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even two or three months. I have seen a number of patients who
have attacks of migraine on Sunday with regularity, and escape
during the interval. Some of these cases ascribed the attacks to
sleeping later on this day than on others, but it is more likely that the
attacks were the result of the culminating effect of a week's hard
work. Between the attacks the patient is usually quite well as far as
headache is concerned, but he may have slight neuralgia in
branches of the trigeminal. The attacks are more or less alike. They
are often preceded by prodromal symptoms for a day or two. The
patient may feel languid or tired for a day before the attack.
Sometimes there is unusual hunger the night before a paroxysm, or
there may be violent gastralgia before each attack. The patient often
wakes in the morning after sound sleep with a pain in the head.
Should the attack come on in the day, it may be preceded by
chilliness, yawning, or sneezing and a sense of general malaise.
Ocular symptoms are frequent as a forerunner of an attack. First
muscæ volitantes are seen, then balls of fire or bright zigzags
appear before the eyes, making it impossible for the patient to read.
These symptoms last for a few minutes or a half hour, and then
cease, to be immediately followed by pain. Hemianopsia is a
precursory symptom of rather frequent occurrence. Ross mentions a
case in which the hemianopsia usually lasted about a half hour, and
was followed by severe hemicrania. The ocular symptoms are often
very alarming to patients.

The pain, as a general rule, is at first in the ophthalmic division of the

fifth nerve and its branches. It may begin in the branches of the
occipital nerve or in the parietal region. It comes on gradually, is dull
and boring at first, but becomes more intense and spreads to one
lateral half of the head, more especially the front part. As it increases
in intensity the pain seems to involve the entire head. Either side of
the head may be affected. Eulenburg thinks that the left side is
attacked twice as often as the right. An individual may have the pain
on opposite sides of the head alternately in different attacks. The
pain is described by patients as dull and boring or intense, and the
head feeling as if it would burst. Patients often make pressure on the
head to obtain relief. At times the pain seems to be of a violent,
throbbing kind, keeping time, as it were, with the pulsation of the
arteries. Lying down usually relieves the pain, but if it is violent the
recumbent position seems to favor the afflux of blood to the head,
and thereby increases the pain. The eye of the affected side
becomes bloodshot, and the tears stream from it. The eyelid droops,
and the sight is dim and clouded or may fail entirely. The least light is
unbearable. During the attack the subject is chilly and intensely
depressed, and the feet are very cold. The pulse is at first slow,
small, and compressible.

Painful points (Valleix's points) are not present, but there is usually
tenderness over the supraorbital notch during an attack of migraine,
and after the paroxysm there is a general soreness of the scalp and
forehead. Sometimes there remains a tenderness of the parts
surrounding the affected nerve. This is not in the nerve itself, but in
the adjacent tissues. Anstie9 says that in his own case, after
repeated attacks of migraine, the bone had become sensibly
thickened in the neighborhood of the supraorbital notch. There is
sometimes hyperæsthesia of the skin in the affected regions of the
forehead and scalp during an attack. As well as hyperæsthesia,
there may be an abnormal acuteness of the sense of touch. Deep
pressure over the superior and middle ganglia of the sympathetic
causes pain, according to Eulenburg. This observer also states that
the spinal processes of the lower cervical and upper dorsal vertebræ
are painful on pressure.
9 Op. cit., p. 182.

During the attack of migraine there is complete loss of appetite, and

any food that may be taken remains undigested in the stomach for
hours. As the pain intensifies there comes on a sense of nausea,
there is a profuse flow of saliva, and large quantities of limpid urine
are passed. Finally, when the pain seems to have reached its
maximum, vomiting occurs. Immediately afterward the pain is greatly
increased, but this is the result of the increased amount of blood in
the cranial cavity from straining. Soon after, the patient is easier, and
falls into a sleep, from which he awakes free from headache. The
crisis is not always accompanied by vomiting. In some instances
there is no nausea, but at the acme of the pain there are two or three
profuse diarrhœic stools, after which the pain is relieved. I have
lately seen such a case in a young man of twenty-three years of age.
Sometimes there is only a profuse sweat or large flow of urine.

