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