Erich Ruttin.

A Clinical study of the serous and purulent diseases of the labyrinth online

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be explained by the slowness of the destructive tubercular
proce (Herzog). All the others (except two, concerning
whose vertigo nothing was noted) uave regularly a history
of di/./inc .

Ordinarily, the beginning of the vertigo attacks is re-



SYMPTOMS 41

f erred back between five weeks and two days; the longest
duration was eight years (Case 25).

Present Symptoms.

Under this heading we understand labyrinthine symp-
toms tinnitus, vertigo, emesis, equilibrium disturbances;
also nystagmus belongs here, though in the table, for prac-
tical purposes, this was separately tabulated.

Tinnitus is altogether an inconstant symptom. It may
occur in all forms of labyrinth inflammation, but in most
cases, relative to the other symptoms, it falls into the back-
ground, as compared with the many cases of non-inflamma-
tory labyrinth diseases in which tinnitus is often the most
trying symptom.

It is to be noted also that tinnitus may occur in total de-
struction of the labyrinth, that is, in purulent labyrinthitis ;
and, further, destruction of the labyrinth by operation does
not always relieve an existing tinnitus (E. U rb ants chit sch).
Neumann endeavors to explain this by assuming that the
tinnitus is caused by degeneration of the ganglion cells in
the nerves.

Of our fifty cases of circumscribed labyrinthitis, tin-
nitus was noted seventeen times, yet only twice was the
tinnitus severe, for the most part it was reported as
only occasional.

Of the twenty diffuse purulent manifest cases, tin-
nitus was noted only three times ; in the twenty-six dif-
fuse latent cases, only four times. It is to be stated
that in three cases (87, 89, 93) the tinnitus continued
after the labyrinth operation, and that in one case
(92) the tinnitus appeared after the labyrinth
operation.

The attacks of vertigo of the circumscribed labyrinthitis
we are not often in a position to observe. We may, how-
ever, provoke them, if we either have the patient make
active movements of the head or if we passively move the



42 DISEASES OF THE LABYRINTH

heat I forward and backward, or laterally. On the other
hand, we see vertigo appearing very often in the diffuse
serous secondary forms, for this comes on chiefly after the
radical operation, and we then see it develop before our
eyes. Ordinarily, between the first and the third day after
the radical operation occur marked nystagmus toward the
healthy side, emesis, disturbances of equilibrium (or the pa-
tient may assume a position of preference [Zivangslage]
on the unaffected side) and vertigo. These typical mani-
festations we see in our eleven cases in which there devel-
oped after the operation, from a circumscribed laby-
rinthitis, a diffuse serous secondary labyrinthitis. In three
other cases there was no vertigo, in spite of the fact that
the same diseased conditions existed (Cases 40, 43, 48).
These manifestations disappear on the average in three to
five days. There are also cases in which likewise there ap-
pears a diffuse secondary serous labyrinthitis which was
at first suppressed ; that is, there occur on the day follow-
ing the radical operation some veriiuo and nystagmus, but
this nystagmus never attains its severest form (third de-
gree) ; the vertigo and nystagmus pass rapidly by, and
there remain no functional symptoms. In the well defined
forms this is regularly the case. There remain always func-
tional disturbances (diminished hearing, eventually total
deafness, sometimes also loss of the caloric or turning re-
actions), of which we will later say more in detail. In some
individual cases the symptoms appear to a certain extent
in a desultory manner; that is, during the first three days
there develop symptoms not at all definite a little dizzi-
ness, nystagmus of the first or second degree to the healthy
side. These symptoms disappear again, and the patient
has two or three days of rest. On the fifth to the sixth day
there appear suddenly the symptoms of a fully developed
diffuse serous secondary labyrinthitis (Cases 30 and 39).

In the diffuse purulent manifest labyrinthitis, the laby-
rinth symptoms of nystagmus to the healthy side, vertigo,
emesis, disturbances of equilibrium, enforced decubitus on



SYMPTOMS 43

the healthy side, all appear in a very marked way, unless the
purulent form has developed slowly out of a serous type.
For example, in Case 70 the serous labyrinthitis began on
the second day after the radical operation, and the purulent
labyrinthitis developed at first gradually to the ninth day,
and accordingly the symptoms were not very marked.

In a co-existing meningitis the symptoms may be consid-
erably masked. After the labyrinth operation the vertigo
diminishes with the nystagmus in ten. to seventeen days.
In one case (No. 65) the nystagmus completely disappeared
immediately after the operation.

