Chapter XXVII: Introduction: The term neurasthenia, signifying nervous weakness, and (5)

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.

In other cases, owing to over-feeding or any of the numerous causes of acute dyspepsia, an individual has a sudden attack of acid stomach, and as this gets to its worst he has alarming vertigo. In these cases the room whirls around or the pavement rocks; the balancing power is disturbed or lost; the sense of movement in the brain itself is sometimes felt; there are slight buzzing or humming sounds in one or both ears; there may be double vision, which comes and goes, while the power to think is lessened and the terror created is quite unendurable. At last come the sweat of nausea, emesis, and relief, with a gradual fading away of all the symptoms.

As a rule, such an attack need cause no uneasiness as to a fatal result, but, unless the case be handled with skill, it is apt to repeat itself 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.

Optic vertigo, if essentially that, is rarely discovered without the help of some one trained to study the defects of vision. Its relief demands, of course, as a rule, glasses, or in extra-optical muscle-troubles these or a compensatory operation. When, however, the vertigo has been grave, it is needful to manage corrections of the eyes with care and judgment, and sometimes experimentally. The sensorium, having become over-excitable, does not always bear accurate correction of the eyes, or this increases the vertigo. Then the glasses are cast aside and the case progresses. In others—and this is purely a matter of individual experimentation—nothing will answer except the most careful and absolute corrections: anything less does no good.

These remarks apply with equal force in chronic vertigoes, essential, gastric, or other. Defective eyes, unfelt in health, soon begin to trouble a head sensitized by chronic dizziness, and optical defects which are sometimes but trifling become then competent to increase the growing intracranial disorders, or to assist lithæmia or a troublesome stomach to create and sustain vertigo.

{428} The Status Vertiginosus.—I have tried to make clear elsewhere and in this article that in several forms of vertigo the disorder ceases to owe its onsets to extracentral irritations, and becomes essential, precisely as happens in some epilepsies, and that we then are apt to have, with more or less distinct attacks or with no attacks, long continuance of a group of symptoms which constitute the status vertiginosus. Its treatment is important, because of its alarming and disqualifying effects. The attacks are often the least part of it, while the lack of power to read and write, to go into crowded streets, to face light, or to exercise, or stand emotions or the slightest mental strain, surround its management with embarrassments, and are well fitted to end in melancholia or hypochondriasis.

In these cases, after the eye has been corrected, the diet should be regulated with care. In extreme cases it may become desirable to limit it to milk, fruit, and vegetables where no obvious peculiarities forbid such a regimen; and I have found it useful to insist also on some food being used between meals.

I like, also, that these patients rest an hour supine after each meal, and spend much time out of doors, disregarding their tendency to lie down. Exercise ought to be taken systematically, and if the vertigo still forbids it, massage is a good substitute. At first near use of the eyes is to be avoided, and when the patient resumes their use he should do this also by system, adding a minute each day until attainment of the limit of easy use enjoins a pause at that amount of reading for a time.

Now, as in vertigo, especially labyrinthine, the eyes become doubly valuable as guiding helps to correct equilibration, I have long found it useful to train these patients to stand and walk with them closed. At first this is as difficult, or may be as difficult, as in locomotor ataxia, but the practice is sure to add steadiness to the postures. Somewhat later I ask my patient deliberately to make such movements of the head and such efforts of mind or memory as are apt to cause vertigo or confusion of head, and to conquer or inhibit these consequences by a prearranged effort of will; and these means also I have found useful. Meanwhile, nothing usually in these cases forbids the use of tonics or of moderate doses of bromides. As I have said, change of air is very serviceable. It is indeed rare that cases do not yield to some such combination of means, but very often it will happen that the fears of the patient are his most grievous foes, and are to be dealt with after every real symptom has vanished.

{429}

TREMOR.

BY WHARTON SINKLER, M.D.

Tremor is a prominent symptom of many diseases of the nervous system, and is met with as an effect of certain poisons which have been taken into the system; so it should not be considered as a disease in itself. It may, however, occur without being associated with any other abnormal condition which can be discovered. It is then called tremor simplex or tremor essentialis. The tremor of old age (tremor senilis) comes under this head.

Tremor is sometimes hereditary, and may exist from early life. I have a patient in whom there is a trembling of the hands which has lasted since childhood. This lady's mother and grandmother both had the same form of tremor, and one of her own daughters also has it. In this case the trembling is most marked when voluntary movements are attempted, but it does not materially interfere with writing, sewing, or any other act she wishes to accomplish. There is slight tremor when the hands are at rest.

Tremor simplex is seen in hysteria. In this disease it affects the hands and the facial muscles as well. It is not uncommon in these cases to find the tongue tremble excessively when protruded.

