BYS. WEIR MITCHELL, M.D.
BYS. WEIR MITCHELL, M.D.
DEFINITION.—The clinical meaning of vertigo has gone, as is common, far beyond what the term implies. We may define vertigo to be a sense of defective equilibrium, with or without actual disturbance of position, and accompanied by varying amounts of subjective feelings of motion of external objects, of the body itself, or of the contents of the cranium.
SYMPTOMATOLOGY.—Vertigo consists of attacks which are single or repeat themselves during a continuous condition lasting for hours or days, and which I have elsewhere described as the status vertiginosus.1
1Med. and Surg. Rep., June, 1877.
The mildest form of vertigo is that in which the patient has a sensation of the contents of the head as being in motion. If more severe, there is disturbed equilibrium, an effort is needed to stand erect, or there is, as in most vertigo, a fear of falling. The brain seems to be moving round or upward. This type is found in insanity, in hysteria, and in the vertigo of mental effort observed in extreme cerebral exhaustion.
In a second clinical species of vertigo the patient appears to himself to be in motion, while outside objects maintain for him their places. This may or may not be accompanied with sensory disturbance or an approach to mental confusion. It is really a delirium of movement. The patient feels as if he were rolling or falling or reeling or dropping through space. Meanwhile, however grave the hallucination, he walks and stands without the least sign of defect in balancing power. These cases are very rare, but are sometimes seen as temporary results of hysteria.
Perhaps it is doubtful whether we should really class this symptom-group as vertigo.
The more common or typical expression of vertigo is marked in its fulness by a false sense of the movement of external objects and of the relations in space of the individual to such objects. The pavement rolls or seems to be coming up in front of him; the houses stand at angles; walls, pictures, chairs, and tables reel around him, are still a moment, and again move; or the bed seems to be aslant or to rock to and fro. In extreme instances objects are seen as if inverted, and whenever the vertigo is marked the victim reels or falls, or seeks by rest supine or by closing his eyes to lessen the terrors of the attack. In severe examples no such help avails, and for hours or days the patient may lie clutching at the bed for support or in deadly fear of a new onset of vertigo,which in some cases is brought on by the least movement of the head, by taking food, by efforts to think, or by mechanical vibrations.
In most cases there is some mental confusion, or even brief loss of consciousness at the close of the attack, and nearly always more or less nausea or vomiting occurs—symptoms which have frequently misled observers as to the cause of the vertigo, but which have in most cases only the significance gastric disturbance has in migraine. As in that disorder, but more rarely, the emesis may be associated with or replaced by looseness of the bowels, and is very apt to be followed by a flow of pale clear urine.
Fits of vertigo are often as distinct clinically as epileptic attacks. The patient has for a few moments, in an acute form, all of the phenomena of vertigo, and may then recover promptly, or it may chance that he has a vertiginous status and a series of fits, or remains for long periods in a state of chronic disorder of head, with now and then an acute onset.
Physicians do not often witness these fits: I have been so fortunate as to see several. I take this description of one from my notes: A young clergyman, after excessive overwork among the poor, came to consult me for vertigo. As I talked to him an attack came on. I asked him to keep as composed as possible and to tell me what he felt. He said: “It has just begun. The objects in the room are moving from right to left; I can seem to hold them still for a moment, then they go on and move faster. If I shut my eyes it is relief, but only for a time. I feel myself as if I were now going round with them. The chair rocks, and my brain seems moving too.” At the same time he became very pale, and slipped from his seat. His pulse was quick and feeble and rapid, and as he lay on the floor unconscious a profuse sweat broke out on his face. In a moment he was again himself, but did not recover so as to walk for a half hour. He then complained of headache, but was able to walk home. This is a fair example of a fit of vertigo, due, as it proved, to at least two of the causes of vertigo, which I shall presently discuss.
A few persons insist that something like a distinct aura precedes the attacks. In other cases the brain symptoms develop gradually, from a faint sense of dizziness up to a tumultuous feeling of confusion with sensory illusions. In a few rare cases there is, as in that above mentioned, an abrupt onset. Something seems to snap in the head, and the vertigo follows; or, most rare of all, we have a sensory discharge felt as light or sound, and followed by the ordinary symptoms.2
2See the author in lectures onNerv. Diseases, Disorders of Sleep, p. 63, 2d ed.
