Sectional Vol. page 1 Proceedings of the Royal Socy of Medicine 52 Section of Otology President-TERENCE CAWTHORNE, F.R.C.S. Meeting November 7, 1958 Vertigo PRESIDENT'S ADDRESS By TERENCE CAWTHORNE, F.R.C.S. London Introduction sufferer, the most regular of which is vertigo; Now that it is generally accepted that the though this may be overshadowed by the underlying cause for dizziness or giddiness is nausea and vomiting which are part of the vagal often to be found in a disordered vestibular effect which so often accompanies a severe system, there is an increasing tendency to turn vestibular disorder, particularly when it attacks hopefully to the otologist for help when vertigo the vestibular end-organ in the labyrinth. is the main complaint, because the delicate In fact one of the difficulties in the past has receptor organs of the vestibular sense are been that in its severest form, which is when a housed in the internal ear where they are suscep- previously healthy labyrinth suddenly fails, the tible to injury from over-stimulation, to fluctua- patient is so prostrated by a disorder which tion in the pressure of their fluids, and in their appears to be affecting so many of the body's blood supply, and to the influence of certain systems, that many find it difficult to appreciate toxins. Thus anything from a head injury to too that the seat of the trouble lies in such a modest much streptomycin may, by affecting the and normally unobtrusive little organ as the vestibular labyrinth, cause vertigo which is the labyrinth. principal symptom of a disturbed vestibular Now one of the difficulties about vertigo is system. that to the sufferer a sudden sharp attack is as The vestibular division of the VIII nerve alarming as it may be difficult to describe. connects the end-organs with the vestibular Alarming not only for the profound effect that a nuclei on each side of the brain stem and in the sudden loss of balance may have on the feeling of roof of the cerebellum near the midline. From security and well-being but also because of its here connexions go forwards in the posterior possible implication of serious disease affecting longitudinal bundle to the nuclei of the nerves to the central nervous or cardiovascular systems. the eye muscles, backwards again in the posterior Unless inspired by what they have been told longitudinal bundle to the neck muscles, back- or have read, patients with vertigo will refer to wards and downwards in the vestibulo-spinal it as dizziness or giddiness, and they may even tract to influence the muscles of the trunk and describe a sensation of movement of objects or of limbs and upwards by some tract as yet unknown themselves. Some patients, however, are unable to reach the posterior part of the temporal lobe to find words in which to describe their feelings, cortex where the reactions can reach the con- and what Sir Geoffrey Jefferson (1953) has said scious level. There is also an association with about vertigo-"It is a subject that cannot be the vagal centres which accounts for the pro- discussed with young children"-sometimes found and frequently misleading symptoms of a applies to adults as well. A further difficulty is severe vagal disturbance which often accompany that some patients use the terms dizziness and a sudden vestibular disorder. giddiness and even vertigo to describe many Thus it is through the vestibular receptors in vague sensations including a fear of over- the internal ear that the eyes and the body are balancing. In consequence vertigo has been kept balanced and steady. Throughout most of used as a sort of umbrella under which a variety our waking and all our walking hours this sense of sensations and complaints have been allowed is constantly at work receiving impressions and to creep for shelter. passing them on to influence the posture of the Definition body and the movement of the limbs and eyes, Therefore it is advisable to decide what is without our being aware of its existence. meant by the term vertigo. By derivation it Any sudden interference with the normal suggests a "turning" or a "whirling", and as working of this vestibular system will, however, such it is often referred to as "true" vertigo. force a group of unaccustomed, unwelcome, and This implies that sensations of movement other often unrecognized symptoms and signs upon the than "turning" or "whirling" are "false" JULY 530 Proceedings of the Royal Society of Medicine 2 vertigo. It is, I feel, safer and simpler to avoid whether something that he ate yesterday dis- these qualifying adjectives and to use the term agreed with him and after all there can be but vertigo for any hallucination of movement no very few who did not eat something yesterday. matter what its character. That is to say the As we know, however, it is not difficult to bring senses of the patient are deceived either into on nausea and vomiting by stimulating the seeing the objects around him in motion or into labyrinth, but the reverse does not apply unless feeling that his head or sometimes his whole what is irritating the stomach is, via the blood