During the attack there are disorders of the circulation. The pulse
may be intermittent or irregular, and the extremities are usually cold.
Disorders of cutaneous sensibility are also often present. A condition
of numbness confined to one lateral half of the body is sometimes
experienced during the early part of the paroxysm. This numbness is
noticed even in one half of the tongue.

The German writers have divided migraine into two types, and the
arrangement may be followed in some instances. The first is called
hemicrania spastica or sympathico-tonica. In this form there is
supposed to be vascular spasm and a diminished supply of blood in
the brain. The symptoms are as follows: When the attack has
reached its height the face is pale and sunken; the eye is hollow and
the pupil dilated; the arteries are tense and feel like a cord. The
external ear and the tip of the nose are cold. Eulenburg10 states that
by actual measurement he has found the temperature in the external
auditory meatus fall 0.4° to 0.6° C. The pain is increased by
stooping, straining, or anything which adds to the blood-supply in the
head. At the end of the attack the face becomes flushed and there is
a sense of heat. The conjunctiva becomes reddened, the eye is
suffused, and the pupil, which had been dilated, contracts. The
sense of warmth becomes general, the pulse is quickened, and the
heart palpitates. The crisis is reached with vomiting and a copious
flow of urine or perhaps a diarrhœic stool. There is sometimes an
abundant flow of saliva. One observer has reported that he has
estimated a flow of two pounds of saliva during an attack.
10 Op. cit.

The other variety is termed hemicrania angio-paralytica or neuro-

paralytica. Here we find the opposite condition of things from that
met with in hemicrania spastica. There is marked increase in the
amount of blood in the brain. When the attack is at its height the face
on the affected side is flushed deeply, hot, and turgid. The
conjunctiva is injected, the lachrymal secretion increased, and the
pupil contracted. Sometimes there is slight ptosis. The ear on the
affected side is hot and red. The temperature of the meatus may rise
0.2° to 0.4° C. The temporal artery is swollen, and throbs with
increased force. The carotid beats visibly. There is free perspiration,
which is sometimes unilateral. Compression of the carotid on the
painful side relieves the pain, while pressing on the opposite carotid
makes it worse. The heart beats slowly, the pulse being sometimes
as low as 48 to 56. At the end of the attack the face becomes paler
and the other symptoms subside.

There are many cases in which the vascular conditions present no

peculiarities during the attack, and which cannot be classed with
either of the varieties just described.

In all forms, if the patient can be quiet, he usually falls asleep after
the crisis has been reached, and awakes free from pain, but feeling
haggard and prostrated.

The paroxysm lasts for several hours, generally the greater part of
the day. It may last for several days, with variations of severity. The
attacks are at longer or shorter intervals of time, and in women they
often appear at the menstrual period. The attack may be brought on
by over-mental or bodily exertion, imprudence in eating or drinking,
and exposure to cold draughts of air. It will often begin as a
supraorbital neuralgia from exposure to cold, and go on through all
the phenomena of a regular migraine.

Seizures are often brought on by fatigue, and there are some

persons who invariably have a violent attack of migraine after a
journey. Nursing women are liable to more frequent paroxysms, and
I have recently seen a lady who within a few days after delivery after
both of her confinements suffered from typical attacks of migraine,
although during gestation she had escaped them.
DIAGNOSIS.—Migraine can readily be distinguished from the other
forms of headache by the comparative regularity of the attacks and
its numerous other characteristics. It differs from neuralgia in the
pain being less acute and shooting. The pain of migraine is more dull
and throbbing, and extends more generally over the head. The
ocular phenomena are more or less constant in migraine and do not
occur in neuralgia.

PROGNOSIS.—Migraine is never fatal, and usually becomes less

severe and less frequent as middle life is reached. Some patients
continue to suffer from it during their entire life, and often when the
typical migraine has ceased it is replaced with paroxysms of
neuralgia. Therapeutic and hygienic means are of decided influence
in the course of the disorder, and many patients experience great
relief or temporary immunity from attacks as a result of treatment.
Cases of long standing and those of an hereditary type are most
unfavorable as to relief from treatment or by spontaneous cure.

