Abstract

The words for vertigo: ‘dinos’, ‘ilinggous’ ,‘skotomatikoi,’ date back to the classical period of Plato and Hippocrates. They were followed by the Latin ‘vertigine’ and ‘scotomia’. Excessive heat or blood in the brain were the original causes of vertigo, followed by Galen’s vaporous pneuma. Not until Flourens’ demonstration of circling movement in pigeons in which he had destroyed the semicircular canals, and Brown-Séquard’s observation of vertigo in man after syringing the ear with cold water, did the vital role of the vestibular apparatus appear. Subsequent syndromes described by Ménière and Bárány showed the role of the inner ear in causing vertigo in man.

There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient’s complaint is dizziness.

WB Matthews. Practical Neurology. Oxford, Blackwell, 1963

From ancient times the physical sensation of spinning was conjoined with attendant mental distress and misery so that vertigo was confusingly applied to both phenomena. During the nineteenth century, opinions ranged from the traditional view that vertigo could indicate a brain disease, a disorder akin to melancholy or hypochondria, or was strictly a hallucination, illusory sensation, or a sign of insanity [1].

Erasmus Darwin (1731-1802) vividly described the feeling:

Thus on turning round on one foot, the vertigo continues for some seconds of time after the person is fallen on the ground.

Sir Walter Scott (1771-1832) in a letter to JG Lockhart Esq, dated 1827 illustrated its use as a disordered state of mind, or of things turning:

Your letter has given me the vertigo, my head turns round like a chariot-wheel. Why, How Now?

Dean Jonathan Swift (1667-1745), who wrote Gulliver’s Travels was a satirical wit and poet, and a sufferer from vertigo. In his Verses on the Death of Dr Swift, (lines 81-84), he says:

See, how the Dean begins to break!
Poor gentleman, he droops apace!
You plainly find it in his face.
That old vertigo in his head
Will never leave him till he’s dead.

Not confined to man, it is sometimes applied to the staggers in horses or the sturdy * in sheep, and to a disorder of hawks. The noun “Spin”, beloved of politicians, is a familiar modern usage with a wholly different meaning and context.

To this day, the definition of vertigo “is inconsistent among otolaryngologists … and should be limited to false illusions of circular motion” [2]. The varied historical conceptions and misconceptions of vertigo serve to emphasise the need for painstaking analysis of the patient’s history which serves to separate it from more common but less specific symptoms of dizziness, faintness, and giddiness (which originally meant light-headedness).

The Oxford English Dictionary gives the first citation for vertigo as Thomas Paynell in 1528:  The heed ache called vertigo: whiche maketh a man to wene that the world turneth. But the symptom was earlier described in classical Greek where the term ‘dinos’ meant a whirling and rotation [3]. The word ‘ilinggous’ also denoted eddies of smoke or whirlpools, accompanied by mental agitation; ‘skotomatikoi,’ meant darkness, gloom, or ignorance. These terms appear in the works of Plato (c.428-348 BCE). Later Latin texts used ‘scotomia’ – dizziness with dimness of sight, and ‘vertigine’ or ‘vertigo’ (from vertere, a turning) [1].

The Hippocratic corpus (c.460-370 BC) represents vertigo as a disease of the head caused by excessive heat or blood. Aretæus of Cappadocia (2nd century AD), a contemporary of Galen clearly described:

Vertigo arises as the successor of cephalæa; but also springs up as a primary affection… If darkness possess the eyes, and if the head be whirled round with dizziness, and the ears ring as from the sound of rivers rolling along with a great noise, or like the wind when it roars among the sails, or like the clang of pipes or reeds, or like the rattling of a carriage, we call the affection Scotoma (or Vertigo) [4].

Galen of Pergamum (AD 129-199) thought vertigo was caused by a “vaporous and warm pneuma within the rete mirabile,” † either a primary affection of the head, or a sympathy with the stomach [5]. This view persisted into the nineteenth century. Indeed Gowers noted: there exists frequently an obtrusive association between this giddiness and certain gastric symptoms… and the nature of the disease consequently misconceived by both the patient and his medical adviser [6].

Nineteenth-century dictionaries show the diversity of nomenclature by long lists of synonyms for vertigo. The ideas gradually changed in evolving 19th century neurology. Spurzheim (1817) for instance characterised “vertigo or giddiness, as an illusory rotation of all objects around us, and of ourselves, with a fear of falling….” It could occur in brain disease and could complicate mental illness and madness.