body is moving when in fact no such movement stream, having a toxic effect on the vestibular is taking place. If the sensation is slight, and system; a state of affairs which can be produced particularly when it lasts but a moment, it is by too much alcohol. unlikely to cause a disturbance of equilibrium. The visual hallucination in which objects When, however, it is severe and sustained, the seem to be whirling round sometimes raises the sufferer, even though he may know that the suspicion that the ocular system is at fault and in movement does not exist outside his senses, will many studies of vertigo ocular imbalance is be compelled by his reflexes to counteract the mentioned as a cause. This is not so, and I have effects of the apparent movement and in so doing never seen a case of vertigo which could be will lose the equilibrium that his instincts are attributed to an ocular disorder. trying to maintain. The momentary dizziness which often follows Incidence a sudden change of posture in those whose Vertigo as a prominent symptom, and it is as cardiovascular system is defective has led to the such that it is now being considered, is by no more pronounced and prolonged vertigo of means uncommon and some idea of the fre- vestibular origin being regarded as evidence of quency with which it is encountered in general ineffective blood pressure; but the transient practice may be gained from Table I which dizziness on suddenly getting up out of a chair shows the frequency of vertigo expressed in or out of a hot bath which is characteristic of terms of patient consulting rate per 1,000 of the cardiovascular instability need hardly ever be population in a group of 106 general practices confused with the definite vertigo accompanying serving 362,829 persons. It is taken from a vestibular disorder. Logan and Cushion (1958) and covers the year It will, of course, be appreciated that in such May 1955 to April 1956. For comparison those cases the exciting cause of the dizziness is a diseases or symptoms whose frequency are near momentary interference with the blood flow to to vertigo are also included. the labyrinth; and other conditions where for Table I certainly suggests that vertigo as a instance the blood is poorly oxygenated may cause dizziness which is either transient or which TABLE I.-FREQUENCY OF VERTIGO AND OTHER will progress, so that other symptoms supervene. DISORDERS OF SIMILAR FREQUENCY SN 106 GENERAL PRACTICES SERVING 362,829 PERSONS A dramatic form is the faint in which loss of Per 1,000 consciousness from failure of the cerebral circu- practice population lation is preceded by dizziness and tinnitus. Ulcer of duodenum 5 9 The hot flushes accompanied by a feeling of Pneumonia. 5-8 Vertigo . .. 50 fullness in the head, sometimes described by the Rheumatoid arthritis 4-8 meno- Appendicitis .. 40 patient as dizziness, which are part of the pause, have resulted in many patients attributing symptom sufficiently prominent to make the a bout of vertigo to the change of life. patient seek medical advice is common enough But perhaps the greatest difficulty arises when to deserve the attention and interest of every the psyche is suspected. The recurrence, often otologist, because it has been my experience that without any warning, of a sharp bout of vertigo in more than half of these patients a labyrinthine can engender a feeling of insecurity in the most disorder is the cause. stout-hearted of sufferers; and in those who are Causes not so psychologically robust the effect may be Now because of the number of bodily func- so profound that the ensuing changes in habit tions which are disturbed in a case of severe and personality often earn the sufferer the label vertigo it has been difficult for the patient, his of functional; but in such cases it will often be relatives and also his doctors, to believe that the found that an explanation of the real cause is cause for his disorder lay only in the labyrinth. gratefully accepted and goes far to encourage The most misleading of all the features of an the functional overlay to melt away. acute vestibular failure is the nausea and vomit- Thus we are left with the central nervous ing. Because of this the digestive system is system, with the ear, and with certain systemic almost always blamed in the first instance. The toxins as the possible causes of vertigo. sufferer or his relatives are bound to wonder In this connexion I would like to refer to what 3 Sedton of Otology 531 Sir William Gowers had to say about vertigo in should be able to place the blame for vertigo 1888: "It is certain that in the majority of cases where it belonged, namely upon the ear; and it in which vertigo has been ascribed to other has only been since the paper of Hallpike and causes, these have only had an exciting influence, Cairns in 1938, in which they were able to estab- and the symptom has been essentially due to lish the pathological changes in the inner ear in unobtrusive labyrinthine diseases." patients with Meniere's disease, that the part When the cause for vertigo lies within the ear, played by the ear