CHAPTER XXIII. VERTIGO. VERTIGO, like headache, is but a symptom. Yet it is often so predominant, and represents by itself so much the results of the morbid action, that it well deserves special notice. Its seat, as we have already remarked, is not in the hemispheres, but in the pons, tubercular quadrigemina, or some adjacent parts. This statement may be disputed, and it may be said that lesions of the hemispheres may cause severe giddiness, which may be absent in lesions of the pons. This is true, but it does not appear to me at all necessary that the lesion should occupy the part whose derangement conditionates giddiness. The converse may afford a more favorable condition. The very circumstance of its tissue being damaged by a tumour, &c., may unfit it for producing this special mode of disorder, and irritation propagated to it from some adjacent part may be much more effectual. Like most other neuroses, vertigo may be produced by primary changes in the encephalon itself, or secondarily by remote irritation. We thus make two principal groups, under each of which we may notice, and afterwards illustrate, sundry operating causes. Under the first we place (1) Hyperæmia, understanding by this term not passive congestion, but increase in the amount of blood traversing the brain in a given time. Andral mentions the case of a woman who ceased to menstruate at æt. 47, became then very fat, and was troubled with constant giddiness of the head. Four years after she had a slight apoplectic attack, and 4 years still later another which proved fatal. Extravasated blood was found in the brain, and the walls of the left ventricle were remarkably hypertrophied. Cases (1) and (2) may be referred to as further illustrations. (2) Anaemia, as in impending syncope. In chronic cases, however, the effect is not very constant; I have notes of some in whom headache was a much more notable symptom than vertigo. No doubt exists, however, that this may be a very efficient cause. (3) Sudden diminution of intra-cranial pressure, as is shown by Cruveilhier's experiments. He states that if in a dog the sheath of the dura mater is punctured between the atlas and the occipital bone, and the spinal fluid allowed to escape, the animal reels about like a drunken man, and lies down for hours in a state of stupor, but the day following is quite recovered. Probably the giddiness which we experience on rising quickly, after having been stooping down for some time, depends in great measure on the reflux of the subarachnoid fluid towards the spinal cavity, which, while the head was depressed, gravitated towards the cranial. It is worth observing that the giddiness does not occur while the pressure is increasing, but when it is diminished. I can hardly, however, attribute great importance to this condition in states of disease, for it is not uncommon to see patients greatly debilitated in whom the bloodpressure must be greatly diminished without any notable vertigo. This is certainly observable in cases of cholera. (4) The most efficient causes by far are those which enfeeble and derange the nervous influence, or, if we prefer it, the molecular condition of certain sets of nerve-cells. These are very numerous; the majority may be ranked as of the nature of toxic agents, others as traumatic lesions, others as immaterial influences. Familiar instances of the first group in action are afforded by the vertiginous effects of excess of alcohol, of febrile miasms, of poisonous gases. Among febrile miasms, the cause of Influenza holds a “bad preeminence." It is very remarkable in this malady how suddenly and severely the cerebral affection supervenes, and how long it continues. In the case recorded at p. 104, it was weeks before the patient could move his head as usual without feeling dizzy. Dr. Falconer says "of the epidemic of 1803, that vertigo, and that to a considerable degree, was in some persons one of the first signs of the disease, and in several instances very alarming and distressful. I saw a lady affected to such a degree as not to be able to raise her head from the pillow without losing all sense, and to whom all objects appeared thrice multiplied; and these uncouth symptoms continued 4 days in their full extent. I observed in several persons that, where the vertigo was most troublesome, and appeared early in the disease, the peripneumonic symptoms were but light, and vice versa. Two of the worst cases of the peripneumonic kind that I saw were not CHAPTER XXIII. VERTIGO. VERTIGO, like headache, is but a symptom. Yet it is often so predominant, and represents by itself so much the results of the morbid action, that it well deserves special notice. Its seat, as we have already remarked, is not in the hemispheres, but in the pons, tubercular quadrigemina, or some adjacent parts. This statement may be disputed, and it may be said that lesions of the hemispheres may cause severe giddiness, which may be absent in lesions of the pons. This is true, but it does not appear to me at all necessary that the lesion should occupy the part whose derangement conditionates giddiness. The converse may afford a more favorable condition. The very circumstance of its tissue being damaged by a tumour, &c., may unfit it for producing this special mode of disorder, and irritation propagated to it from some adjacent part may be much more effectual. Like most other neuroses, vertigo may be produced by primary changes in the encephalon itself, or secondarily by remote irritation. We thus make two principal groups, under each of which we may notice, and afterwards illustrate, sundry operating causes. Under the first we place (1) Hyperæmia, understanding by this term not passive congestion, but increase in the amount of blood traversing the brain in a given time. Andral mentions the case of a woman who ceased to menstruate at æt. 47, became then very fat, and was troubled with constant giddiness of the head. Four years after she had a slight apoplectic attack, and 4 years still later another which proved fatal. Extravasated blood was found in the brain, and