Tremor from chronic poisoning is usually from the absorption of lead, mercury, or some of the narcotic drugs or alcohol. Lead tremor is to be looked for among persons who are exposed to the action of lead, such as painters, printers, or manufacturers of white lead.[1] Such persons generally have had some other symptom of lead-poisoning, such as colic or paralysis. The tremor, however, may be the only symptom of saturnine poisoning. Mercurial tremor is not so often seen. It occurs in looking-glass makers or those who work in quicksilver, and may also be a result of the medicinal administration of mercury. The tremor from the excessive use of alcohol or opium is familiar to all. Tobacco, if used immoderately, also causes trembling in the hands. Tea or coffee may have the same effect. There are other drugs which, when taken for a length of time, are liable to cause tremor. Quinine is one of these.

[Footnote 1: Lead in hair dyes or in cosmetic powders often gives rise to plumbism by its absorption by the skin.]

Exhausting diseases, like the fevers, or any conditions which enfeeble the system, cause tremor which occurs in voluntary effect. I saw a lady some years ago who was greatly weakened by a malignant growth. She was extremely anxious to sign her name to a legal paper, but, although the hand was perfectly quiet when at rest, when she attempted to write {430} the first letter such intense tremor came on that it was impossible for her to make any mark which was legible.

Tremor follows violent bodily exertion or mental excitement. The action of cold or the chill of intermittent fever is accompanied with an extreme degree of trembling, which we all know. Tremor is also a result of neuritis, but in this case it is associated with other symptoms.

SYMPTOMS.—Tremor is met with as a fine or a coarse trembling. We may also find a fibrillar tremor, such as exists in progressive muscular atrophy. Tremor is divided by some (Van Swieten, Charcot, and others) into two classes: the first is where the tremor occurs while the part is at rest; the second is where it comes on during volitional muscular movements. The former has been termed by Van Swieten tremor coactus, because he believed that it arose from an irritation which affected the nervous centres in an intermittent way. The latter he conceived to depend upon a defect of stimulus, the result of an insufficient amount of nervous fluid, which causes contraction of the muscles under the influence of the will. This he called tremor a debilitate.[2]

[Footnote 2: Charcot, _Lectures on Diseases of the Nervous System_.]

In paralysis agitans we have an example of tremor coactus, and in disseminated sclerosis, where the tremor occurs only as muscular effect, it belongs to the variety of tremor a debilitate. Those divisions, however, are of but little importance.

When tremor first begins it is slight in degree and extent, and occurs generally only on voluntary effort. Later there may be a constant trembling even when the part is at rest. Beginning usually in the hands, it may extend to the head and legs. It is seen in the tongue and facial muscles after the disease has lasted for some time.

In some cases the trembling can be controlled to some extent by a strong effort of will. The tremor from alcohol or opium is most marked when the individual has been without the use of the stimulant for a short time, and the trembling may be temporarily checked by renewing the dose of alcohol or opium as the case may be.

The muscular trembling from plumbism and mercurial poisoning is more violent than the other forms of simple tremor, and often resembles the tremor of paralysis agitans. In toxic tremors there are often secondary paretic symptoms and indications of other disturbances of the brain and nervous system.

In simple tremor there is no loss of muscular power, and the electrical reactions of the affected muscles are not abnormal. The duration of simple tremor is almost always great. Usually it persists throughout life, becoming more general and more intense as the subject of it grows older. The tremor of hysteria is shorter in duration. Occasionally there are seen cases of simple tremor, which are apparently the result of some trivial cause in a nervous person, which last but a short time.

I have seen a case of tremor of the head in a woman of about forty years, in which the trembling ceased entirely after it had lasted several weeks. Hammond[3] describes what he calls convulsive tremor. Under this name he includes cases of non-rhythmical tremor or clonic convulsions, which are unaccompanied by loss of consciousness, but are paroxysmal in character. Pritchard in 1822 presented an account of this affection and {431} related two cases; Hammond mentions six cases. The affection is characterized by paroxysms of violent and rapid convulsive movements, which are more or less general and occur many times a day. The seizures last from a few minutes to several hours.

[Footnote 3: _Diseases of the Nervous System_, p. 696.]

The PROGNOSIS in convulsive tremor seems to be favorable.

Tremor may be regarded as a form of clonic spasm. It consists of slight intermittent contractions of individual muscles or groups of muscles. Fibrillar tremor, such as is seen in progressive muscular atrophy, depends on contractions and relaxations of the muscular fibrillæ, and can be seen under the skin, but does not cause any movements of the limb.

There are no pathological data for explaining what portions of the nervous system are the seat of disease in simple tremor. In experiments upon the lower animals it has been found that trembling occurs in muscles which have been separated from the nerve-centres by division of the nerve. So too in man: when there has been a wound or section of a nerve accidentally, there is likely to be tremor in the muscles which it supplies.