in causing vertigo has once the condition is rarely serious so far as life is again been re-established. concerned, even though the vertigo may be Most of my experience of vertigo has been overwhelming in its severity and widespread in gained at the hospital where Sir William Gowers its effects. worked, and it is interesting to find that to-day On the other hand causes within the central the proportion of cases of vertigo in which the nervous system may be serious to health and to ear is likely to be the seat of the disorder is not life and so the first thing to do when confronted very much greater than it was in his day. At by a patient suffering from vertigo is to exclude that time the ear was only regarded as being the possibility of any disorder within the central implicated if there were cochlear symptoms, nervous system. If this can be done then the hence Gowers' statement: "in no less than 94 ear cause will almost always be located in the symptoms were present." We now know, how- internal ear, except for a small group due to a ever, that the vestibular end-organ in the inner ear circulating toxin. As our knowledge extends can be affected without any cochlear symptoms. this group may prove to be larger than it is at In Table II the cases of vertigo which I have present. To-day, however, the main cause seen, and upon which this paper is based, are under this heading is streptomycin, though as a grouped into central, when an obvious cause temporary, and almost one might say social within the central nervous system can be demon- cause, alcohol certainly and tobacco possibly strated; into peripheral, in which the central may have to be included. I do not believe, nervous system is normal and usually an however, that either of these social drugs often abnormality is to be found in the end-organ of causes troublesome and persistent vertigo and I balance and often of hearing as well; and finally have rarely found that abstinence from them a group in which both central nervous system helps a case of vertigo. and end-organs appear to be normal. Many of With regard to the central nervous system, these may belong to the central group but some, most of the patients suffering from vertigo whom I suspect, are toxic. The streptomycin cases I see are referred by my colleagues at the National have been included in the peripheral group as Hospital for Nervous Diseases, Queen Square, the most recent work on streptomycin intoxica- where a neurological cause has either been tion of the vestibular system favours the end- excluded or diagnosed. I was always surprised organ or ganglion on the vestibular nerve as the that I did not see a higher proportion of central primary seat of damage. nervous system causes until I read Sir William TABLE II.-CAUSES OF VERTIGO iN 3,116 CASES Gowers on the subject, and once again I would Central .367 like to quote from the chapter on vertigo in his Peripheral .2,391 "Diseases of the Nervous System". Writing Unclassified .358 mainly of his experience at the National Hospital Central Nervous System for Nervous Diseases, Queen Square, he says: First of all I would like to deal with the central "Of 106 consecutive cases in which definite group in which, though vertigo is a prominent vertigo made the patient seek advice, in no less and often sustained symptom, there are other than 94 ear symptoms were present, tinnitus or features which indicate a lesion within the central deafness, or more often both; defect of hearing nervous system. I mention this because a fleet- through the bone always existed, and in almost ing dizziness which can be severe may accompany all cases in which it was slight a distinct difference many disorders within the central nervous between the two sides emphasised its pathological system, but here we are only considering those character.... On account of the frequency with patients in whom it is a prominent symptom. which vertigo seems to the patient himself to TABLE III.-CAUSES OF VERTIGO WITHIN THE preponderate over the auditory symptoms, a CENTRAL NERVOUS SYSTEM large proportion of the sufferers seek advice of Epilepsy Disseminated sclerosis physicians rather than of aural surgeons, and Vascular accidents Posterior fossa tumours most text books of diseases of the ear give a Basilar insufficiency very imperfect representation of the malady." It is to me very interesting to find that a An epileptic seizure can be heralded by a bout physician with no special knowledge of otology of dizziness or a disturbance of balance and three 532 Proceedings of the Royal Society of Medicine 4 forms may be distinguished. There may be a tion of cases of damage to those vessels supplying definite vertiginous aura preceding a typical the inner ear, vertigo does not last and is soon epileptic attack with loss of consciousness and all displaced by other and more serious symptoms the features that go with such an attack. In of an intracranial disorder. another form the patient suddenly falls without The exception is the posterior inferior cere- any obvious preceding dizziness and without bellar artery which, when