palliation of the attacks and to their prevention. So little is known
of the direct cause of the disease that it is difficult to lay out any
distinct course to be followed. Many cases, however, which seem to
depend upon a run-down state of the patient are vastly improved by a
course of tonics and building up. I have often seen anæmic and feeble
women whose attacks were frequent become exempt for a long period by
simply taking iron, quinine, and strychnia, and taking an increased
amount of nourishment. The rest-treatment of Weir Mitchell is
particularly applicable to these cases. In persons whose digestion is
bad, and who suffer from constipation, much can be done by relieving
these conditions. Some cases which are due to uterine disturbances are
benefited by treatment directed to the womb. There are many cases,
however, in which no cause is apparent. The patient is well nourished,
his eyes are good, he undergoes no strain mentally, morally, or
physically, and yet the attacks of migraine come with tolerable
regularity. In these persons change of climate sometimes works
marvellously beneficial results. I saw last year a young lady who
suffered from terrific headaches which sometimes lasted for days. No
plan of treatment or regimen seemed to exert the slightest influence
upon the attacks, and yet on going to the far West for the summer she
remained without an attack during the whole time she was there. In
some individuals all forms of treatment may be tried in vain.
Anti-periodics have been tested, but with doubtful benefit. Cannabis
indica is probably the most potent remedy which is at our command. Its
effects are most decided, and many cases of severe hemicrania have
been cured by this means alone. It must be given for a long time, and
in some instances it is necessary to give gradually-increasing doses
up to the physiological effects. The drug must be of good quality,
otherwise we need expect no good from it. Indian hemp is well known to
be variable in strength, and the best form in which to use it is a
fluid extract made by some reliable chemist. Arsenic, phosphorus, and
strychnia do not seem to do as much good as in other neuralgias,
except so far as they build up the general health.
Ergot has been used with success as a curative means, and it probably
{414} acts by contracting the vessels of the medulla oblongata. A
combination of ergotin and extract of cannabis indica may be given
together; and if persisted in for a long time will often be of benefit
in lessening the frequency of the attacks. The prolonged use of one of
the bromides is sometimes found curative.
Anstie has found the careful use of galvanism to the head and
sympathetic of positive advantage in keeping off attacks, and
Eulenburg has had the same experience.
In the treatment of the attack the patient should be freed from all
sources of external irritation. He should lie down in a darkened room,
and all noises should be excluded. If the attack is of the hyperæmic
variety, the patient's head should not be low, as this must favor
increase of blood to the head. In this form the patient is often more
comfortable sitting up or walking about. Occasionally an impending
attack can be warded off by the administration of caffeine, guarana,
or cannabis indica. Purgatives are of but little value in this form of
headache. The local application of menthol or of the oleate of
aconitia to the brow of the affected side will sometimes prevent an
attack. If a person can lie down quietly when he feels an attack
coming on, one or two doses of fifteen grains each of the bromide of
lithium will enable him to sleep, and wake free from pain. I have
found the lithium bromide far more valuable in migraine than any other
of the bromides. An effervescing preparation known as bromo-caffeine
is often efficacious in aborting a paroxysm or in palliating it when
it has got under way.
Quinine, in my experience, seems to be of little use in preventing or
cutting short a paroxysm of migraine, although Ross[11] has found that
a dose of ten or fifteen grains may arrest it. Ergot has been found
useful, and, as it acts by contracting the arterioles, should be given
only in the angio-paralytic form. The fluid extract of ergot may be
administered, but ergotin in pill form is more acceptable to the
stomach.
[Footnote 11: _Diseases of the Nervous System_, vol. ii. p. 558.]
Inhalations of nitrate of amyl have been used with advantage. Berger,
who was the first to employ this remedy, found that a single
inhalation of a few drops relieved the pain at once, and it did not
return that day. It is indicated only in the sympathico-tonica type.
If it is used, two or three drops of the nitrate in a glass pearl may
be crushed in the handkerchief and inhaled. Nitro-glycerin may also be
given in this variety of migraine.
Once the attack has begun fully, we can only attempt to mitigate the
pain. Firm pressure on the head generally gives relief, and encircling
the head firmly with a rubber bandage is often of great comfort.
Compression of the carotids gives temporary but decided ease to the
pain. Strong counter-irritation in the shape of a mustard plaster to
the nape of the neck or a stimulating application, like Granville's
lotion, to the vertex, will afford relief. I have found in some cases
that placing a hot-water bag, as hot as could be borne, against the
back of the head alleviates the pain. In other instances cold affords
more relief, and an ice-bag resting upon the forehead is the most
efficacious way of applying cold. Hot bottles to the feet are an
accessory not to be overlooked.
In the way of medicine we may give the bromide of lithium every hour.
The bromide of nickel has been recommended by DaCosta as {415} having
peculiar advantages. Cannabis indica may be given in doses of a
quarter of a grain of the extract every two hours until relief is
obtained. Anstie believes strongly in chloral, and says that a single
dose of twenty or thirty grains will often induce a sleep from which
the patient wakes free from pain. The same writer advises the
administration of muriate of ammonium, but it is too nauseous a dose
to be given when the stomach is as much disturbed as it usually is in
an attack of migraine.
Croton chloral is preferred by some to the chloral hydrate. Ross, for
example, gives it in doses of five grains every four hours until
relief is obtained.
Galvanism through the head is often of relief, especially at the
beginning of an attack; but this means is not often available, for it
is not easy to have the suitable apparatus for the constant current at
a patient's home when it is needed. Should galvanism be used, one pole
should be placed on each mastoid process, and a weak current passed
through the head for two or three minutes. The sympathetic may be
galvanized by placing one pole over the upper cervical ganglion, just
behind and below the angle of the jaw, while the other pole is held in
the hand or placed upon the sole of the foot. In hemicrania spastica
the positive pole is put over the ganglion, and in the angio-paralytic
type the negative pole is placed in this location.
Should all of the above means fail, we may resort to morphia
hypodermically. Jewell[12] favors the administration of morphia and
atropia, either by the mouth or hypodermically, from the beginning of
an attack until the pain is eased; but I believe that morphia, except
as a last resort, is very undesirable in migraine. Although a small
dose hypodermically will usually promptly bring relief, there are the
unpleasant after-effects of opium felt, and the patient feels more
prostrated and with more disordered digestion than had no morphia been
used. Besides, the morphia habit is liable to be formed, especially in
women, when the drug has once begun to be taken.
[Footnote 12: _Journal of Nervous and Mental Diseases_, 1881.]
It is for this reason that I prefer to use the bromides, and if a
patient is seen at the beginning of a paroxysm, given a fifteen-grain
dose of bromide of lithium, his feet put in hot mustard-water, and he
then goes to bed, he will almost always cut his attack short, and on
waking from sleep will feel refreshed and able to take food.
I am strongly convinced of the importance of arresting or shortening
the paroxysms of migraine, especially in the young, at the beginning
of the disease. By this means the habit of long attacks is prevented,
and their prostrating after-effects are avoided. Should we succeed in
checking the first few attacks, we may by tonics and regimen improve
and fortify the constitution so as to eradicate or modify the
neuralgic tendency.
{416}
VERTIGO.
BY S. 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]
[Footnote 1: _Med. 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, {417} 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]
[Footnote 2: See the author in lectures on _Nerv. 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 the {418} sensorium—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.
The DURATION of 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
centres {419} from 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.[3] When 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.
[Footnote 3: I 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 brain {420} tumor, 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.