DIAGNOSIS.—Vertigo is of course, as a rule, only a complex symptom of one or more numerous conditions. Acute isolated fits of vertigo are sometimes puzzling, because epilepsy may be preceded by brief vertigo and exist without notable spasms. Time may bring to us a frankly expressive epilepsy to explain former and less distinct fits. But usually it is the attacks of vertigo which are the causes of doubt. A man has sudden giddiness, and falls unconscious for a moment. These attacks persist. How shall we know them as vertigo? how be secure that they be not some form of the lesser epilepsy? As a rule, if they be vertigo there will be nausea or emesis, while the intervals between attacks will offer the usual signs of confusion of head, fear of losing balance, and all the numerous evidences of disturbed and easily excitable states of thesensorium—conditions rare in the interepileptic periods. The effect of bromides may aid the diagnosis, for, although often of use in vertigo, they have not such power to inhibit the fits as they possess in epilepsy. Persons long liable to any form of vertigo can readily cause attacks, or at least vertiginous feelings, by closing the eyes while standing, by the least rotation, or by putting a prism on one eye, so that among these tests we may frequently find the material for a diagnosis, which will of course, in many instances, be made easy enough by the presence of causes obviously competent to occasion the one or the other disease.
PROGNOSIS.—In true vertigo, if we exclude the organic causes, and especially intracranial neoplasms, there is very little to be feared. Deaths have been seen in Menière's disease, but are most rare. Even in grave examples of labyrinthine vertigo there is a probability that the worst which can occur will be deafness, and that vertigo will gradually cease as the delicate neural tissues become so degenerated as to cease to respond to irritations.
TheDURATIONof other forms of vertigo it is less easy to predict. Ocular vertigoes get well soon after the eye trouble is corrected, and the like is true of most vertigoes due to peripheral causes. So also the giddiness which is sometimes seen as a very early symptom in locomotor ataxia is transient, and will be apt, like the ocular and bladder troubles which mark the onset, to come and go, and at last to disappear entirely. It is to be remarked that vertigo at the beginning of posterior sclerosis is common, and is not due to ocular motor conditions.
Sometimes in vertigo, as in epilepsy, the removal of a long-existing cause may not bring about at once a cessation of the abnormal symptoms its activity awakened, so that it is well, as to the prognosis of duration, to be somewhat guarded in our statements. Nor is this need lessened by the fact that vertigo may be an almost lifelong infliction, without doing any very serious damage to the working powers of the person so disordered.
ETIOLOGY.—It is generally taken for granted that vertigo has always for its nearest cause some disorder of cerebral circulation; but while either active congestion or anæmia of brain may be present with vertigo, and while extreme states of the one or the other are certainly competent to produce its milder forms, it does not seem at all sure that they are essential to its being. Indeed, there is much reason to believe that vertigo is due in all cases to a disturbance of central nerve-ganglia, and that the attendant basal condition is but one incident in the attack.
In vertigo there are the essential phenomena, as disturbed balance, with a false sense of movement within or without, or of one's self. Then there are the lesser and unessential phenomena, which vary in kind and degree, and these are the moral and mental symptoms—terror, confusion of mind, and sensory illusions; and, last, the nausea and sickness met with here as in migraine, and the flow of clear, thin urine.
All of these symptoms should be accounted for in speaking of the intracranial organs, disorder of which causes vertigo. Ferrier has especially made it clear that equilibration involves afferent impressions, co-ordinative centres, and efferent excitations preservative of balance.
Guiding impressions, which direct the muscles through centres below the cerebrum, so as to aid in preserving our balance, reach these centresfrom the skin and the muscles, so that great loss of tactility or of the compound impressions called muscular sensations results in disturbance of equilibrium, but not in true vertigo, which is clinically this and something more.
A second set of impressions, of use in preserving equilibrial status, come through the eye, or rather habitually through the eyes, because the consensual impressions arising out of double vision and the co-ordinate movements of the two fields of sight have, as is well known, much to do in this matter. It is hardly needful to dwell on this point. Certain parts of the ear have, however, the largest share in maintaining our balance, and it seems likely that the semicircular canals—the part most concerned—although lying within the petrous part of the temporal and receiving nerves from the stem which constitutes the nerve of hearing, may have slight relations or none to the sense of audition.3When the horizontal canals are cut, the head moves from side to side and the animal turns on his long axis. When the posterior or lower vertical canals suffer, the head sways back and forward, and the tendency is to fall or turn over backward. When the upper erect canals are cut, the head moves back and forward, and the tendency is to turn or fall forward.
