In an individual who has already arrived at the climacteric without having experienced tbe slightest irregularity in the menstruation, or any change in the nutritive condition, violent attacks of vertigo may occur. The latter oft,en appear while the menses are regular, even before the usual time for the menopause, and we shall seldom go amiss if we regard these as the first manifestations of the approaching climacteric. The menses may disappear so gradually at the climacteric, and the system may accommodate itself favorably to the cessation of the usual flow, yet severe attacks of vertigo may possibly occur.
The amount of blood lost at the time of the menopause may be dis proportionately greater than before (not including the case in which actual amemia developes), and yet there may be attacks of vertigo that are exactly similar. The periods may be absent for a long time (so that the system becomes accustomed to the cessation of the flow, and the man ner of life may at the same time be quite rational, through the avoidance of sedentary habits, rich food, etc., and still vertigo may persist. Finally, as we would emphasize here, in consequence of severe climacteric hem orrhages, a profound amemia may have developed, and a particularly nervous individual may, in consequence of disturbance of nutrition or other complications, be extremely reduced, and almost invariably under such circumstances she will complain of vertigo. I frequently see exam ples of the latter condition. But, from what has been said, it is suffi ciently evident that the frequent appearance of attacks of vertigo at the menopause do not (at least in the majority of the cases) depend upon hypenemia, due to cessation of the flow. It cannot be denied also, as I expressly affirm, that relative hypemmia frequently occurs at the cli macteric. Only, I hold that it is not true that this is not responsible for most of the cases of vertigo to be observed at this time. Now and then we are certainly obliged to suppose this mode of origin for the vertigo, as in cases in which there is dizziness when the periods are absent, and good health when they are present, relief of the vertigo after the reap pearance of menstruation, or after scarification of the cervix, etc. If we assign hypenemia as the only, or even the principal cause of vertigo at the menopause, we must do so if another cause can not be found. In
my opinion there are various things which can give a satisfactory ex planation of the phenomenon in question, and that we are to take the proper view of this question if we assume at the outset that the attacks of vertigo at this period of life may rest on an entirely different basis. Clinical observations agree with this opinion. Aside from the reported cases (which are certainly not very many) in which hyperEemia is the e,ause, I believe that simple hysteria first, then chronic disturbances of the ali mentary canal, and finally =Emil', three conditions that complicate the menopause far more often than is commonly supposed, should be regarded as causal factors of vertigo. Hysteria is especially mentioned by Landois in this connection, in addition to chronic affections of the respimtory organs, etc. In so-called gastric vertigo, according to 1Voakes, the ab normally irritated nerves of the stomach act upon the vaso.motor centre, especially the nerves of the labyrinth, in consequence of which variations in the tension of the fluid may be produced, and hence attacks of vertigo. Goltz explains the dizzy feelings by supposing that within the internal ear are the terminal ramifications of another nerve, having special func tions, in that the auditory nerve can only receive sensations of sound. So much for true vertigo.
Of similar character, but not to be confounded with true vertigo, are the conditions due to variations in the amount of blood in the cortex eerebri, " which are observed often enough in ansemic patients." So far as I have observed, these vertiginous attacks, which depend upon cerebral anaamia during the climacteric, and for some time afterward, seem to play an important role, and are very often misunderstood. Cer tain profuse hemorrhages are soon forgotten by patient and physician, because they are " self-evident; " a persistent, fairly-satisfactory condi tion of nutrition, of a perfectly healthy appearance, leads them to think only of " plethora," and every fresh threatening of vertigo is now ascribed still more to the absence of the periods, while really it is due only to a persistent anEemia. We often hear indeed of " suppressed " menstrua tion, and the need of a diminution of the amount of blood urged in ex planation of vertigo in certain individuals, who evidently have typical ansamia.