In the diffuse purulent latent labyrinthitis there are no
symptoms, though they are usually to a greater or less ex-
tent brought out again by the labyrinth operation. We must
imagine that by the operation nerve cells and fibers still
capable of some function, though they do not respond to
our tests, are now destroyed. The duration of these symp-
toms arising after a labyrinth operation is very variable,
according to the completeness of the labyrinthine
destruction.

The longer the labyrinth disease lasts, so much more
likely is there a complete organization of the exudate,
eventually even a bony substitution. Accordingly, the more
complete is the destruction of the nervous elements of the
vestibular apparatus which are imbedded in the exudate.
In such old cases the symptoms after the labyrinth opera-
tion are exceedingly slight, but in other cases in which the
labyrinth suppuration is of more recent date the symptoms
are often quite severe. According to our experience, these
symptoms last ordinarily from three to five days. We have
never seen the limit exceed fourteen days, and during this
period they always show diminishing severity a fact of
great importance in the differential diagnosis of meningitis
and brain abscess.



In circumscribed labyrinthitis the nystagmus is directed



44 DISEASES OF THE LABYIUXTH

at DUO time to the healthy side, at another to the diseased
>!<!; again, it is directed to both sides, or there may be no
nystamnus present. This corresponds with our theoretical
assumption, for we kno\v that from each labyrinth, by irri-
tation, nystagmus may IK> produced to the right as well as
to the left. The nystagmus in circumscribed labyrinthitis
we must consider a symptom of irritation. In our Cases
1, 3, 4, 6, 7, 8, 9, 11, li 14, 17, 18, 19, 25, 26, 27, 30, 31, 34,
35, 36, 38, 39, 40, 41, 42, 43, 45, 46, 47, 48 and 50, which
before the operation we regarded as cases of pure circum-
scribed lahyrinthitis, there occurred nineteen times no nys-
tagmus; fourteen times nystagmus to both sides, that is,
in extreme lateral fixation of the eyes. Only once was there
nystagmus to the healthy side. However, in the diffuse
lahyrinthitis, as well as in the serous and in the purulent
manifest form, we encounter a nystagmus, since it also oc-
curs after operative destruction, which we must regard as
called forth by the preponderance of the well side. This is
the severest grade of nystagmus to the healthy side, with,
of course, the gradual dying out of the symptom. In the
diffuse purulent latent labyrinthitis, nystagmus is entirely
absent; that is, it has run its course before the time of out
observation.

Acuteness of Hearing.

In the pure circumscribed labyrinthitis we find regularly
a more or less well-preserved hearing power.*

Of our fifty cases, thirty-three had hearing and sev-
enteen were deaf. Of these thirty-three, nineteen had
a hearing power of more than one meter (the greatest
was six meters). These were clear circumscribed laby-
rinthites; fourteen had a hearing of less than one
meter, of whom eleven were pure circumscribed and

'"! I-,,,- (. \n-li. f. O. 79) found in his cases regularly deafness, though
ho hirnsvlf makes the significant observation that this was probably, with
his limited material, a coincidence.



SYMPTOMS 45

six were diffuse serous secondary labyrinthitis.
Of the seventeen deaf cases, six were of the diffuse
serous secondary type, which were diagnosed as such
from other symptoms, one a purulent manifest arising
from a circumscribed labyrinthitis, seven were tuber-
cular, very likely also serous labyrinthites which had
run their course, which is so often true in the tuber-
cular eases, as Herzog and I myself have already sug-
gested. Two cases were previously deaf, and one was
deaf on both sides, the deafness having come from
other causes.

Of the thirty-three cases with hearing, eight became
deaf after the radical operation (Nos. 1, 3, 14, 26, 31,
43, 45, 50). All of these showed signs of a diffuse
serous secondary labyrinthitis. Of the remaining
twenty-five cases, only three had the symptoms of a
serous labyrinthitis (Nos. 23, 32, 49). Two of these re-
tained their hearing after the subsidence of the serous
labyrinthitis. In the third case, the labyrinth opera-
tion was performed (No. 32).

From these figures we may conclude that the cases with
a circumscribed labyrinthitis have a more or less useful
hearing power, and that a spontaneous labyrinthitis, or one
occurring after and probably in consequence of a radical
operation may obliterate the hearing function.

In the diffuse purulent labyrinthitis, both manifest and
latent, naturally there is always total deafness on the af-
fected side. Only in the purulent manifest labyrinthitis is
it possible to have in the very first stages some hearing
power, which, however, can persist only a very short time.
Two observations, one by Bdrdiiy and one by Bondy, con-
firm this.

Caloric Reaction.