3I have seen a single case of vertigo, with slight deafness on both sides, in which the sense of the position of sounds was absolutely lost.
In pigeons, injury on one side may get well, but when the canals are cut on both sides there is permanent loss of balance. In some way, then, these little organs appear to be needful to the preservation of equilibrium; and of late some interesting attempts have been made to explain the mechanism of this function. It probably depends on the varying pressure relations of the endo-lymph to the nerve-ends which lie in the membranous canals.
Wm. James of Harvard has shown that total loss of hearing is usually accompanied by lessened susceptibility to vertiginous impressions, so that the stone-deaf are not apt to be seasick or giddy from rotation, owing to their having lost the organ which responds to such impressions. It would seem also that the entirely deaf have peculiar difficulty in certain circumstances, as when diving under water, in recognizing their relations to space.
There is a general tendency to regard the cerebellum as the centre in which all the many impressions concerned in the preservation of equilibrium are generally received and made use of for that purpose. There may be several such centres, and the matter is not as yet clear. Whatever be the regulative ganglion, it seems clear that it must be in close relation to the pneumogastric centres, to account by direct connection or nerve-overflow for the gastric symptoms. But, besides this, vertigo has clinical relation to moral and mental states not easy to explain, and in extreme cases gets the brain into such a state of excitability that mental exertion, emotion, strong light, or loud sounds share with the least disorder of stomach capacity to cause an attack.
Vertigo may be due to many forms of blood-poisoning, as at the onset of fevers, inflammations, the exanthemata—notably in epidemic influenzas. It may arise in malarial poisoning, sometimes as the single symptom, as well as in diabetes, albuminuria, lithæmic conditions, and in all the disorders which induce anæmic states. Common enough as sign of braintumor, and especially of growths in or near the cerebellum, as a result of degenerated vessels, it is also not very rare in the beginning of some spinal maladies, especially in posterior sclerosis, and is not always to be then looked upon as of ocular origin.
Alcohol, hemp, opium, belladonna, gelsemium, anæsthetics, and tobacco are all, with many others, drugs capable of causing vertigo.
In hot countries heat is a common, and sometimes an unsuspected, cause of very permanent vertigo.
Lastly, excess in venery, or, in rare cases, every sexual act, profound moral and emotional perturbations, and in some states of the system mental exertion, may occasion it, while in hysteria we may have almost any variety of vertigo well represented. Outside of the brain grave organic diseases of the heart are apt to produce vertigo, especially where the walls of the heart are fatty or feeble from any cause. Suppression of habitual discharges, as of hemorrhoids or menstrual flow, is certainly competent, but I have more doubt as to the accepted capacity of rapidly cured cutaneous disease.
The following are some of the more immediate causes of vertigo: They are disorders of the stomach or of the portal circulation; laryngeal irritation; irritation of the urethra, as passing a bougie, especially when the patient is standing up; affections of nerve-trunks; nerve wounds; sudden freezing of a nerve (Waller and the author); catarrhal congestion of the nasal sinuses; inflammation and congestion of inner ear, many irritations of the outer and middle ear; prolonged use of optically defective eyes; insufficiency of external muscles of the eye.
It will be needful to treat of some of these causes of vertigo in turn.
Gastric Vertigo.—Trousseau certainly misled the profession as to the frequency of this form, but he did little more than represent popular medical views, and we may now feel sure that a good many so-called gastric vertigoes are due to lithæmia or to troubles of ear or eye. There are, I think, three ways in which the gastro-duodenal organs are related to the production of vertigo. Acute gastric vertigo arises in some persons inevitably whenever they eat certain articles, and the limitations are odd enough. Thus, I know a gentleman who cannot eat a mouthful of ice-cream without terrible vertigo, but otherwise his digestion is perfect. I know another in whom oysters are productive of vertigo within ten minutes; and a curious list might be added, including, to my knowledge, milk, eggs, oysters, crabs, etc. In these cases digestion is arrested and intense vertigo ensues, and by and by there is emesis and gradual relief.
In other cases, owing to over-feeding or any of the numerous causes of acute dyspepsia, an individual has a sudden attack of acid stomach, and as this gets to its worst he has alarming vertigo. In these cases the room whirls around or the pavement rocks; the balancing power is disturbed or lost; the sense of movement in the brain itself is sometimes felt; there are slight buzzing or humming sounds in one or both ears; there may be double vision, which comes and goes, while the power to think is lessened and the terror created is quite unendurable. At last come the sweat of nausea, emesis, and relief, with a gradual fading away of all the symptoms.
