be considered their
underlying cause or final common pathway or as tapping a common
physiological disorder.

Sir Clifford Allbutt (alias Tertius Lydgate), who studied under Drs
Bence-Jones and Meniere, gave an excellent description of Meniere’s
disease (1). Provided it was considered, he said it was common and easy
to diagnose, but was often misdiagnosed as intestinal problems. It could
cause flatulence. He recognised a vestibular variant, labyrinthine

Mitochondrial disorders often cause ear disease. In one prominent
case (2), vomiting was definitely triggered by otitis media, a common
cause of vomiting in children. Fluid in the middle ear with low middle
ear pressure is likely to affect inner ear fluid pressures and upset the
vestibular system.

Darwin was diagnosed with neurasthenia (3) in 1901, which then (4)
usually presented with morbid head sensations – dull heavy feeling, like
[cotton] wool. Onset may have been with an explosive sensation, or
tinnitus and deafness. Goodhart seldom saw typical cases of Meniere’s
disease yet he clearly recognised the Menieriform picture and conceded
that there may be irritative or destructive lesions of the semicircular
canals even in those with strong family history of neurosis. This
illustrates the paradox still prominent today, that the more severely the
ear affects the psyche, the less interested otologists are and the less
sympathy the patient gets from society, including psychiatrists. Goodhart
accepted that there were hundreds of neurotics who fought and struggled
and tried not to give in. He recognised neurotic vomiting, especially in
children, but said it was of cerebral not gastric origin. Likewise,
flatulence went with the debilitated nervous system. These cases often
ended up as chronic tinnitus and progressive deafness, with comprehension
problems when several people were talking.

Kempf’s (3) diagnosis was anxiety neurosis, Freud’s (5) term for a
subset of neurasthenia. A very prominent symptom was vertigo, which Freud
said differed from Meniere’s vertigo. (While this is usually
characteristically rotatory, it does not follow logically or clinically
that other forms of giddiness or dizziness are non-Menieriform.) Also seen
as part of or secondary to these attacks were agoraphobia,
audiosensitivity, insomnia, diarrhea, nausea, biliousness, hunger,
paresthesia, exhaustion, palpitations, sweating, shuddering and anxious
expectation. He doubted if vertigo was ever of gastric origin.

Although known for over a century, the substantial comorbidity
between migraine and Meniere’s disease has only recently been generally
recognised. In a prospective study (6), 8% of migraineurs had Meniere’s
disease (all women aged 31 to 60y); Meniere spectrum symptoms
(audiosensitivity, tinnitus, vertigo, fluctuant deafness, aural fullness,
and right-sided canal paresis, often in combination) were very common in
the rest, clearly implicating the peripheral labyrinth.

The proposal of these other disorders or diagnoses only adds further
evidence for his underlying Menieriform disorder.

1. Anon. St George’s Hospital Reports. Am J Med Sciences 1877;74:491-
2. Boles RG, Chun N, Seadheera D, Wong LJ. Cyclic vomiting syndrome and
mitochondrial DNA mutations. Lancet 1997;350:1299.
3. Kempf EJ. Charles Darwin – the affective sources of his inspiration and
anxiety neurosis. Psychoanal Rev 1919;5:151-192.
4. Goodhart JF. Common neuroses, or the neurotic element in disease and
its rational treatment. Lancet 1892;139:123-9.
5. Freud S. Collected papers. Vol 1. London, International Psycho-analytic
Press, 1924.
6. Dash AK, Panda N, Khandelwal G, Lal V, Mann SS. Migraine and
audiovestibular dysfunction : is there a connection? Am J Otolaryngology

Competing interests:
None declared

Competing interests: No competing interests

13 January 2010
Anthony G Gordon