Tim BRITISH 3 JULY 6, 1935 THE CLINICAL ASPEiCT OF VERTIGO IAJ~NL difficult to accept the view that waterlogging of the body should affect the labyrinth on one side only. It is reasonable to expect that both labyrinths would be involved and, being symmetrical, vertigo should not occur. Again vertigo is not a symptom in cases of dropsy subsequent to renal and cardiac disease. However, Mygind and Dida Dederding are in favour of the theory of waterlogging. Palliative Treatment Palliative treatment

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... was carried out in the greater number of these cases. Rest in bed and the exclusion of all stimuli likely to produce vertigo, and a mild calomel purge with the administration of luminal (1/2 grain) or bromide, were usually successful. If the blood pressure is low ephedrine or ergotin may be given. Tobacco and alcohol usually aggravate the vertigo, and should be suspended. A careful and detailed investigation of the patient's method of living should be made to find any contributory cause. An attack of vertigo can sometimes be aborted if the patient resolutely fixes his eyes on some neighbouring object and so restores his equilibrium. The psychological element in these cases is very marked, and the patient should be encouraged and reassured. For this reason any definite and detailed line of treatment is sometimes successful, but the variety of drugs and treatments prescribed indicates that at present there is no real specific for vertigo. In spite of this a large proportion of these patients recover. There are a number of cases due to suppuration of the ear in which the mastoid operation alone has been entirely successful and satisfactory. The labyrinth has not been touched and labyrinthotomy or labyrinthectomy has not been necessary. Operations on the Labyrinth Operations on the labyrinth for vertigo are comparatively rare, because such an operation is only performed: 1. When the diagnosis that the vertigo is caused by the internal ear is certain. 2. When the vertigo is so severe and frequent as to make the patient miserable and unable to work. 3. When all other remedies have failed. It must be remembered that the operation destroys the hearing and is not usually performed unless there is a considerable degree of deafness. The cases which fulfil these oonditions are few and far between. Richard Lake, who specialized in this operation, performed th-e labyrinth operation in fourteen cases only. Many patients refuse to have any operation, and improve with palliative treatment. The most satisfactory operation is known as superior and i-nferior vestibulotomy, in which the ampulla of the external semicircular canal is opened by a fine chisel. The slit-like lumen of the canal is easily recoginized. If the chisel is then applied to the little ridge of bone between the fenestra ovalis and fenestra rotundum the promontory is flaked off and the vestibule opened. The nerve ending is destroyed by removing the modiolus with a curette. Complete excision of the semicircular canals, or labyrinthectomy, is not generally performed, and I venture to say that it is unnecessary. I have done six cases of superior and inferior vestibulotomy wit-h satisfactory results. Mollison's method of injecting alcohol into the external semicircular canal was adopted and, in addition, the vestibule was opened by removing the promontory. All six patients had had a previous radical mastoid operation. The vestibulotomy or labyrinthotomy was easily performed, and with the presenit-day technique was not dangerous. After the operation there was considerable post-anaesthetic vomiting, a riotous nystagmus, and increase of the vertigo, bult withinl three weeks the wound had healed and the patients were discharged from the hospital qulite well. ,One patient who had had a radical mastoid operation done on both sides and was very deaf, had vestibulotomy performed on the right ear. The vertigo continued, and after an interval of three weeks a left vestibulotomy was performed with complete success. The operation has been done for tinnitus, but the result was negative and the tinnitus persisted. About twenty-five years ago Ballance divided the auditory nerve within the skull to relieve a distressing case of tinnitus. The result was unsatisfactory. Cairns has carried out a similar operation of division of the auditory nerve for vertigo in four cases with success, Dandy has also done forty-two successful operations for vertigo, and, incidentally, in a few only has the tinnitus been relieved. This operation appears to be too formidable and too uncertain to be popular. Vertigo is not dangerous to life except when it arises from suppuration of fthe labyrinth, which may lead to meningitis. Summary Vertigo arising from the ear has distinctive features which make its recognition easy and certain. A hundred cases of vertigo have been classified according to their clinical etiology. The pathology is discussed. There were no cases associated with high blood pressure. Lumbar puncture has produced negative results. The majority of the cases were given palliative treatment. The mastoid operations in cases of suppuration of the ear were very successful. The indications for the destruction of the labyrinth or internal ear are the failure of palliative treatment, and a certain diagnosis that the vertigo arises from the ear.