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.
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 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.