Of our fifty cases of circumscribed or diffuse serous
secondary labyrinthitis, the caloric reaction was re-



46 DISEASES or 7///V I.AHYH1MH

tained in thirty-six cases, both before and after the
radical opera tion, in so far as the labyrinth operation
was not performed.

In seven cases the caloric reaction was lost before
the operation; of these seven, four already before the
operation showed the symptoms of a diffuse serous sec-
ondary labyrintliitis; in two cases (Nos. 2 and 44) it
had already clearly run its course, and in one case (No.
10) it developed before the operation into a purulent
labyriuthitis.

Seven more cases lost their caloric reaction through
a diffuse serous secondary labyrintliitis, clearly the re-
sult of a radical operation. In all cases with lost ca-
loric reaction the hearing was lost, with one single ex-
ception (Case No. 48).

Accordingly, we may state: In the circumscribed laby-
rintliitis both hearing and caloric reaction are retained.
Through the onset of a diffuse serous secondary laby-
riuthitis, whether spontaneous or in consequence of the rad-
ical operation, the hearing is lost more often than the ca-
loric reaction. In a series of cases the hearing and the
caloric reaction both are lost clearly severe cases. The
caloric reaction is never lost with retained hearing power
(exception, Case No. 48).

In the purulent manifest, as well as latent labyrintliitis,
the caloric reaction is naturally always destroyed.

Turning Reaction.

In general, the turning reaction is retained when the ca-
loric reaction is retained. Yet the caloric reaction is the
finer test, in that to be elicited it requires a greater move-
ment of the endolymph than does the turning reaction. Ac-
cordingly, there are cases in which the caloric reaction is
lost while the turning reaction remains. In the pure cir-
cumscribed labyrinthitis, the turning reaction is always re-
tained (Nos. 18, 31, 35, 36, 39, 46, 47). The onset of a dif-



SYMPTOMS 47

fuse serous secondary labyrinthitis can, simultaneously
with the loss of bearing and of the caloric reaction, also
cause the loss of the turning reaction (Nos. 10, 16, 22, 44).
Nevertheless, in diffuse serous secondary labyrinthitis, the
hearing is alone most commonly lost; less often, hearing,
caloric and turning reactions. Very seldom do we have loss
of hearing and the caloric reaction, with retained turning
reaction, after the radical operation. Only once did we ob-
serve loss of turning reaction with retained hearing and
retained caloric reaction (No. 48). This case belongs to
the exceptions and does not agree with our theoretical as-
sumptions. Equally rare and difficult of explanation is the
loss of the caloric reaction with retained hearing and turn-
ing reaction (No. 47 before the radical operation).

From the above, we may divide the diffuse serous second-
ary labyrinthitis into the following grades:

Caloric Turning

Hearing Eeaction Keaction Fistula

I. Grade . . . + + + +

IL "... + + +

III. "-..'. + +

IV. " . . . +
V. " ...

The fifth grade cannot be differentiated from the puru-
lent manifest labyrinthitis.

In those cases in which the turning reaction was tested
before and after the diffuse serous secondary labyrinthitis,
the numerical value in seconds, when the turning reaction
remained at all after the serous labyrinthitis had run its
course, was less, as a rule, for both sides.

Case 1 : before the serous labyrinth- f R. Turning, Xys., horiz., left 20"

itis (right ear diseased) 1 R. Turning, Xys., horiz., left 20"

After the serous labyrinthitis f R. Turning, Xys., horiz., left 12"

{ L. Turning, Xys., horiz., right 12"

Case 37 : before the serous labyrinth- f R. Turning, Xys., horiz., left 25"

itis (left ear diseased') 1 L. Turning. Xys., horiz., right 24"

After the serous labyrinthitis, ( R. Turning. Xys.. horiz., left 10 -14"

two months later { L. Turning, Xys., horiz., right 24"



DISEASES OF THE LABYKL\TH



Case 39: before the serous labyrinth- ( R
iti- i ri^'lit t-ar diseased)
After the serous labyrinthitis,
one month later



\ I



Case 47: before the serous labyrinth- '

it is (left ear diseased t
After the serous labyrinthitis



II



Turning. Xys. horiz., left 25"

Turning. Nys. horiz., right 10 -12'

Turning. Xys. horiz., left 14"

Turning, Xys. horiz., right 8"

Turning. Xys. horiz., left 32"

Turning, Xys. horiz., right 15"

Turning, Xys. horiz., right 20"