PATHOLOGY AND MORBID ANATOMY.—Migraine not being a fatal

disease, we know nothing of the changes which exist in the brain; we
can only surmise what are the conditions which exist in the brain
during and before an attack.

It is evident that there is a strong relationship between migraine and

neuralgia of the trigeminal nerve, and if we study the symptoms of
the two conditions, and consider the causes which produce attacks
of each, we cannot but arrive at the conclusion that migraine is a
variety of a neuralgia of the ophthalmic division of the fifth. The late
Anstie has most clearly and forcibly given his reasons for believing
this to be the case, and we cannot but uphold his view.

Migraine is constantly met with in early life as the type of a neuralgia

which in later years loses the special features of a sick headache
and becomes a pure neuralgia. The same forms of trophic lesions
may occur in migraine and in trigeminal neuralgia. Anstie instances
his own case, in which in early life he had distinct attacks of
migraine, with corneal ulceration, orbital periostitis, and obstruction
of the nasal duct, while later in life his attacks were only neuralgic,
without any stomach complications.

Migraine, as already remarked, attacks early life especially at the

time of sexual development, and the same is true of epilepsy. There
is also the same hereditary predisposition to the former as to the
latter. Patients who have migraine belong often to families other
members of which suffer from epilepsy, chorea, and an
uncontrollable tendency to alcoholic excesses. Indeed, occasionally
migraine and epilepsy are interchangeable in the same individual.
Many cases of epilepsy have suffered at some time of their lives
from severe headaches.

Hughlings-Jackson describes the attacks of migraine as arising from

a discharging lesion of the cortex of the brain in the sensory area, or
in that part of it which corresponds to the region of pain in the head.
Genuine epilepsy he holds to be due to a discharging lesion from the
motor area of the cortex. During an attack of migraine the
discharging lesion does not remain confined in the sensory portion of
the cortex, but extends into the medulla oblongata and the cilio-
spinal region of the cord, causing irritation or paralysis of some of
these centres, and causing the vaso-motor and oculo-pupillary
symptoms which are conspicuous during an attack.

In the form of migraine known as hemicrania sympathico-tonica

there is tonic spasm of the vessels of one side of the head. This
explains the pallid face, the lowered temperature, and the sunken
eyes. After the cause of the contraction is removed, then the vessels
relax and the amount of blood-supply greatly increases. Hence the
redness of the conjunctiva, lachrymation, and redness of the ear at
the close of an attack. The vomiting is explained by Eulenburg as
being due to variations in the intracranial blood-pressure. This
causes fitful contractions of the vascular muscles, alternating with
partial relaxation. These conditions must arise in the sympathetic
nerve of the corresponding side.

The dilation of the pupil during an attack depends upon irritation of

the cervical sympathetic ganglia. Other symptoms, such as the
largely increased flow of saliva and the flow of tears or drying of the
Schneiderian mucous membrane, indicate a morbid condition of the
cervical sympathetic. The sensitiveness to pressure in the region of
the upper cervical ganglia and over the spinous processes of the
lower cervical and upper dorsal vertebræ, corresponding to the cilio-
spinal region of the cord, confirms the idea of a morbid state of the
cervical sympathetic.

In hemicrania angio-paralytica there is supposed to be a relaxed

condition of the vessels of one side of the head. Here, instead of an
irritation of the sympathetic, there is a paralytic condition, and we
have the same results as are seen in animals when the cervical
sympathetic is divided. There seem to be good grounds for holding
this view when we consider the flushed face, contracted pupil,
retraction of the eyeball, and occasional ptosis which accompany
this form of headache. Possibly there may be a brief stage of spasm
of the vessels preceding the relaxation which occurs in hemicrania
angio-paralytica.