the walls of the left ventricle were remarkably hypertrophicd. Cases (1) and (2) may be referred to as further illustrations. (2) Anemia, as in impending syncope. In chronic cases, however, the effect is not very constant; I have notes of some in whom headache was a much more notable symptom than vertigo. No doubt exists, however, that this may be a very efficient cause. (3) Sudden diminution of intra-cranial pressure, as is shown by Cruveilhier's experiments. He states that if in a dog the sheath of the dura mater is punctured between the atlas and the occipital bone, and the spinal fluid allowed to escape, the animal reels about like a drunken man, and lies down for hours in a state of stupor, but the day following is quite recovered. Probably the giddiness which we experience on rising quickly, after having been stooping down for some time, depends in great measure on the reflux of the subarachnoid fluid towards the spinal cavity, which, while the head was depressed, gravitated towards the cranial. It is worth observing that the giddiness does not occur while the pressure is increasing, but when it is diminished. I can hardly, however, attribute great importance to this condition in states of disease, for it is not uncommon to see patients greatly debilitated in whom the bloodpressure must be greatly diminished without any notable vertigo. This is certainly observable in cases of cholera. (4) The most efficient causes by far are those which enfeeble and derange the nervous influence, or, if we prefer it, the molecular condition of certain sets of nerve-cells. These are very numerous; the majority may be ranked as of the nature of toxic agents, others as traumatic lesions, others as immaterial influences. Familiar instances of the first group in action are afforded by the vertiginous effects of excess of alcohol, of febrile miasms, of poisonous gases. Among febrile miasms, the cause of Influenza holds a “bad preeminence." It is very remarkable in this malady how suddenly and severely the cerebral affection supervenes, and how long it continues. In the case recorded at p. 104, it was weeks before the patient could move his head as usual without feeling dizzy. Dr. Falconer says "of the epidemic of 1803, that vertigo, and that to a considerable degree, was in some persons one of the first signs of the disease, and in several instances very alarming and distressful. I saw a lady affected to such a degree as not to be able to raise her head from the pillow without losing all sense, and to whom all objects appeared thrice multiplied; and these uncouth symptoms continued 4 days in their full extent. I observed in several persons that, where the vertigo was most troublesome, and appeared early in the disease, the peripneumonic symptoms were but light, and vice versa. Two of the worst cases of the peripneumonic kind that I saw were not frowning and anxious. No strabismus. No tache meningitique. No discharge from ears. No deafness, is distressed by any noise. No intolerance of light. Belly caved in, flaccid. Has been sick repeatedly during the last week, vomiting. Pupils equal, rather large. Tongue rather red, with thin whity coating. Temperature 101°. Pulse 80. Broth diet. Pot. Iod. gr. iiss + Aq. 3ss ter die. The next day he was free from pain, Tr. Cinchon. 3ss was added to each dose, and a pint of milk and egg to his diet. The day following he was very restless, had been sick during the night, complained much of thirst, perspired much in morning. No pain in head complained of. Wishes for meat and potatoes. From this time he improved steadily, taking after 19th Bark alone and Ol. Morrh., and was discharged Dec. 4th. The symptoms in this child looked rather threatening at first; vomiting without notable stomach disorder, intolerance of sound, anxious frowning expression, thirst, elevated temperature, a shrunken abdomen, and a rather (for a child) infrequent pulse might have led to a diagnosis of tubercular meningitis, especially as the child had always been weakly. There were, however, no certain signs of brain mischief, the headache was frontal, the previous eruption was rather suggestive of rheumatism (erythema nodos. ?), depletion was evidently undesirable, and a treatment directed against rheumatic neuralgia soon removed all doubt. CASE 15.-C, æt. 40, seen April 19th, 1864. Ill 18 months with pain all over head attended with great soreness, can hardly lay his head on the pillow at night; the pain extends down neck into both shoulders. The worst of the pain is at a spot on each side of the posterior part of the vertex, but the pain shoots all over the head and into the eyes, and often extends to the jaws. He would sleep at night but for the soreness of head which wakes him up every 15 or 20 minutes. He feels very weak, and has lost flesh wonderfully. Perspires very much, especially in bed. Lung and heart sounds normal. No bad teeth. Two years ago a lot of bricks fell upon him and broke some ribs, after which he had rheumatism. Has now a good deal of rheumatism in shoulders and neck, and some in loins. Has had chancres, and suppurating buboes; there are two cicatrices on the penis. No sore throat of any moment, no eruption. Appetite not good. Tongue coated. Bad cough. BR Potass. Iodidi gr. 8+ Ammon. Carb. gr. 4+ Tr. Cinch. flav. 3j+ Infus. Cascarill. 3j ter die. Linim. Belladon. On 23rd there was improvement, and Ol. Morrh. Zij bis die was ordered. By May 10th he could lay his head down comfortably, slept much better, and had gained flesh, but there was some tendency to return of pain. I saw no more of him then until the end of December, 1865, when he came to me with an indurated sore on the glans and non-suppurating glands in the groin. This disorder was of recent origin, and had been communicated to his wife very speedily. Had it not been for this subsequent piece of evidence I should have remained in much uncertainty whether the cephalalgia of the previous year had been of rheumatic or syphilitic nature. The previous chancres having been soft ones and this being hard makes it improbable |