of that fact is great. Frequently the attack of vertigo is associated with an intensification of the tinnitus, or there are subjective sounds of a violent character, described as "pistol shots," "something breaking in the head," etc. Sometimes a quick movement of the head in a given direction produces it. This apparently has relation to a particular semicircular canal, which is mainly or alone affected. A further characteristic of aural vertigo is the fact that the subjective or objective gyrations are uniform in the given case, or the stagger or falling is always in the same direction. In epilepsy we not infrequently encounter an indescribable vertiginous aura, but never the formulated vertigo of aural disease. The epileptic attack is usually followed by mental hebetude, which is lacking in aural attacks, where the vertigo may be maintained for a long time, giving rise to distressed feelings, vomiting, and collapse. The sensorium is always clear in aural vertigo, excepting the initial momentary unconsciousness of the severest form, or in the delirium that a continuation of the extremest variety may produce in very rare instances. The persistent vomiting usually gives rise to the idea of “biliousness," and frequently a brisk cathartic, relieving all the symptoms of vertigo, is supposed to confirm the idea of intestinal or hepatic derangement, its influence on cerebral circulation being overlooked. Again, the sudden onset of the attacks in the Ménière form suggests cerebral disease or cardiac attacks, to which mistake the age of the patient and his arterial degeneracy often conduce. The repetition of the aural attack during periods of rest, and even during sleep, with absence of cardiac and cerebral symptoms in the meanwhile, will correct a misconception of this character.

The labyrinthine variety may be readily confused with ocular vertigo in some instances, as it occasionally gives rise to nystagmus, and even has produced diplopia. The patients sometimes describe oscillating movements in viewed objects, rapid in one direction with slow return, similar to the nystagmic movements of the eyeballs. The mutual dependence of space sensations and ocular impressions only needs to be mentioned to explain the secondary ocular movements. Ocular vertigo ceases the moment the eyes are closed, but this has no effect on the aural form. Vertigo is associated with numerous abdominal disturbances, particularly those of the stomach, liver, and small intestine. These forms of vertigo are usually attended by indigestion or other symptoms of a local character, and the vertigo lacks the distinctive gyratory feature of ear trouble. In some cases of aural vertigo, however, the patients complain merely of "dizziness," "giddiness," or "swimming" sensations. If the vestibule alone is involved, without any implication of the cochlea, as is conceivable, all auditory symptoms default. In such cases the diagnosis must largely depend on the exclusion of other sources of vertigo.

Treatment. If aural vertigo is recognized as an irritation symptom, its rational treatment will depend on appreciating and, if possible, removing the basic disease. Cases may be relieved or even cured by Politzer's inflation, by the removal of cerumen, or by the correction of a pharyngeal catarrh. In others the sclerotic changes in the labyrinth

are irremediable and treatment is directed to reducing the irritability by bromids. Charcot strongly recommended in the Ménière type the use of quinin in large doses, but others have not had his success with that drug, and it should not be used in acute cases. He even advocated the destruction of the inner ear, producing loss of hearing, or, in other words, a removal of all irritability and the cessation of the vertigo at once, in the same way that sometimes occurs naturally. Removal of the malleus and incus and mobilization of the stapes have given relief in many instances and may be advised with propriety, especially if the hearing is greatly impaired. Gout and arteriosclerosis, middle-ear disease, and lesions of the auditory stem must be treated in their own several ways. Electricity is of questionable value, though it is asserted by some that the positive pole over the tragus and the negative on the back of the neck, with a current of three or four milliamperes gradually increased from zero, continued for five minutes and then decreased, has a quieting influence. All interruptions should be avoided. Cases of acute onset are sometimes benefited by pilocarpin, as in nervous deafness, with which they are usually combined.

CHAPTER IX.

DISEASES OF THE GLOSSOPHARYNGEAL, VAGUS, AND ACCESSORY NERVES.

It

Anatomical Considerations.-The glossopharyngeal and pneumogastric nerves and the bulbar portion of the spinal accessory should be considered as one mechanism. Their nuclei in the medulla are practically inseparable, and they continuously subserve sensation and motion for the gastro-intestinal tract from the pharynx to the duodenum. In addition they furnish motor filaments, which all come from the accessory portion, to the lungs, larynx, and heart. They are visceral nerves. is to be kept clearly in mind that the spinal portion of the accessory is a pure motor nerve to the skeletal muscles of the neck, and is only locally associated with the pneumogastric. The interrelations of the glossopharyngeal-vagus-accessory group are so complex, their distribution so wide-spread, and their indirect disturbances so vague that they furnish many perplexities. A short outline of the glossopharyngeal is first given, and then the vagus and true accessory are discussed together.