As a rule, such an attack need cause no uneasiness as to a fatal result, but, unless the case be handled with skill, it is apt to repeat itself withor without repetitions of the originating cause, until what I have called the status vertiginosus is created, and we have more or less steadily present a slight sense of defective balance, of confusion of mind, of blurred vision, and, more rarely, of slight noises in the ears. After two or three grave attacks, attacks are added for which the patient sees no cause. He lives in a state of constant terror, and the status vertiginosus attains its highest development, and may last for unlimited periods, while the brain becomes endowed with new morbid susceptibilities. To read, to write, to face sudden sunlight, to see moving bodies or passing crowds, cause vertigo. Loud sounds disturb the balance; even music will affect it. Emotions or any decided mental efforts are equally competent to bring on attacks, while fatigue or sudden changes of posture have to be alike avoided.
I have sketched an extreme case, but whatever causes grave vertigo is able to bring on the set of symptoms here described, which are, after all, more apt to be due to aural than gastric states.
Vertigo as a result of chronic dyspepsia in any of its forms is rare, and as a rule is less severe than that which grows out of acute gastric dyspepsia. The sensory symptoms are trifling, and the confusion of head and the lack of balance less notable, while the vertigo, which is more or less constant, seems to be most often met with two to four hours after meal-time, so that it is usually doubtful as to how much is due to reflected impressions from the digestive tracts, and how much to the direct influence of imperfect material in the circulation.
In a third form the gastro-intestinal tract is but indirectly concerned. In a person who is anæmic, or who is nervous and perhaps hysterical without being anæmic, but in whom it is impossible to detect in the stomach or bowels, in the feces or urine, any sign of defective digestion or of malassimilation, we find that during the act of digestion there is at some time, and in a few cases constantly, some transient but not grave vertigo.
This is due simply to the influence exerted on an over-sensitive head of a normal functional activity, which may act directly as any peripheral cause would act, or may be due, in the anæmic, with this to the withdrawing of blood from other parts of the body which occurs in digestion. It is an illustration of what is too often overlooked, the capacity of a healthy functional act to disturb morbidly a sensitive brain.
Aural Vertigo.—Vertigo may be due to a variety of irritative causes acting on the outer, middle, or inner ear. We shall consider them separately.
Vertigo from Causes acting on the External Ear.—In animals I have found that the injection of iced water or a rhigolene jet into the meatus is at once the cause of convulsive movements in the rabbit, and that repetitions of this cause at last a permanently vertiginous state, so that when a rabbit or guinea-pig thus disordered was shut up in darkness for some hours, sudden sunlight caused it to be for a few moments vertiginous. It is remarkable that while in birds many parts of the skin are competent under irritations (Weir Mitchell, Ott, Brown-Séquard) to give rise to vertiginous phenomena, in mammals only the skin of the external auditory meatus appears to be thus responsive. The author was himself the best illustration of this fact. Some years ago, when bymishap water at about 52° F. was thrown into his left ear, he fell instantly on his left side, with slight disturbance of vision, the room seeming to rock in the direction of the fall—that is, to the left. He arose with some difficulty, his head swimming, and with a distinct sense of lack of power in the whole left side, and with, for a half hour at least, an alarming tendency to stagger to the left.
Thus, injections of cool water in some cases (or in others of water at any temperature), and in certain persons very hot water, will cause vertigo. Foreign bodies—hardened wax, aspergillus, ulcers—or any inflammation may occasion it, while it is curious that usually the painful abscesses of the ear do not, especially in children, who are, as a rule, less liable to vertigo than are adults.
The tendency of aurists is, I believe, to explain the phenomena by either direct influence propagated as sound-waves through the auditory apparatus to the labyrinth, or by admitting inhibitory impressions affecting the vaso-motor loops and causing increased pressure in the semicircular canals. I am disposed to think that the effect may be a more direct one, and to regard the centres as directly influenced through the fifth nerve, including vaso-motor phenomena of course—a question to be, however, easily solved in the laboratory.
In this form of vertigo tinnitus is slight or transient, coming and going, or if permanent but faintly felt.
Middle-ear vertigo may arise from any inflammation of the part or from closure of the Eustachian canal. There are then direct mechanical influences affecting the labyrinth, as well as sensory irritations, not causing auditory phenomena; whilst also the inner ear is apt soon to suffer from direct propagation of inflammatory processes. There is then paroxysmal vertigo, variable hearing,4and early tinnitus.