L. Turning, Xys., horiz., right 20



We find in the recorded cases, as well as in other exam-
ined cases, differences which show the affected side to be
less irritable. But we cannot ascribe to these differences
any diagnostic value. Only when the differences are so no-
ticeable that in turning toward the healthy side, that is,
from the diseased side there is practically no after-
nystagmus, or one of the briefest duration, while the dura-
tion of the nystagmus produced by turning toward the dis-
eased side, that is, the nystagmus proceeding from the
healthy labyrinth, is nearly normal (between 20" 30").
Only under these conditions do we conclude that there is an
absence of the reaction on the diseased side. Many cases
of labyrinth disease, however, while confined to bed can-
not be tested for the turning reaction. This influences very
much the value of this test, particularly in those cases of
diffuse serous secondary labyrinthitis, following a circum-
scribed labyrinthitis immediately after the radical opera-
tion. The turning test, as regards its delicacy of reaction
upon the vestibnlar apparatus, is between the caloric test
and the fistula test. The caloric reaction may, indeed, be
already lost, and the turning reaction remain present; but
if the turning reaction is not lost, then surely the much
coarser test for fistula is positive, so that we find the caloric
test and the fistula test in these cases sufficient in order to
give us a picture as to the condition of the vestibular
apparatus.

\\ ' will now consider the figures for the turning nystag-
mus in the purulent labyrinthites :



SYMPTOMS



49



Case


55:


Diseased side


"


62:





"


65:


a, tt


"


71:


1 1 tt


"


72:


tt tt


"


74:


tt tt


"


77:


tt tt


"


81:


tt tt


i t


83:


tt 1 1


11


84:


tt tt


"


86:


tt tt


11


90:


a tt


11


92:


it tt


1 1


93:


tt tt


11


95:


tt it


"


96:


n n



12" Healthy side 16"

10" " " 20"

15" " " 20"

5" " " 30"

" " (20")

8" " " 16"

trace (?) " " trace (I)

tt tt (20")

1 .>// < < t< 01 "

10" " " 15"

10" " " 26"

I// 01 "

-^5"

10" " il 40"

^0"

OQ"

Note: Naturally, for example, "diseased side 12"
and healthy side 16"" means that after turning to the
healthy side and stopping (irritation of the diseased
side) after-nystagmus to the diseased side lasting 12"
results, and after turning to the diseased side and ar-
resting the movement (irritating the sound side)
after-nystagmus to the healthy side lasting 16" occurs.
The bracketed figures are the average time which in
the history were recorded as "typical" or "normal."

From the figures given, we see at once that in most cases
there is a difference between the duration of the nystag-
mus of the healthy and the diseased sides, the duration for
the healthy side being more than twice that for the diseased
side. But in normal cases we also notice great differences.

Bdrdny has already given the average difference for per-
sons with one-sided labyrinth destruction as from 14" to
28". Practically, for the diagnosis I consider as significant
only those cases in which the after-nystagmus for the af-
fected side gives a duration of at most 4" to 5", compared
with a normal duration (20") for the healthy side. For I



50



DISEASES OF THE LABYRINTH



have not observed this proportion in normal cases, and
I ^n nn 11 has observed it only very exceptionally.

On the other hand, in complete destruction of the laby-
rinth of long standing (for example, after ossification or
sequestration) a compensation of the turning nystagmus
apparently takes place. "My own personal investigations of
this feature show that such cases may have an equal turn-
ing nystagmus, while cases apparently destroyed by opera-
tion (yet not completely destroyed), as in one case, after
six years, showed no compensation.*

Fistula Test.




FIG. 16

The demonstration of a fistula can be made by inspection
during operation. But it is desirable before operating to
recognize the presence of a fistula. This is done by the so-
called fistula test. The reaction is present if, by compres-
sion and aspiration of the air in the external auditory canal
by means of a Politzer bag armed with a tube and olive tip,
we get either nystagmus or only a slow movement of the
eyes. "We call the nystagmus typical when it occurs in the
manner observed in the majority of cases; that is, when on

* Aa I have already shown, M. f. O. 43, No. 2.



SYMPTOMS 51

compression we get nystagmus toward the affected side
(typical compression nystagmus), and on aspiration we get
nystagmus toward the healthy side (typical aspiration
nystagmus).

This was to be noted in twenty-four of our fifty cases.

A series of cases in which only "fistula symptom"
was recorded (i.e. eight cases) belongs with these. In-
cluding these, thirty-two out of fifty cases showed "typ-
ical nystagmus." From this frequency, which was al-
ready noticeable before we had enough cases for statis-
tical purposes, and because it is consistent with theo-
retical grounds, there appeared the justification to des-
ignate this nystagmus as typical.

