to the orthopedist, to see that the apparatus is right. In that way, I think that we can cure a great many cases of ptosis and other conditions that operative interference will not correct. Operation in cases of loose kidneys, for instance, is not always successful; and it may be a question of balance, which the orthopedist will help us to correct.

THE PRESIDENT: The paper will next be discussed by Dr. William Porter, Jr., of Hartford. Is Dr. Porter here?

DR. WILLIAM PORTER, JR. (Hartford): I am sorry that I did not hear all of Dr. Cook's paper. I am sure that we shall all study it and read it with care, when published. I must heartily agree and also heartily disagree with Dr. Cook's proposition that we start to find out what is really the matter with the patient. I disagree, because I think that that is not alone for the orthopedist, but for all of us. It must be done. It is the one thing that we do not find in order to treat our patients successfully that someone else does find. Dr. Cook and I have been so long and so pleasantly associated that all this work interests me very much. The question of straight legs and straight backs or crooked legs and crooked backs is one of very great importance. I can only ask you all to really read and study his paper carefully, think it over, and actually put it into practice; because I know that it will be useful.

THE PRESIDENT: Does anyone else wish to discuss the question further? If not, we will proceed to the next paper. Oh, I beg your pardon, Dr. Cook; I should have asked you to close the discussion.

DR. ANSEL G. Cook (Hartford): I have nothing to say. Thank you, gentlemen.

The Clinical Significance of Vertigo.

CHARLES A. MCKENDREE, M.D., CROMWELL.

The physician confronted by vertigo as a prominent symptom or as one of a complication of symptoms should have a working knowledge of all possible morbid processes which etiologically may contribute to its production. In attempting to present this subject, I shall not presume to shed any new light upon a problem fundamentally little understood, but rather to bring before general practitioners of medicine a comprehensive consideration of vertigo from the standpoint of its many causes.

Before entering upon the discussion, I will ask your attention for a few moments to a preliminary outline of the chief sources from which is derived the maintenance of normal equilibrium. The semicircular canals, by means of the endolymph contained within their walls, acquaint us with the position of our body in space. Whenever there is a contradiction between the nervous impulses arising from the labyrinthine structures and the position of the body there arises a disturbance of equilibrium. Any movement of the fluid content sends impulses, by way of the vestibular portion of the auditory nerve, to the coördinating centers within the cerebellum. The strength of the impulse depends upon the nature of the stimulus, and also upon the excitability of the delicate nerve cells within the labyrinth. Individuals vary greatly in the latter respect. Some are predisposed to manifestations of labyrinthine disturbance upon the slightest provocation. Others require a strong irritating influence to bring about even a small degree of reaction.

The cerebellum serves as the general coördinating center for equilibrium, receiving impulses from many sources, chief of which are the semicircular canals. The close connection of the cerebellar centers with those of the oculomotor apparatus is of considerable clinical importance, affording another source of equilibratory balance. The cerebellum receives also, by means of the spinal tracts, those afferent impulses derived from skin, muscle, joint and tendon stimuli.

From the cerebellum it is generally known that fibres lead, by relays, to cells located in the cortex of the cerebral hemispheres, which have as their sole function the regulation of equilibrium.

It is with manifestations of disturbance as reported to consciousness by means of these sources, namely, labyrinthine, ocular and static, that I wish especially to deal. But there are many other factors, whose mechanism is still more unsatisfactorily explained, that will be included in the discussion, as representing forms of equilibratory disturbance. Some of them have to do with mechanism entirely apart from that of the semicircular, cerebellar or optic apparatus, but indirectly involve one or more of them.

The term vertigo in its true etymological sense should signify a turning or reeling, but we have come to employ it for various degrees of equilibratory disturbance. The use of the words dizziness and giddiness, although truly not synonymous, is justifiable in referring to the lesser degrees of instability. Vertigo as described here will include many forms of discomfort, from a mere sensation or feeling of unsteadiness, loss of balance and disturbance of one's bodily relation to space, to the more profound manifestations, such as rotation, subjective or objective.