The tremor does not begin at once on section of the nerve, but comes on after a few days. As the peripheral end of the nerve undergoes degeneration the tremor increases. It may last months or even years.

In some of the conditions where tremor occurs the influence of the will is weakened or is entirely absent. This is seen in hysterical trembling and in the tremor of old age as well as in those cases where there is general enfeeblement of the body, as in the fevers.

Trembling is connected with disease of the pyramidal tracts, because in this way the influence of the cerebral centres is withheld from the muscles. When a muscle is in a condition of tonic spasm, it is the result of the running together of very rapidly-repeated muscular contractions. It is like the contraction in a muscle from an interrupted electrical current. If the interruptions are slow, the muscular contractions are seen at intervals like a tremor; but if the interruptions are rapid from frequent vibrations of the hammer of the instrument, then the contractions in the muscle are fused together, as it were, and the muscle is in a state of tonic spasm.

It is held by some writers that tremor is caused by the want of balance between the cerebrum and cerebellum. When, for example, the control of the cerebrum is enfeebled the action of the cerebellum is so great as to bring about tremor by its uncontrolled power.

If we accept the first view, we must consider the tremor as a preliminary stage of paralysis; for the lesion, which at first is slight and causes only an interruption of the conduction of impulses from the brain to the muscles, as it becomes more extensive totally prevents conduction, and paralysis ensues.

Hughlings-Jackson's view, that general convulsions are the result of discharges from the cortex of the brain, and that the tonic contractions of tetanus are caused by discharges from the cortex of the cerebellum, may be applied to the pathology of tremor as well. When, for instance, in a disease like disseminated sclerosis a voluntary effort instead of causing a steady muscular contraction results in irregular spasmodic contractions and relaxations of the muscle, we may imagine that a series of discharges were taking place from the cortex of the cerebellum as long as the voluntary efforts were persisted in. On the other hand, in paralysis agitans {432} it is more probable that a lack of conducting power in the pyramidal tracts prevents the influence of the centres being continuously exerted upon the muscles through their motor nerves.

It is probable that in simple tremor the lesion is situated in the spinal cord; for in this disease we seldom see any evidences of cerebral disturbance. There are no paralytic or psychical symptoms, and no vertigo. In toxic tremors the disease is no doubt located in the brain, for accompanying the trembling resulting from alcohol, opium, mercury, and other drugs are mental changes and more or less muscular enfeeblement.

TREATMENT.—Should the tremor depend upon some cause which can be discovered, of course the obvious course is to attempt to remove the source of trouble. The effort is of greater or less success in different conditions. The tremor from mercurial poisoning sometimes yields to treatment which is directed to the elimination of the mercury. The free administration of the iodide of potassium is the best means to be used, and is often successful. The same means are available in lead tremor. Of course the patient must be removed during treatment from the risk of further absorption of the poisonous substances.

In simple tremor many remedies have been recommended, but the results of treatment are not encouraging. Baths of various kinds and galvanism have been used, and many drugs are advised. Hyoscyamus and its alkaloid, hyoscyamine, have enjoyed a high reputation, and good results have been reported from their use. I have seen relief, but not cure, from their administration. Arsenic is a more reliable remedy and it may be used hypodermically. Eulenburg[4] has used this method with good results. I have given arsenic per orem with beneficial effects in cases of simple tremor. In a case to which I have referred above the tremor was relieved while the patient was taking Fowler's solution, and on changing to hyoscyamus the trembling got worse. On returning to the arsenic the symptoms improved, and finally the tremor ceased after the remedy had been taken for some weeks. Hysterical tremor requires that the hysteria should be relieved. Franklinic electricity sometimes controls the tremor in these cases.

[Footnote 4: _Ziemssen's Cyclopædia_, vol. xiv. p. 392.]

{433}

PARALYSIS AGITANS.

BY WHARTON SINKLER, M.D.

SYNONYMS.—Parkinson's disease; Shaking palsy; Trembling palsy; Senile chorea; Chorea festinans. The first name is due to the fact that the disease was first fully described by Parkinson in a book published in England in 1817.

Paralysis agitans is a neurosis, chronic in its forms and characterized by a tremor which gradually increases in extent and severity. The tremor is not increased by voluntary muscular movements. A peculiar manner of walking, known as festination, comes on later in the disease, and there are also alterations in the attitude of the head and trunk.