Mechanisms

Antonio Maria Valsalva (1666-1723) recognised the function of the tympanic membrane and the ossicular chain for the transmission of sound via the cochlea. Antonio Scarpa (1752-1832) in his De structura fenestrae rotundae auris, et de tympano secundario 1772, was the first to demonstrate the anatomy of the bony and membranous labyrinths and the peripheral (Scarpa’s) ganglion of the vestibular sensory receptors [7]. But how ear disorders caused vertigo remained uncertain. The physiologist and juvenile prodigy Marie-Jean-Pierre Flourens (1794-1867) in 1825 observed that when a pigeon’s horizontal semi-circular canal was destroyed, the bird continued to turn in a circle: thus demonstrating the function of the vestibular labyrinth [8]. Purkinje (1787-1869) showed the influence of the head position on the directional component of vertigo, and the maintenance of posture and equilibrium in man [9] – Purkinje’s Law of Vertigo.

Perhaps the most fundamental advance appeared in a course of lectures on the Physiology and Pathology of the Central Nervous System in 1858, in which Brown-Séquard described vertigo and spontaneous rotational movements as evidence for irritability of the acoustic [syn. vestibulocochlear] nerve:

Any one who has received an injection of cold water in the ear may know that it produces a kind of vertigo, and that it is difficult to walk straight for some time after this irritation. A sudden noise makes the whole body jump… Vertigo and various convulsive movements, in cases of irritation of the acoustic nerve, have been observed in adults and children. Rotatory movements have taken place in cases of suppurative inflammation of the ear, and twice immediately after an injection of a solution of nitrate of silver…[10]

Clinicopathological features

Prosper Ménière (1799-1862) famously described the triad of deafness, tinnitus and vertigo — “On a particular form of severe deafness resulting from a lesion of the Inner Ear.” His case was not an instance of what we now call Ménière’s syndrome, but some form of haemorrhage. However, significantly he showed no pathology of the middle ear, vestibulocochlear nerve or brain and related vertigo to the endolymph of the semicircular canals [11].

I have already spoken, a long time ago, of a young girl, who, having travelled by night in winter on the outside of a diligence, when she was at a catamenial period, had, in consequence of a considerable cold, complete and sudden deafness. … her chief symptom continual vertigo, the slightest effort to move produced vomiting, and death followed on the fifth day. The necropsy showed that the cerebrum, cerebellum and spinal cord were absolutely exempt from any alteration, but as the patient had become suddenly deaf after having always had perfect hearing, I removed the temporals in order to examine with care what could be the cause of this complete deafness, so rapidly supervening. The sole lesion I found was the semicircular canals filled with a red plastic material, a sort of bloody exudate, of which scarcely any traces were perceived in the vestibule, and which did not exist in the cochlea. The most attentive search has enabled me to establish with all the precision desirable that the semicircular canals were the only parts of the labyrinth which showed abnormality, and this consisted, as I have said, in the presence of a plastic lymph replacing the liquid of Cotugno [12].

Similar symptoms were later shown in haemorrhage, tumours, trauma, and infections of the labyrinths and vestibulocochlear nerves. Ménière’s syndrome was thought to be idiopathic until the discovery of endolymphatic hydrops.

Gradenigo in 1892 showed the first audiograms of hearing loss involving all frequencies. Gruber in Vienna in 1895 found a great variation of the endolymphatic sac in studies of more than 100 temporal bones. He postulated a disturbance of resorption of endolymph, which might induce periodic distension, and eventually rupture of the membranes of the labyrinth resulting in the onset of Ménière’s attacks. The pathological findings of Hallpike and Cairns in 1938 [13] confirmed Gruber’s hypothesis and showed that Ménière’s endolymphatic hydrops was a nosological entity, albeit of unknown cause.

Robert Bárány (1876-1936) with caloric tests established that the semi-circular canal was a sensory organ for the perception of rotary motion and vertigo [14]. In 1914, whilst incarcerated in a prisoner-of-war camp as a Jew, he was awarded the Nobel Prize for ‘Some New Methods for Functional Testing of the Vestibular Apparatus and the Cerebellum.’ Recent visualisation of endolymphatic hydrops with gadolinium contrasted 3Tesla MRI has shown several variant forms. From this has developed the Bárány Society diagnostic criterion for definite Ménière’s syndrome:

An episodic vertigo syndrome associated with low- to medium frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12 h.

*Attributed to cyst of the Taenia multiceps, in sheep brain (Coenurosis)
† Galen’s rete mirabile was found in the brains of animals he dissected, but is not present in the human brain.

References

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