it becomes thrombosed, being conscious of having fallen. He finds gives rise to a definite syndrome of which deaf- himself on the ground, usually unhurt, and in a ness, vertigo and disturbance of sensation and few moments is able to get up without any un- temperature sense are the main features. Though toward after-effects. This small seizure is not well described and not difficult to diagnose, this uncommon and Spillane (1950) has drawn is not in my experience a very common cause of particular attention to it. The absence of any central vertigo. vertigo, the unawareness of having fallen because In tumours in the posterior fossa vertigo can be of momentary unconsciousness and, of course, a prominent, persistent, and for a time the only the absence of any signs of a vestibular disorder symptom. suggest the diagnosis which is confirmed by By far the commonest tumour in the posterior changes in the electroencephalogram. fossa is the acoustic neurofibroma but contrary In the third group an epileptic fit is precipitated to the general belief vertigo, though it is some- by a vestibular disturbance, so-called "reflex times present in the early stages, is rarely a epilepsy". The vestibular disturbance may, of prominent symptom (Edwards and Paterson, course, be Meniere's disease and I can call to 1951; Dix and Hallpike, 1958). This is probably mind about four such cases. In addition I have because the tumour usually involves the vestib- had three patients in whom a typical but short ular division of the VIII nerve first of all, and epileptic seizure with, of course, loss of con- vestibular function on that side gradually dis- sciousness was precipitated by caloric stimulation appears, probably before the hearing is affected. of the vestibular end-organ. Behrman and This gradual loss of function on one side allows Wyke (1958) have described such cases of for central compensation to take place, so that vestibulogenic epilepsy in some detail, but in my transient vertigo may be noticed only with experience they are not common. sudden head movements. In the later stages Any patient who loses consciousness during a when the tumour is pressing on the brain-stem vestibular disturbance should be suspected of and cerebellum, ataxia will often supervene. having epilepsy, because loss of consciousness in Gliomas of the cerebellum are more common aural vertigo is extremely rare. It does, how- in young people and if, as so often happens, they ever, occasionally happen that after a sharp involve the central part of the cerebellum then attack of vertigo and vomiting there is a short the vestibular nuclei in the flocculo-nodular loss of consciousness which is due to syncope. area are likely to be involved and vertigo and Another disorder which must be considered here nystagmus, which are brought on by putting the is the vaso-vagal syndrome about which much head back or to one side, are likely to persist so has been written in the past. In these cases long as the offending position is maintained. A there is the sensation of things being far away, child is often so terrified by this that he will not loss of balance and possibly loss of consciousness allow the test to be carried out. but rarely prolonged vertigo, and no disturbance In much older patients the possibility of a of the vestibular mechanism. Possibly such secondary deposit from a primary carcinoma, par- cases should be regarded as a form of faint. ticularly in the bronchus, must be borne in mind. In disseminated sclerosis the disease may In the past three years I have seen no less than implicate one of the vestibular nuclei in the four elderly patients in whom vague but per- brain stem and cause vertigo, but it is unusual sistent dizziness with slight spontaneous nystag- for it to do this as an isolated incident. By its mus accentuated or even altered by placing the very name the patches of sclerosis are scattered head back (positional nystagmus of the central throughout the central nervous system so that type) were the presenting features of an un- commonly there are eye symptoms (diplopia), suspected and, ofcourse, asymptomatic bronchial sensory disorders (numbness and tingling) carcinoma. affecting the trunk and limbs, disturbance of Thus in childhood vertigo of central origin gait and of micturition. If any of these features may be due to a cerebellar glioma, in adult life to accompany vertigo then the possibility of dis- disseminated sclerosis, epilepsy or an acoustic seminated sclerosis must be considered. neurofibroma, and in later life to a vascular dis- If an intracranial blood vessel ruptures or turbance or to a carcinomatous secondary becomes thrombosed, sudden vertigo may be an deposit in the brain-stem or cerebellum. early feature of the disorder, but with the excep- The differential diagnosis of lesions of the 5 Section of Otology 533 posterior fossa was fully discussed at the Section and Hewlett, 1954). Of these, half were bilateral of Neurology of the Society (Proceedings, 1953, more or less from the onset, while in the remain- 46, 719). Basilar insufficiency has been put ing half