4Burnett, Sect. Otol.,Int. Med. Cong. Proc., 1876.
Inner-ear vertigo seems to be due to irritations, auditory, mechanical, or inflammatory—whatever disturbs seriously the nerves of the semicircular canals, since, if we may trust recent research,5the cochlea is not a source of vertiginous impressions. This form of vertigo was first described with pathological proof by Menière in 1860, and is probably in its variety of degrees the most common of all the origins of dizziness.
5Gellé.
The acute attack is nearly always preceded by more or less deafness, and in many cases by middle-ear catarrh,6with or without tinnitus. More rarely all the symptoms arise abruptly. There are sudden tinnitus, deafness, nausea, vertigo. The loss of hearing remains, and is variable, or, finally, the hearing is lost altogether. The tinnitus is permanent or varies in amount, but as the deafness grows complete the vertigo disappears, and although cases of death have been described, labyrinthine vertigo is, as a rule, prone to get well in time.
6Burnett.
Single attacks are rare. It is apt to repeat itself, and finally to cause all the distressing cerebral symptoms which characterize the worst gastric vertigo, and at last to be capable of easy reproduction by light, heat, over-exertion, and use of the mind or eyes, by emotion, or by gastric disorder.
Even after the vertigo has ceased to exist the fear of loss of balance remains, while perhaps for years the sense of confusion during mental effort continues, and gives to the sufferer a feeling of what a patientdescribed to me as mental vertigo—some feeling of confusion, lack of power to concentrate attention, loss of hold on trains of thought, with now and then a sensation as if the contents of the cranium moved up or down or swayed to and fro.
The attack in the gravest forms is often abrupt, and, according to Charcot, is always preceded by a sudden loud noise in the affected ear. I have, however, notes of many cases in which this was not present. The patient reels, staggers, or falls, usually forward or to one side, loss of consciousness being very rare. The sensory hallucinations are remarkable. If at rest or after his fall he seems to himself to sway, and tends to pitch or roll over; the bed rocks, the room and its contents reel. The patient's terror is intense; he clutches the bed; seeks relief in fixing his eyes on an object, which in slight attacks is competent to relieve, or else he closes them. The least motion starts the vertigo afresh. In some cases turning the head or looking up will bring it back, or the patient may remain for days or weeks in this condition, with continuous dizziness and frequent recurrences of severe vertigo, while there is more or less constant nausea and sometimes vomiting.
There should be no trouble in distinguishing the cases in which deafness exists, but the nausea is apt to direct attention to the stomach. Tinnitus is common in vertigo, however arising; and when, as I am sure does chance, there is for years now and then a slight and transient deafness with vertigo, or a permanent deafness in one ear, and therefore not noticed, the inner ear is apt to be overlooked as a source of trouble.
Vertigo from growths on the auditory nerve before it enters the inner ear is rare in my experience. It is described as slow in its progress, the deafness and tinnitus being at first slight, but increasing steadily, while there is tendency to fall toward the side affected.7In the cases of disease attacking the seventh nerve within the cranium there is usually so much involvement of other and important nerve-tissues as makes the disorder of audition and equilibration comparatively unimportant.
7Burnett.
Vertigo from coarse organic lesion of brain, such as a tumor, is common, and is, indeed, rarely absent in such cases. The cases in which it is lacking or least remarkable are, I think, to be found in the anterior and middle cerebral lobes, while it is almost sure to exist at some time when the tumor is in or near the cerebellum.
Growths or other causes of irritation in the crura of the cerebrum or cerebellum, or on the pons, are sure to give rise to disturbed equipoise or to methodical involuntary actions; but these are not always, though often, accompanied with delusive impressions as to exterior objects, or with the other symptoms found in typical vertigo. I recall one remarkable case where a blow on the left side of the occiput resulted in a tendency to roll to the left which finally triumphed over volitional control, so that the patient would at times roll over on the floor until arrested by a wall. After the rotation had lasted for a minute there was, when it ceased, a false sense of movement of objects to the left, but at the outset there were no sensory illusions, and at no time any mental disorder. The patient recovered, and is now in good health; but it is interesting to learn that while, during the time of these attacks, he had normal hearing, he has gradually lost hearing in the left ear and acquired permanenttinnitus. I have reached the conclusion that there is a group of functional vertigoes, and that in some of them the trouble lies in the semicircular canals; that is to say, the lesion is slight or transient, but in rare cases recurs until a more distinct and permanent result justifies the original diagnosis.