The slowing of the pulse during an attack of migraine is due probably

to cerebral hyperæmia from relaxation of the vessels, or to the
secondary anæmia and irritation of the medulla oblongata. This
irritation of the medulla is also able to explain the other symptoms of
vaso-motor disturbance which occur during an attack of migraine; for
instance, the small and contracted radial artery, the extreme
coldness of the hands and feet, and the suppression of perspiration
over the whole body except perhaps on the affected side of the
head. Following the stage of irritation of the medulla with contraction
of the vessels comes one of exhaustion with relaxation of the
vessels. This latter state may account for the profuse flow of saliva
and the copious secretion of sweat and urine, as well as the
increased secretion of bile and the condition of broncho-tracheal
catarrh during the attack.

We now come to the question of the origin and seat of the pain in
migraine. This question has involved a great deal of thought, and
has been answered in various ways by different writers. E. du Bois-
Raymond thought that the pain was due to tonic spasm of the
muscular coats of the vessels, and that thereby the nerves in the
sheaths of the vessels were pinched, as it were, and so caused pain.
Moellendorff was of the opinion that the pain was due to dilatation of
the vessels, and not to contraction; and this theory might explain the
pain in the angio-paralytic form. There are many cases in which
neither of these views is sufficient, for we have no reason to believe
that a condition of either anæmia or hyperæmia is present.

Romberg believed that the pain was situated in the brain itself, and
Eulenburg holds that the pain must be caused by alterations in the
blood-supply, without regard to their origin, in the vessels of one side
of the head. He thinks that the vessels may contract and dilate with
suddenness, just as is often seen in some neuralgias, and thus
intensely excite the nerves of sensation which accompany the
vessels. The increase of pain upon stooping, straining, or coughing,
and the influence upon it by compression of the carotids, seem to
give force to this view. But are we not here confusing cause with
effect? Are not these variations in the calibre of the vessels due to
the irritation of the sensory and vaso-motor nerves, which are in a
state of pain? No doubt increase in the blood-supply augments the
pain, just as it does in an inflamed part when more blood goes to the
part. Let a finger with felon hang down, or let a gouty foot rest upon
the floor, what an intensity of pain follows!

Anstie very ably advocated the theory of migraine being a variety of

trigeminal neuralgia in the ophthalmic division; and we incline
strongly to his view. An attack of migraine often begins with pain
distinctly located in the supraorbital nerve as the result of exposure
to cold. Frequently it begins in the infraorbital nerve or in the
branches of the inferior maxillary division of the fifth. The pain then
spreads over one side of the head, both outside and inside, and
goes through the recognized symptoms of migraine. In my own case
I have often had an attack begin with sharp pain in the supraorbital
notch in a spot which could be covered by the tip of the finger. The
nerve has seemed swollen, and has been highly sensitive to
pressure. Then have come pain extending over the entire side of the
head, without its limits being distinctly definable, and the
accompanying phenomena of lachrymation, excessive salivation,
and copious flow of urine, winding up with vomiting or ineffectual
nausea and retching.

Anstie brings forward as arguments to support his view the facts that
the attacks of migraine often interchange with neuralgic seizures,
and that a person who has been migraineuse in early life may in later
years lose his hemicranial attacks, and have violent neuralgia in the
ophthalmic division of the fifth nerve.

The true seat of the lesion, if we may so call it, upon which the
exaggeration of pain-sense depends, is probably in the nerve-centre;
that is, in that part of the trigeminal nucleus back to which the fibres
go which are distributed to the painful areas. The pain is no doubt
chiefly intracranial, and in those portions of the cerebral mass and
meninges to which branches of the trigeminal are distributed. All of
the divisions of the trigeminus send branches to the dura mater.
Many nerves are found in the pia mater as plexuses around the
vessels, some of which penetrate into the centre of the brain. Most of
these nerves come from branches of the trigeminus.

TREATMENT.—The treatment of migraine must be directed to the

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 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 Ross11 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.
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
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. Jewell12 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.
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.

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
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, 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
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 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 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.
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 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.