there was an interval sometimes of many forward recently as a possible cause of vertigo years before the second ear was attacked. and it is said to be caused by narrowing of the The attacks usually come on with but little basilar artery by atheromatous plaques, which in warning and rarely last more than two hours. certain circumstances leads to temporary inter- Sometimes the attacks are solitary with a free ference with the blood supply to one or both interval of months or even years, the sufferer labyrinths. It is likely to be seen in elderly being quite well in the meantime. It is, how- subjects and may be provoked by sudden move- ever, quite common for there to be an active ments which lead to severe but transient vertigo phase lasting some weeks, during which time and loss of balance. As the interference with the there may be several attacks. During this active flow of blood to the inner ear is but momentary phase there is likely to be a sustained depression there are often no signs of a peripheral vestibular of hearing with perhaps a feeling of fullness in or cochlear disorder. the ear or of pressure on that side of the head Peripheral Vestibular System which only lifts when the active phase has sub- As will be seen from Table IV, Meniere's sided. Then the hearing may improve and any disease dominates the picture and accounts for accompanying tinnitus is likely to be less notice- more than twice as many as all the other causes able. There may then be an interval or quiet put together. phase of months or even a year or two before the attacks recur, usually to be preceded by an TABLE IV.-PERIPHERAL CAUSES OF VERTIGO For- M6ni6re's disease. 1,701 increase in the cochlear symptoms. Peripheral positional nystagmus and tunately attacks are rarely prolonged beyond vertigo. . 266 Vestibular neuronitis .227 half a day, though very occasionally they may Infective .145 return after an interval of a few days. I have Streptomycin .52 even seen patients who had daily attacks for Menie're's disease.-Prosper Meniere of Paris several weeks. was the first to draw attention to the ear as being It is usual for both cochlear and vestibular responsible for attacks of vertigo and vomiting function to be affected, but occasionally the associated with tinnitus and deafness, and ever brunt is borne mainly by only one of these senses. since his name has been associated with this When vertigo is the prominent feature there is syndrome. Though his life was far from un- usually slight deafness or perhaps tinnitus during eventful, having included being Physician the attacks to indicate the nature of the dis- Accoucheur to the wife of the Pretender to the order. On the other hand, it is by no means French Throne, a friend of Balzac and Super- uncommon to find deafness only without vertigo intendent of a Deaf and Dumb Institution, he but with the low tones mainly, if not entirely, would not be remembered except for this affected and the characteristic distortion for loud, discovery in 1861, the last year of his life. musical and high-pitched sounds. Such patients Though many clinicians recognized a disorder usually develop vertigo at some later date. with a definite pattern, which quite rightly they It is sometimes puzzling to find that, despite a attributed to the inner ear, it was not until 1938 typical history of attacks of sudden cochlear and that Hallpike and Cairns were able to demon- vestibular failure, functional tests reveal no strate that the disorder was accompanied by a impairment of function. In such cases the distension of the endolymphatic system. Thus endolymphatic distension must have been slight it has been possible to separate this condition and of short duration and the end-organ un- from a number of others grouped under the usually resilient, for it must be remembered that syndrome and to call it appropriately enough the loss of hearing, bearing more heavily on the "Me'niere's disease", and it is sometimes given low tones, and the reduction of response to the descriptive sQb-title of endolymphatic caloric stimulation are the result of the damaging hydrops. effect of excessive endolymphatic pressure on the The principal features of this disorder are end-organs which takes place during the active summarized in Table V. phase of the disease and particularly just before TABLE V.-M;NIERE'S DIsEAsE OR LABYRiNTHINE HYDROPS an attack. Usually unilateral Occasionally the distension of the endolym- Sudden attacks of limited duration Both balance and hearing usually affected phatic system, instead of subsiding before Hearing often distorted damage has been done to the delicate sense Hearing and noises often fluctuate with attacks organs, may be kept up and even go on to In a series of 900 cases of Meniere's disease we rupture of the endolymphatic sac, in which case found that only 12% were bilateral (Cawthorne all function may be destroyed. It has been 534 Proceedings of the Royal Society of Medicine 6 customary to regard such labyrinthine disasters that the dizziness is brought on by lying back in as due to htemorrhage and at times this may bed, or by turning over in bed. In the daytime well be true. However, the onset of the symp- the housewife may experience it on lifting her toms with the gradual building up of pressure, head to reach for something high up, or the deafness with distortion and tinnitus, and motor mechanic will find that he is unable to finally vertigo suggests a severe hydrops going get underneath a car. The histological findings on to rupture as an alternative explanation. associated with this disorder have since been Positional vertigo and nystagmus.