OCULARCAUSES OFVERTIGO.—For the most part, the eyes as a source of vertiginous impressions are neglected in the textbooks; but as the cause of certain of the slighter vertigoes, and as a fertile agent in emphasizing or recalling vertigoes due to the stomach or inner ear, they are well worthy of careful study, nor is it ever wise to neglect these organs in cases either of headache or of vertigo.
A number of eye conditions cause giddiness or increase it or reproduce it. Thus, sudden loss of accommodation in one eye or in both may occasion it, and perhaps the enlarged pupil may have its share, since even in healthy people, and surely in all habitually vertiginous patients, sudden exposure to brilliant light gives rise to sense of instability.
Abrupt change in intraocular pressure is another cause, as in acute glaucoma or in sudden partial collapse of the eye from discharge of the aqueous humor.
Permanent vertigo of quite severe character may arise from astigmatic defects, and from almost any form of disorder affecting steadily the power of the eye to accommodate itself to distances; but simple myopia of moderate grades, excessive one-sided myopia, or presbyopia is unlikely to do so. Oculo-motor troubles, paralytic or spastic, are very effective causes of vertigo, which is sometimes quite promptly producible by the wearing of a prism on one eye or by the use of glasses which over-correct, or if exact are for some reason badly borne. This latter is apt to be the case, I think, in accurate corrections of long-standing hypermetropic astigmatisms. There is one point on which, in this connection, I have again and again insisted: Optically defective eyes may exist through life without notable brain disturbance, unless, from over-use with worry, work under pressure, the strain of prolonged or of brief and intense emotion, or any cause of ill-health, the centres become sensitive, as they are then apt to do. When this occurs defective eyes, and in fact many other sources of irritation, grow at once into competence for mischief, and occasion vertigo or headache or other cerebral disorders.
Then it is that even slight defects of the eye may cause vertigo, which if usually slight and transient, coming and going as the eyes are used or rested, is sometimes severe and incapacitating. I have over and over seen vertigo with or without occipital pain or distress in persons whose eyes were supposed to be sufficiently corrected with glasses, but who found instant relief when a more exact correction was made; and this is, I think, a matter which has not yet generally received from oculists the attention it demands.
When vertigo, essential, gastric, or aural, is present, the use of the normal eye becomes a common source of trouble. Bright lights, things in irregular motion, reading or writing, and especially rapid changes in accommodation, as watching the retreat or approach of a moving object, are prone to cause or increase the dizziness.
Vertigo in old age, if not due to the stomach or defective states of the portal system, kidneys, or heart, is either caused by atheromatous vesselsor multiple minute aneurismal dilatations of vessels, or in full-blooded people by some excess of blood or some quality of blood which is readily changed by an alteration in the diet, of which I shall presently speak. Whatever be its source, it is in the old a matter of reasonable anxiety.
Laryngeal Vertigo.—Under this name J. R. Gasquet,8and later M. Charcot, have described a form of vertiginous attack in which irritation of the larynx and a spasmodic cough invariably precede the onset. I have never seen such cases, nor do they seem to me entitled to be called vertigo. The symptoms are these: After bronchitis, gout, or rheumatism there occurs an irritation of the larynx or trachea, or of both, which at times is expressed in the form of a tickling cough, simple or in spasms. With these arises a slight sense of vertigo, or else in the grave attacks the patient falls insensible, without convulsion or with no more than one may see at times in fainting. The face is flushed, even deeply, and the attacks last but a few moments. The term vertigo seems to have in such a group of symptoms but little application, nor do these attacks ever bring upon the sufferer the status vertiginosus.
8Practitioner, Aug., 1878.