Of these thirty-two fistula cases with typical nystag-
mus, the fistula was demonstrated twenty-six times dur-
ing the operation. Four cases were not operated; in
one case it could not be looked for, because of the con-
servative operation of Bdrany; and once the fistula,
in spite of a search during the operation, could not be
found. The location of the fistula in these thirty-two
cases occurred twenty-three times in the horizontal
semicircular canal, once in the oval window, once in
the frontal semicircular canal, and once almost the en-
tire pyramid was destroyed.

It is also possible for the nystagmus in the fistula test
to be reversed, that is :

On compression, nystagmus to the healthy side (reversed
compression nystagmus).

On aspiration, nystagmus to the diseased side (reversed
aspiration nystagmus).

Reversed nystagmus in the fistula test occurred in
twelve cases out of fifty. In these, the fistula was lo-
cated six times in the horizontal canal, once in the
promontory, once in the oval window, once in the hori-



DISEASES OF THE LABYRINTH

zontal canal and the oval window in a nearly necrotic
labyrinth wall. Two cases were not operated; in one
case the fistula appeared some time after the radical
operation.

From these figures it follows that we can draw no posi-
tive conclusion as to the localization of the fistula* from the
kind of fistula symptom.

Instead of nystagmus, it frequently happens that there is
only a slow movement of the eyeballs, and this we call typi-
cal when it is of the following character: With compres-
sion, slow movement to the healthy side; with aspiration,
slow movement to the diseased side; or reversed compres-
sion movement and aspiration movement; with compres-
sion, slow movement to the diseased side, and with aspira-
tion, slow movement to the healthy side.

A typical movement of the eyes was present in two cases,
and a reversed movement in one of our cases.

Ordinarily, compression has a stronger" effect than aspi-
ration; less frequently the reverse is true (in four cases).

Correspondingly, we may have, with compression, nys-
tagmus to the diseased side; with aspiration, only slow
movement to the diseased side (typical compression nystag-
mus and typical aspiration movement).

Rarely is. the reverse true: With compression, slow
movement to the healthy side; with aspiration, nystagmus
to the healthy side (typical compression movement and
typical aspiration nystagmus).

It is also possible that only compression or only aspira-
tion is effective (typical or reversed compression nystag-
mus, or only typical or reversed compression eye movement,
or only typical or reversed aspiration nystagmus, or only
typical or reversed aspiration eye movement).

The reason why we get in the one case nystagmus, in
the other only eye movement, we might assume to be as
follows: When the irritant, in consequence of favorable

* As I have already reported, M. f. O. 43, No. 2.



SYMPTOMS 53

pathological-anatomical relations (size of the fistula, free
accessibility for the compression air current), is great, then
there follows close upon the vestibular irritation, whose ef-
fect is the slow movement of the eyes to the opposite side,
the central reaction in the form of the rapid, opposed move-
ment. This produces a nystagmus to the same side.
On the other hand, should the irritation produced by com-
pression be slight, through unfavorable anatomical rela-
tions, then the vestibular reaction is followed by no central
reaction, but there follows after cessation of the stimulus
only a slow movement in the opposite direction (restoring
the eyes to their former position). In fact, in such cases
the eyes remain in their diverted (abducted) position as
long as the irritation (compression) is in operation, and
return to their ordinary position only when the compres-
sion ceases, while in those cases with nystagmus, the quick
component appears during compression.

A fine example of this is shown by Case 50.

Here the compression produces a typical movement of
the eyes, that is, a slow movement to the right side (the
healthy side), and immediately following we get the typical
nystagmus to the left. The central reaction comes equally
tardy. AVith aspiration we get a typical eye movement,
that is, a slow movement to the left (diseased) side. But
this, contrary to what we would expect, is not followed by
a nystagmus to the right, but both eyeballs, during the en-
tire period of the aspiration, remain fixed in the left
canthus. The weaker irritation produced by aspiration is
not of sufficient force to arouse a central reaction.

Peculiarities are shown by other cases (Case 12). Nys-
tagmus under the fistula test is quite typical, but aspira-
tion is without effect. The operation showed a very small
dehiscence in the semicircular canal, impassable to the
probe.

In a second case (No. 48), with typical fistula symp-
toms, aspiration was entirely uneffective. In this case there
was a vi-ry large cholesteatonia.



54 DISEASES OF THE LABYRIM'H

The condition in which the fistula symptom is only occa-


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Online LibraryErich RuttinA Clinical study of the serous and purulent diseases of the labyrinth → online text (page 4 of 18)