-It has long confirmed in other cases by Cawthorne (1954) been known that certain tumours, particularly and Cawthorne and Hallpike (1957). those in the posterior fossa, and probably dis- Vestibular neuronitis.-This condition which is orders of the otolith system were responsible for nothing more or less than sudden failure of one bouts of nystagmus and vertigo provoked by vestibular end-organ was described and named by putting the head in certain positions (Bartany, Hallpike in 1949. The features are summarized 1920-21; Nylen, 1950). Thanks to the work of in Table VII. Dix and Hallpike (1951) it has been shown that TABLE VII.-VESTIBuAlR NEuRoNTis there are two distinct types ofreaction, depending Sudden unilateral vestibular failure upon whether the lesion is central or peripheral. Intense vertigo made worse by head movement Vertigo and nystagmus diminishing daily In the peripheral group they found a definite Normal hearing. No tinnitus Central nervous system normal lesion in the utricular end-organ. Lesion in vestibular pathway, possibly Scarpa's ganglion The importance of this group is that only by positioning the head may the abnormality be The suddenness and the severity of the attack, discovered, for the other tests of vestibular which often appears in early middle age, makes function may all be normal. The central group the diagnosis of an intracranial disaster very in which the nystagmus appears as soon as the tempting in the absence of any cochledr symp- head is placed back and continues so long as toms or signs. The patient is unable to leave his the position is held is, as has already been said, bed for one to three weeks, after which he usually found to be due to tumours involving manages to get about, though his self-confidence the cerebellum in the mid-line. Often in such may be badly shaken. cases there is already some spontaneous nystag- In this connection it is interesting to recall mus which is very much accentuated or even that after sudden loss of vestibular function from altered in direction by the alteration in position a lesion of the end-organ, the resulting nystagmus of the head. The vertigo accompanying the and vertigo, which to start with are intense, nystagmus may not be so severe as in the peri- gradually diminish each day until at the end of pheral group, but in some it may be very severe three weeks the nystagmus will have disappeared as in the flocculonodular syndrome described by and vertigo is only likely to be provoked by a Botterell and Fulton (1938). sudden movement of the head. This is, of course, The paroxysmal type of vertigo and nystagmus due to compensation within the central nervous due to a lesion in the utricular end-organ is system for the loss of one set of end-organs and much commoner than the central type and in it probably takes place between the vestibular my series there are eight peripheral to every one nuclei in the brain-stem. central. The only physical sign will be an absence or Table VI gives the principal distinguishing reduction of the normal response to caloric features of the peripheral group. stimulation on one side. The site of the lesion is not definitely known, but it can be anywhere TABLE VI.-PARoxYsMAL PEuPHERAL VERTIGO AND NYSrAGMUS Induced by placing the head back or to one side in the vestibular nerve from the end-organ to Short latent period before onset of vertigo and nystagmus in the brain-stem. It is Nystagmus usually rotatory and vertigo severe, disappear- the vestibular nuclei ing after few seconds quite possible that Scarpa's ganglion on the On resuming head position little or no vertigo or nystagnus for some minutes vestibular nerve in the temporal bone is the site Often history of recent head injury of the lesion and it may be due to a focus of Often only physical sign of labyrinthine disorder infection or even a virus. It is probable that so- The most important feature of this group is called epidemic labyrinthitis comes within this that it may be the only physical sign of a utricular group. It is benign, though occasionally it may lesion and, as it not infrequently follows a head recur on the other side. However, in most of injury, it can be overlooked and the symptoms those seen in this series the subsequent course may be attributed to the post-concussional syn- was benign which suggests that the lesion was an drome or to traumatic neurasthenia. Spencer isolated one and probably not in the brainstem. Harrison (1956) has reported an interesting Infective vertigo.