Vertigo in Anæmia and in Neurasthenia and Hysteria.—A passing vertigo readily caused by abrupt changes of posture, felt even in health, at times is far more profoundly experienced in grave anæmic states, while in neurasthenic conditions, with deficiency of globules or defect of hæmaglobin, it is still more common. In well-pronounced neurasthenic states, where there is no measurable lack of red corpuscles, but where hæmaglobin is apt to be deficient, it is a frequent symptom, and is then either an immediate result of functional central disorder or of gastric or optical troubles. While the dizziness of neurasthenia is never profound, certainly never repeats the agony of Menière's vertigo, it is apt to be but a too constant symptom, and to be, like the other disqualifying cerebral symptoms of neurasthenia, almost the last to get well. Usually there is little, often no, tinnitus, no deafness, no nausea, slight but a pretty constant sense of unsteadiness, and rarely or but for a few moments any false subjective visual illusions. This, at least, is the type, but, on the other hand, in extreme cases and within these limits the brain is liable to be confused, and the sense of need for difficult controlling volitions called out by almost any use of the eyes in near vision, owing usually to oculo-muscular paresis. Even looking at a mirror or at persons passing by, or the least distinct mental effort, may reproduce it. There is, too, in most of these cases an extreme sense of mental confusion, and more often a false sense of movement within the head than without, while in no other patients is the sexual act so apt to increase all of the symptoms in question.
Hysteria, as might be expected, offers now and then examples of vertigo. It does not exclude the presence of true aural, optic, or gastric dizziness, which is then apt to become the starting-point of a long train of hysterical disorders. On the other hand, we meet with hysterical vertigoes which, in a sense, may be said to simulate any of the more usual types. I have certainly seen hysterical girls with deafness, tinnitus, and a great development of equilibrial disturbance, in whom the disease passed away without leaving a trace behind it, so that in these cases some caution is needed as to prognosis. They become far more difficult to dealwith when they are found in old women or women in advanced middle life, since it is then hard to know what share senile changes may have in the production of the symptoms.
Vertigo from mechanical causes, such as sea-sickness, railway sickness, swinging, etc., it is hardly worth while to deal with here at length. The research of Prof. James has made it probable that disturbances of the labyrinth are responsible for the vertigo of sea-sickness. Certainly, deaf-mutes seem to have lost the power to be made vertiginous from rotation, and do not suffer at sea.
It is, however, worth recording here that I have more than once seen enduring vertiginous status, with occasional grave fits of vertigo, arise out of very prolonged sea-sickness. In the last example of this sequence seen by me there was, after a year or more, some deafness.
The elevators in use in our hotels sometimes cause, in those who live in them all day and control their movements, a cumulative vertigo, and I have known such persons to be forced on this account to seek other occupation.
Essential Vertigo.9—There can, I think, be no doubt that the centres may evolve the symptom vertigo from causes which are transient, and the nature of which sometimes evades our most careful search. We reach the diagnosis of a state of essential or true central vertigo by exclusion, but, once developed, this vertigo does not greatly differ from vertigo of peripheral cause. It is sometimes associated with states of pallor, at others with flushing, while the disturbance of balance and the false perceptions as to the place of outside objects may vary from the least to the most profound disturbance. In some of these examples the nausea or emesis does not appear at all, and the patient, escaping acute attacks altogether, may with occasional aggravation continue to be merely and almost constantly vertiginous.
9Ramskill and others.
TheTREATMENTof acute attacks of vertigo, however caused, consists, of course, in rest in bed and in the use of large doses of bromides or hydrobromic acid, and if the trouble be grave in that of hypodermatic injection of morphia, and where there is plainly pallor of face in inhalations of amyl nitrite or in the exhibition internally of nitro-glycerin and alcoholic stimulants. Sometimes to lie on the floor in total darkness is helpful when the disorder continues and is severe. I have known patients liable to be attacked suddenly to carry a little flask of brandy, and to find that very often an ounce of brandy, taken at the first sign of trouble, would enable them, by also lying down, to break the attack; and ether is yet more efficient. After the severer sense of vertigo has gone they find that stimulus is comforting, and for a time at least gives strength. I have used amyl nitrite but twice. In each case it is said to have broken the attack, but I have had no larger experience with it.
Gastric vertigo demands, in the acute attacks, a treatment directed to the cause. Antacids may be valuable, or in arrested digestion emetics, but in all cases these should be followed for some weeks by moderate doses of bromides, while gouty or lithæmic states should be treated by the usual means.
Vertigoes from portal disturbances are best treated by aperients, and a like lessening of animal food, which, in the vertigo of old age or middlelife arising from excess of blood, will also be found available. The change of cerebral states of passive congestion, which can be brought about by a pure vegetable or milk-and-vegetable diet is sometimes quite remarkable; and I know of few things in therapeutics which are more satisfactory.
The treatment of anæmic or neurasthenic vertigo involves nothing peculiar. So long as the want of blood lasts, or some one of the several groups of symptoms loosely classed as neurasthenia exists, so long will the associated vertigo endure.