DISEASES OF THE GLOSSOPHARYNGEAL NERVE.

The ninth cranial nerve is still a source of anatomical contention and physiological doubt. In consequence its diseased conditions are uncertain and obscure. Practically, in man, it is never alone diseased. If its relations to other cranial nerves are considered, this fact is readily understood. Through Jacobson's nerve it forms, with the sympathetic, the tympanic plexus, whence a branch connects it through the Vidian

with the facial nerve, and another branch through the small superficial petrosal connects it with the otic ganglion. It is connected with the pneumogastric at the petrous ganglion of that nerve, and also in the pharyngeal plexus. Its nuclei are intimately associated with those of the vagus and accessory nerves. It probably subserves sensation in the upper part of the pharynx and in the tympanum, and nausea is associated with its disturbance. Probably through its distribution to the root of the tongue it peripherally carries the fibers of the special sense of taste for that area, but these are not embraced in its root. They reach the brain by a circuitous route, probably entering the petrous ganglion of the glossopharyngeal nerve from the middle branch of the fifth through the tympanic plexus and otic ganglion. It seems to have some motor control of the upper portion of the pharynx, and, perhaps, of the palate.

Intracranial disease and cranial fractures may implicate the glossopharyngeal, causing weakness and some insensitiveness in the upper pharynx and in the palate. Its nuclei in the medulla usually suffer in bulbar palsy, and thus are produced, at least in part, the pharyngeal symptoms of that disease.

DISEASES OF THE VAGUS AND BULBAR PORTIONS OF
THE ACCESSORY.

The

Pharyngeal Branches.-The pharyngeal branches of the pneumogastric follow below the glossopharyngeal, and with it form the pharyngeal plexus, supplying motion and sensation to the uppermost portion of the intestinal tube. These branches are paralyzed by nuclear disease and in diphtheric palsy, but seldom otherwise. Bulbar involvement is invariably attended by symptoms in other cranial nerves. pharynx is more or less insensitive and motionless. The pharyngeal reflex is lost. Food tends to accumulate and lodge in the gullet or overflows into the larynx, producing spasmodic cough and strangling. If the palate at the same time is weakened, food and fluids may be forced into the nasal passages and regurgitate through the nose. pharyngeal spasm furnishes the condition commonly noted in hysteria globus," or esophagismus, and is always functional. At times it may be mistaken for pharyngeal paralysis, or the difficulties in swallowing in the latter may be attributed to spasm. The use of a sound will at once clear the doubt. The decided pharyngeal grasp of health is increased in spasm and lost in paralysis. Moreover, spasm is temporary or recurrent, and paralysis is continuous.

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A

Laryngeal Branches.-The larynx is innervated by two branches of the pneumogastric: (1) The superior laryngeal governs the movements of the epiglottis and controls tension in the vocal cords through the cricothyroid, which is the only intrinsic laryngeal muscle supplied by this nerve. It also furnishes sensation to the larynx above the vocal cords. (2) The recurrent laryngeal, which turns about the aorta on the left side and the subclavian artery on the right side, supplies sensation

to the trachea and to the larynx below the vocal cords. It controls all the intrinsic laryngeal muscles except the cricothyroid. These muscles have three principal vocal actions: First, to draw the vocal cords tense; second, to bring them close together; third, to draw them apart. Though many laryngeal movements are highly complex, requiring the synergic action of several groups of muscles, it is well to remember that the chief tensors are the cricothyroids, the chief abductors are the posterior crico-arytenoids, the chief adductors are the lateral crico-arytenoids. In addition, the thyro-arytenoids, which in part form the vocal cords, serve to stiffen them and make their apposition uniform and effective. By some they are considered tensors and by others laxors of the cords, and probably serve both purposes.

Laryngeal paralyses vary in degree and in distribution. They may be unilateral or bilateral, partial or complete. Further, the abductors, the adductors, or the tensors of the cords may be alone or mainly involved. Abductor paralysis is, however, by far the most common, 1 even when the lesion falls upon the recurrent. A full knowledge of the anatomy and mechanism of the larynx is required to understand this subject, and the use of the laryngoscope is requisite for exact diagnosis. The following table is given to show the common varieties of laryngeal paralysis, with diagrams of the corresponding mirror pictures, which should be compared with the normal outlines in phonation, respiration,

and death.

Fig. 57.-Bilateral thyro-arytenoid paralysis and paralysis of arytenoideus, giving an hour-glass open