-Infection, often chronic, series of cases following head injury. The con- may spread from the middle ear by erosion of dition is suspected when the patient complains the bony labvrinth causing giddiness which may 7 Section of Otology 535 end in generalized infection of the labyrinth and been given over the course of three days. Such even spread to the meninges. The presence of susceptibility seems to have been more noticeable an active fistula in a case of long-standing otitis where there has been some impairment of renal media always raises the possibility of such a function, so that caution needs to be exercised dangerous complication and operative treatment when giving streptomycin to such patients. The may be needed to remove the disease. early symptoms of streptomycin intoxication There is one interesting group where, either often pass unnoticed because the patient is in because of former disease or as the result of an bed and the swimming feeling in the head or operation, there is a fistula in the lateral semi- on being turned to have the bed made is easily circular canal and probably at the same time attributed to the illness which made the rest in actively moving round and oval windows. Thus bed and the administration of streptomycin the presence of a third window in the bony necessary. If possible it is safer not to exceed labyrinth gives rise to irregular stimuli which a total dose of 0-5 gram daily, as we have never affect the vestibular labyrinth and cause in- heard of toxic symptoms appearing with this stability. The cause of the unsteadiness when dosage (Cawthorne and Ranger, 1957). walking is not understood and in consequence a Many patients can tolerate 1 gram or even curious syndrome may develop, which Hallpike 1 5 grams a day for several weeks without and I have recognized for many years and for developing toxic symptoms, but the effect of which we have been in the habit of using the losing all vestibular function can be so crippling term "perilabyrinthitis" (Cawthorne, 1957). that we feel such doses are only justified in the Another small group which comes under this presence of serious disease which cannot be heading is where there are three movable combated by any other means. windows in the bony labyrinth as the result of Unclassified fenestration of the lateral canal for deafness or This includes some early cases of post-trau- for giddiness with, of course, active function in matic vertigo when the significance of postural the vestibular labyrinth. Either the same vertigo was not appreciated. Also some of this mechanism takes place as in perilabyrinthitis, or group may be toxic while others are probably the effect may be due to a loud sound stimulating central even though no other signs of a central the vestibular labyrinth (Tullio effect), nervous disorder could be found. (Cawthorne, 1956). In any case it should always Differential Diagnosis be borne in mind that the presence of two mobile Finally a few words about the differential windows in the bony labyrinth on the vestibular diagnosis between central and peripheral lesions side of the basilar membrane may give rise to in vertigo. The history combined with the troublesome and persistent vertigo. The clinical presence of other signs helps to localize the dis- features are summarized in Table VIII. order; for instance deafness and tinnitus point TABLE VIII.-PERLABYRINTMS to the inner ear as the source of the trouble. Constant slight vertigo when walking The presence of spontaneous nystagmus may Often bizarre gait History of former mastoid operation or of otitis media offer a valuable clue. Spontaneous nystagmus Active fistula sign may be seen in the early stages of a peripheral Other forms of infective vertigo include the vestibular disorder, but it will diminish in neurolabyrinthitis of meningococcal meningitis intensity each week and will have disappeared at which unfortunately usually affects both ears the end of three weeks. The intensity of vertigo leaving the child stone deaf, and mumps which will be in proportion to the intensity of the fortunately only affects one ear. The vestibular nystagmus. On the other hand the spontaneous nuclei may be affected in polyneuritis but rarely nystagmus due to involvement of the central as an isolated event, while in the Ramsay Hunt vestibular pathways in the brain-stem will persist syndrome both divisions of the VIII nerve may indefinitely even though the vertigo may not be affected together with the VII nerve. always be in proportion to the nystagmus. Streptomycin.