Aural vertigoes are easy or difficult to treat, as they arise from external or middle and internal ear troubles. Irritations in the external ear are of course to be removed, and catarrh of the middle ear to be treated by attention to its conditions, whether of blocking of the Eustachian canals with depression of the membrana tympani or of accumulations in the middle ear, with the opposite state of fulness. Aural vertigo, as has been pointed out, may arise from disorders of any part of the ear, so that it is needful to look for wax, ulcers, foreign bodies, etc. in the external meatus; for catarrhal states, closure of the tubes of Eustachius, states of fulness or of vacuum in the middle ear; and for inflammatory conditions, direct or transmitted, in the inner ear. Very often vertigoes from irritations of the outer or middle ear may be relieved with more or less ease, but labyrinthine vertigo, however acquired, is always troublesome, often lasting, and if grave gets well only when deafness has become great.
In this form of vertigo, and while acute, morphia is very serviceable, and is to be used with full doses of bromides. When, as happens, both cease to be of value, Charcot's plan of the heroic use of quinia salts I have seen do good; but it is advisable to use with it hydrobromic acid in full doses. It has been constantly my practice to employ over the mastoid or on the neck frequent but not deep cauterization. It is well in these cases to warn some near relative that while remote relief from the vertigo is probable, it will be bought at the cost of increasing deafness, and that we can rarely do more than help the patient to endure his state until time and the slow processes of pathological change have come to our aid.
Optic vertigo, if essentially that, is rarely discovered without the help of some one trained to study the defects of vision. Its relief demands, of course, as a rule, glasses, or in extra-optical muscle-troubles these or a compensatory operation. When, however, the vertigo has been grave, it is needful to manage corrections of the eyes with care and judgment, and sometimes experimentally. The sensorium, having become over-excitable, does not always bear accurate correction of the eyes, or this increases the vertigo. Then the glasses are cast aside and the case progresses. In others—and this is purely a matter of individual experimentation—nothing will answer except the most careful and absolute corrections: anything less does no good.
These remarks apply with equal force in chronic vertigoes, essential, gastric, or other. Defective eyes, unfelt in health, soon begin to trouble a head sensitized by chronic dizziness, and optical defects which are sometimes but trifling become then competent to increase the growing intracranial disorders, or to assist lithæmia or a troublesome stomach to create and sustain vertigo.
The Status Vertiginosus.—I have tried to make clear elsewhere and in this article that in several forms of vertigo the disorder ceases to owe its onsets to extracentral irritations, and becomes essential, precisely as happens in some epilepsies, and that we then are apt to have, with more or less distinct attacks or with no attacks, long continuance of a group of symptoms which constitute the status vertiginosus. Its treatment is important, because of its alarming and disqualifying effects. The attacks are often the least part of it, while the lack of power to read and write, to go into crowded streets, to face light, or to exercise, or stand emotions or the slightest mental strain, surround its management with embarrassments, and are well fitted to end in melancholia or hypochondriasis.
In these cases, after the eye has been corrected, the diet should be regulated with care. In extreme cases it may become desirable to limit it to milk, fruit, and vegetables where no obvious peculiarities forbid such a regimen; and I have found it useful to insist also on some food being used between meals.
I like, also, that these patients rest an hour supine after each meal, and spend much time out of doors, disregarding their tendency to lie down. Exercise ought to be taken systematically, and if the vertigo still forbids it, massage is a good substitute. At first near use of the eyes is to be avoided, and when the patient resumes their use he should do this also by system, adding a minute each day until attainment of the limit of easy use enjoins a pause at that amount of reading for a time.
Now, as in vertigo, especially labyrinthine, the eyes become doubly valuable as guiding helps to correct equilibration, I have long found it useful to train these patients to stand and walk with them closed. At first this is as difficult, or may be as difficult, as in locomotor ataxia, but the practice is sure to add steadiness to the postures. Somewhat later I ask my patient deliberately to make such movements of the head and such efforts of mind or memory as are apt to cause vertigo or confusion of head, and to conquer or inhibit these consequences by a prearranged effort of will; and these means also I have found useful. Meanwhile, nothing usually in these cases forbids the use of tonics or of moderate doses of bromides. As I have said, change of air is very serviceable. It is indeed rare that cases do not yield to some such combination of means, but very often it will happen that the fears of the patient are his most grievous foes, and are to be dealt with after every real symptom has vanished.