It is a disease which belongs to middle age, being rarely seen before forty years, although cases are quoted by Charcot as early as twelve and sixteen years. Constant and prolonged exposure to dampness and cold seems to bring on the disease, and it is sometimes caused by sudden emotion, like fear or distress. The following case is an instance of the latter:

Case I.—Mr. A. M——, æt. fifty-two years, consulted me Oct. 1, 1883. He is a bookbinder by occupation. His habits have been good. He had a chancre in 1861, but had no secondary troubles. He was in the army from 1861 until 1866. In 1866 he went into business for himself, and, although his business was large, he had no great anxiety or worry. His general health has been good, and he has had no illness except an attack of malarial fever about six years ago. In May, 1883, he was standing by an elevator door on the fourth floor of his place of business, and, seeing that the elevator was caught by something, released it. It immediately fell with a crash to the second floor, and as there were two or three persons on it, Mr. M—— thought they must have been killed or severely injured. He was greatly excited and alarmed, and soon after he had assured himself that none of the occupants of the elevator had been hurt, discovered a trembling of the right hand. The tremor has continued ever since, and has extended to the arm and leg.

On examination there is seen a coarse tremor of the right arm and leg while the limbs are at rest. A voluntary muscular movement stops the tremor, and it also ceases during sleep. When he makes an effort with the right hand, as, for instance, in squeezing the dynamometer, the tremor ceases in the arm, but becomes greatly exaggerated in the right leg. While occupied in doing anything he does not notice the tremor, and it stops when he is lying down.

The dynamometer shows, right hand 150°, left hand 120°. After two years have elapsed the disease has gradually progressed in severity.

{434} SYMPTOMS.—The course of the disease has been divided into three stages—the period of invasion, the stationary period, and the terminal period.[1]

[Footnote 1: _Lectures on Diseases of the Nervous System_, by J. M. Charcot.]

Period of Invasion.—There are several modes of invasion, but the most frequent by far is slow in its onset. The disease comes on gradually, first showing itself as a slight tremor in the hand or fingers while the part is at rest. It is not constant, and ceases as soon as the patient's attention is called to it. There is sometimes preceding the tremor rheumatic or muscular pain in the affected arm. The tremor may first occur in the foot. Should the disease begin in the hand—and this is most common—the movements are peculiar. They may consist of a fine rhythmical tremor, or the fingers move in a methodical way over each other. Charcot speaks of the thumb and forefinger being rubbed together as if the patient were spinning wool. While this movement of the thumb and finger is going on the wrist is being flexed by jerks. During the early stages of the disease the tremor is observed only at intervals. It comes on intermittently when the patient is not thinking of it and while the limb is at rest, and ceases as soon as any voluntary muscular effort is attempted. The act of grasping the hand or taking up an object is enough to check it for the time. In a patient now under my care I have often noticed during the early stages a well-marked tremor of the right hand while it was lying in her lap, but it would at once cease when I called attention to it. As soon as the mind of the patient was diverted to some other subject the tremor would begin again.

As the disease progresses voluntary effort no longer controls the tremor, or if it does at all it is only for a few seconds, when it begins again. As the tremor increases in violence it extends to other parts of the body. At first it may have been confined to the hand; now it extends to the arm, a little later to the foot and leg on the same side. Then the other arm will be affected, and finally all of the limbs will succumb to the tremor.

Charcot speaks of decussated invasion—that is, the disease begins in the right upper extremity, for example, and next passes to the left lower extremity. This is a rare form; it is much more frequent to see the hemiplegic type, which may persist for some time, or the paraplegic type, when both legs are affected.

There is a progressive form of invasion when the tremor is not the first symptom. The patient has neuralgic or rheumatic pains in the limbs, which are afterward affected with tremor. Sometimes there is some mechanical injury of the limb, which subsequently is the seat of pain and tremor. The general health of the patient is at the same time more or less impaired. There is a sense of general weakness and lassitude; the temper is irritable, and there may be some vertigo. The features and countenance are characteristic even at the earliest periods of the disease. There is an absolute absence of expression, and the features are fixed. The face looks like a mask, and although the patient may smile or laugh, immediately after the features return to the original blank expression. Amidon showed two cases of paralysis agitans to the American Neurological Society in 1883, in which there was no tremor whatever, but all the other features of the disease were present.

{435} After a great mental or moral shock the trembling begins suddenly, abrupt invasion, as in Case I., or the case described by Charcot, where the wife of a gendarme, seeing her husband's horse return riderless to the barracks, received a shock of great severity, which was followed on the same day by tremor. The tremor is at first confined to one limb. It may even disappear for a time, but gradually and slowly extends to the other limbs, and takes the same progressive course.

Period of Stationary Intensity.—After the disease has become fully developed the tremor is incessant. The intensity is not the same all the time. It may be augmented by cold, over-excitement, or voluntary effort, and is lessened by repose and sleep. The trembling ceases during anæsthesia.