-Vertigo causedby the vestibulo- In Meniere's disease spontaneous nystagmus toxic properties of streptomycin sulphate or will only be found at the height of the attack calcium streptomycin has been recognized since and will usually disappear with the vertigo in a 1947 when Glorig and Fowler reported it. In matter of hours. In vestibular neuronitis the order to overcome this the di-hydro compound nystagmus may last for two or three weeks; but was developed but unfortunately this was found if in a case of vertigo spontaneous nystagmus to have a toxic affinity for hearing as well as for persists for weeks or months then the cause will balance. What, however, was not generally be found within the central nervous system. appreciated was that some patients were so The methods used for investigating the susceptible that vestibular function might be vestibular system of patients with vertigo are severely damaged after as little as 3 grams had those described by Cawthome et al. (1956), and 536 Proceedings of the Royal Society of Medicine 8 include the caloric test first described by CAwTHORNE, T. (1956) Brit. med. Bull., 12, 143. Fitzgerald and Halpike and tests for - (1957a) In: Modem Trends in Neurology. (1942) Second series. Ed. D. Williams. London; p. 193. spontaneous, positional and optokinetic nystag- - (1957b) Laryngoscope, St. Louis, 67,1233. mus. In addition, of course, tests of cochlear - , Dix, M. R., HAxLLPEnn, C. S., and HOOD, function and a full examination of the ears, nose J. D. (1956) Brit. med. Bull., 12, 131. throat are carried out, and X-rays of , and HIALLPIKE, C. S. (1957) Acta otolaryng., and often Stockh., 48, 89. the temporal bones will be needed. , and HEWLETr, A. B. (1954) Proc. R. Soc. In concluding this account of the significance Med., 47, 663. of vertigo, I should like to express my gratitude , and. RANGER, D. R. (1957) Brit. med. J., in particular to my colleagues at the National i, 1444. Dix, M. R., and HALLpnKE, C. S. (1951) Ann. Otol. Hospital for Nervous Diseases, Queen Square, Rhin. Laryng., 61, 987. to my colleagues at King's College Hospital and -,- (1958) Proc. R. Soc. Med., 51, 889. to friends elsewhere who, by referring their EDwARDS, C. H., and PATERSON, J. H. (1951) Brain, 74, 144. patients with vertigo to me, have given me an FrrzGRALD, G., and HALLPUx, C. S. (1942) Proc. R. opportunity of learning something about this Soc. Med., 35, 801; Brain, 65, 115. interesting symptom. To my colleague at the GLOluG, A., and FowLER, E. P., Jr. (1947) Ann. Otol. National Hospital, Dr.C. S. Hallpike, I should like Rhin. Laryng., 56, 379. GowERs, W. (1888) A Manual of Diseases of the to extend my thanks for all that I have learnt Nervous System. London; 2, 719. from him and to say how much I admire what he HALLPKE, C. S. (1949) IV. Congr. int. Oto-rhino- and the staff of the Otological Research Unit of laryng., 2, 514. the Medical Research Council have done in the - and CAIRNS, H. (1938) J. Laryng., 53, 625. HARRIN, M. S. (1956) Brain, 79, 474. field of neuro-otology. Finally I shall always be JEFESON, G. (1953) Proc. R. Soc. Med., 46, 719. grateful to my associates at the National Hospital, LOGAN, W. P. D., and CUSHION, A. A. (1958) Stud. Dr. A. B. Hewlett, and, until recently, Mr. med. Popul. Sub]., No. 14. Douglas Ranger, for all their help. MNIIRE, P. (1861) Gaz. med. Paris, 16, 597. NYLEN, C. 0. (1950) J. Laryng., 64, 295. REFERENCES SPuILANE, J. D. (1950) Proc. R. Soc. Med., 43, 1111. BARANY, R. (1920-21) Acta otolaryng., Stockh., 2, 434. Professor G6STA DOHLMAN read a short BEHRMAN, S., and Wsc, B. D. (1958) Brain, 81, 529. supporting paper on Modem Views on Vestibular BOrERELL, E. H., and FuLToN, J. H. (1938) J. comp. Physiology. Neurol., 69, 31. CAWTHORNE, T. (1954) Ann. Otol. Rhin. Laryng., 63, This paper has been published in the Journal 481. ofLaryngology, 73, 154 (March 1959).

Meeting December 5, 1958 Towards a Dry Ear.-Mr. CHARus SMm!H. THE following papers were read: Rosen's Operation in Diagnosis.-Mr. WIuAm The Surgical Management of Congenital Atresia McKENzIE. of the Ear.-Senator J. A. SULLiVAN Preliminary Experience with the Vein Graft for (Toronto). Otosclerosis.-Dr. I. SmsoN HALL. The Establishment of Sound Conduction in Con- The following took part in the subsequent dis- genital Deformities of the External Ear.- cussion: Dr. I. SIMsON HALL, Mr. W. McKENzIE, Mr. GAvIN LIViNGSTONE and Mr. E. W. PEET. Mr. T. B. LAYTON, Mr. L A. TurmARKIN, Mr. Personal Experiences of the Surgery of Congenital R. F. J. MARTIN, Mr. STUART MAWSON, Mr. Atresia of the External Auditory Meatus and H. J. GROVES, Mr. G. H. BATEMAN, Mr. J. F. Middle Ear.-Mr. N. W. GiLL. SIMsON, Mr. P. H. BEALES, Mr. W. A. MILL. Sir HAROLD GILLIES and Professor F. C. Meeting March 6, 1959 ORMEOD took part in the subsequent discussion. THE following papers were read: The meeting has been published in the Journal Fundamentals and Tasks of Plastic Surgery in ofLaryngology, 73, 201-241 (April 1959). Operation for Restoration of Hearing.-Pro- Meeting February 6, 1959 fessor H. WULLSTEiN (Wurzburg, Germany). TiE following short papers were read: The Problem of the Mastoid Segment after Causation ofDeafness in Children.-Mr. KENmTH Tympanoplasty.-Mr. PHImP H. BEALES and HARRISON. Mr. W 'RED HYNES. Nystagmography in the Various Tests ofVestibular The following took part in the subsequent Function (Film).-Professor F. C. ORMEROD. discussion: Mr. F. McGucKIN, Mr. STUART The Place of the B6k6sy Audiometer in Clinical MAWSON, Mr. I. B. THoRBmRN, Mr. H. V. Audiometry.-Mr. KENNETH McLAY. FORSER and Mr. E. G. COLLINS. Sudden Perceptive Deafness in Young People.- The February and March meetings will be Mr. T. J. WILMOT. published in the Journal ofLaryngology.