In obtaining a history from the patient who complains of vertigo it is most important to ascertain exactly what he means, the nature of the sensation that he experiences, whether this sensation precedes a fall or necessitates support, whether there is loss of consciousness for any period of time, the number of previous attacks, if any, their duration and the circumstances surrounding them.

Gowers was one of the first investigators to emphasize the importance of auditory lesions in the procution of vertigo. In his well-known series of one hundred and six cases he found the eighth nerve affected in ninety-four.

Auditory vertigo is always associated with more or less marked deafness, often nystagmus to one or the other side and disturbance of equilibrium. There is always a loss in bone con

duction; and in the minority of cases a persistent tinnitus aurium.

Meniere's disease is truly only one form of the great variety of auditory vertigoes. It should be regarded as a separate and distinct affection. Meniere's is treated by Lake as a disease occurring only in leukæmia and allied blood conditions. McBride states that in order to establish a diagnosis of true Meniere's there must be a history of sudden hemorrhage, embolism, or trauma. Osler believes it may be produced occasionally by a temporary excessive increase in the perilymph, possibly of angioneurotic character. In any case the resulting lesion temporarily deprives the inner ear of an opportunity to afford compensatory changes in pressure.

The acute and chronic forms are generally recognized. By Turner and Stewart the acute attack is described as follows:

"Intense vertigo, with vomiting; rotation of the body and well-defined nystagmus toward the unaffected side. In bed the patient assumes the position of the sound side. The severe symptoms last two or three days and then gradually subside, but nystagmus may persist for a longer period. Eventually all symptoms pass away, leaving deafness and tinnitus."

In the chronic form there may be subjective or objective vertigo, associated with some degree of staggering. The patient is often taken by seizures, being suddenly hurled to the ground, as if struck on the head. Repeated attacks of tinnitus, labyrinthine deafness and severe vertigo suffice to make the diagnosis.

Aural vertigo, on the other hand, embracing many forms, may be produced by progressive ear deafness or arterio-sclerosis. The symptoms commonly seen are vertigo, unilateral deafness and tinnitus. One must remember that he can have a true aural vertigo even when the labyrinthine portion of the auditory nerve is intact. Wax in the external auditory canal pressing upon the tympanum, and violent blowing of the nose, occasionally give rise to this symptom. Middle ear disease, which we include in the consideration of aural vertigo, either by continuity of inflammation, interference with the blood supply, reflected irritation or by producing some obstacle to the normal varia

tions in intra-labyrinthine pressure, is often the cause of vertigo. Affections of the nasopharynx in general, and particularly of the Eustachian tubes, are important considerations. Labyrinthine symptoms are very rare in acute diseases of the ear.

What can we do to relieve such a patient? The first indication is that of soothing an irritated labyrinth. Milder cases yield to the judicious use of drugs. Sir Victor Horsley, before attempting any of the major methods of relief, advocates an absolute rest treatment, and hydrobromic acid. If there be any evidence of a gouty diathesis he administers drugs against such a possibility. Charcot's classic favoritism for quinine is still advocated by many competent men, usually given in three-grain doses, three or four times daily, omitting the drug several days during the month. Sodium salycilate is used to advantage by many. In the paroxysmal attacks strontium bromide ten to forty grains per day, with complete rest, and immobilization of the head if necessary, is often efficacious. The question of the dietary is important in gouty individuals and also in those manifesting some arterial degeneration. This means essentially a reduction of the proteid food elements, and a quantitative rather than qualitative choice of other foods. Tobacco, alcohol, and coffee are regarded as harmful.

From the investigations of Babinski and others we have gained a second method of great advantage, namely, that of lumbar puncture. By lumbar puncture, intracranial, and therefore intra-labyrinthine, pressure is reduced. Supported notably by Blake and Putnam in this country, this form of treatment has had remarkable results. The most favorable cases are those of short duration, involving only the labyrinth. When the lesions have become so extensive as to produce nerve degeneration one cannot hope for lasting alleviation. Usually ten to fifteen cc. of fluid are withdrawn and the patient is kept at rest for at least twenty-four hours. Ordinarily some improvement is felt after the second day. The local condition is never aggravated by this method of treatment. Blake's experience has been that of temporary amelioration in certain cases, but in the majority, entire relief from vertiginous attacks, varying in