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 with {421} or 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 by {422} mishap 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,[4] and early tinnitus.
[Footnote 4: Burnett, 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,[5]
the 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.
[Footnote 5: Gellé.]
The acute attack is nearly always preceded by more or less deafness,
and in many cases by middle-ear catarrh,[6] with 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.
[Footnote 6: Burnett.]
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
patient {423} described 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.[7]
In 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.
[Footnote 7: Burnett.]
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 permanent
{424} tinnitus. 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.
OCULAR CAUSES OF VERTIGO.—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
vessels {425} or 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,[8] and 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.
[Footnote 8: _Practitioner_, 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 deal {426} with 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.
[Footnote 9: Ramskill and others.]
The TREATMENT of 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
middle {427} life 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.