THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES Gift of Dr. Roy Van Wart o E LABYRINTH BY DR. ERICH RUTTIN Privatdocent in the Otological Clinic, University of Vienna WITH A FOREWORD BY PROFESSOR DR. VICTOR URBANTSCH1TSCH AUTHORIZED TRANSLATION BY HORACE NEWHART, A.B., M.D., Instructor in Otology, University of Minnesota; Otologist and Rhinologist, North- western Hospital; Fellow American Academy of Ophthalmology and Oto-Laryngology; Fellow American College of Surgeons, etc. WITH 25 TEXTUAL FIGURES NEW YORK REBMAN COMPANY U1-H5 WEST 36TH STREET COPYRIGHT, 1914, BY REBMAN COMPANY OF NEW YORK PRINTED IN AMERICA Uhtir/ wv 11114 TRAXSLATOE'S PREFACE THIS translation of Dr. Ruttin's Klinik der serosen und < ifrigen Labyrinth-Entziindungen has been made in re- sponse to the persistent demand on the part of many Ameri- can and English students of otology who have followed the author in the Vienna clinic and who wish to possess the monograph in their own language. Others, both otologists and general practitioners, who are not familiar with recent progress in the diagnosis and treatment of labyrinthine complications will find it a prac- tical treatise upon the subject, which should prove a useful guide in dealing intelligently with those cases of labyrinth involvement which are constantly appearing in practice, but which until very recently have too often been unrecog- nized or misinterpreted. The original text has been closely followed, though the case histories have been somewhat abbreviated. HORACE NEWHART. 910 Donaldson Building. Minneapolis, Minnesota. * 111 FOKEWOKD DISEASES of the labyrinth have at the present time become the center of interest among otologists, and justly so, for the recognition of diseases of the labyrinth claims our closest consideration, not only because of the functional im- portance of this organ, but also because of the vital signifi- cance of an extension of an inflammatory process from the labyrinth into the cranial cavity. It may be stated here without presumption that the Vienna school has very mate- rially advanced our knowledge concerning the normal and diseased labyrinth, particularly of the vestibular appa- ratus, and possesses a valuable experience as regards the therapy of the labyrinth. Naturally the establishment of basic principles in re- gard to the diagnosis and treatment of the various affec- tions of the labyrinth demands still further exhaustive investigations on the part of specialists. And from this point of view it would appear justifiable, because of its large wealth of clinical material, that the present position of the Vienna school of otology be presented. My assistant, Dr. Ruttin, who for years has devoted him- self zealously to the study of diseases of the labyrinth, and to whom we are already indebted for several valuable mono- graphs, presents in the following work a detailed descrip- tion of the diseases of the labyrinth, in which the functional manifestations of the normal and diseased labyrinth, the different clinical aspects and the therapeutic considerations in each case are discussed and presented in a manner com- prehensible even to the non-specialist. I hope, therefore, that this book will receive the general notice and circulation it deserves, and that it is destined to yield a valuable contribution to our literature, not only by way of enlarging our knowledge of labyrinthine diseases, but also helping to clear up some as yet unsettled views in PROF. DR. VICTOR URBANTSCHITSCH. Vienna. CONTENTS PAGE TRANSLATOR'S PREFACE iii FOREWORD v CHAPTER I FUNCTIONAL EXAMINATION 1 1. Examination of the cochlea 1 2. Examination of the vestibular apparatus 3 A. Definition 3 B. Direction of the nystagmus 5 C. Degree of the nystagmus 6 D. Production of nystagmus by means of physiological stimuli 8 1. Rotation or turning stimulus 8 2. Caloric stimulus 18 3. Mechanical stimulus (fistula test) 23 E. Relative value of the stimuli 24 F. Disturbances of equilibrium ' . 25 CHAPTER II CIRCUMSCRIBED, DIFFUSE SEROUS SECONDARY AND DIFFUSE PURULENT LABYRINTHITIS 28 A. Pathology 28 B. Etiology 31 C. Symptoms 34 Circumscribed labyrinthitis 35 Diffuse serous secondary labyrinthitis 36 Diffuse purulent manifest labyrinthitis 36 Diffuse purulent latent labyrinthitis 36 Anamnesis 40 Present symptoms 41 Tinnitus aurium 41 Nystagmus 43 Hearing 44 Caloric reaction 45 Rotation or turning test 46 Fistula test , 51 D. Fever 55 E. Therapy, i.e., the indications for the radical and the labyrinth operations 59 Indications , 59 Circumscribed labyrinthitis ... 60 Diffuse serous secondary labyrinthitis 63 Diffuse purulent manifest labyrinthitis 64 Diffuse purulent latent labyrinthitia 65 Technic of the labyrinth operation 67 vii viii CONTENTS PAGE F. Termination 73 Circumscribed labyrinthitis 73 Diffuse serous secondary labyrinthitis 74 Diffuse purulent manifest labyrinthitia 74 Diffuse purulent latent labyrinthitis 75 CHAPTER III INJURIES OF THE LABYRINTH 77 G. Statistics 81 CHAPTER IV SEROUS INDUCED LABYRINTHITIS 85 CHAPTER V LABYRINTHITIS AND BRAIN ABSCESS 91 CASE HISTORIES 98 INDEX 231 CHAPTER I FUNCTIONAL EXAMINATION SINCE we have united in the labyrinth two organs each having a different function, the cochlea and the vestibular apparatus, so the functional examination must include both organs separately. It is advantageous to take up the functional tests accord- ing to a scheme which we use at the clinic as follows : Coclilear Examination Right Left Conversational Voice Whispered Voice Weber Rinne Schwabach C, C 4 Vestibular Examination Spontaneous Nystagmus Turning or Rotation Reaction Fistula Symptom Caloric Reaction Galvanic Reaction In this scheme the cochlear and the vestibular portions are considered separately. 1. Examination of the Cochlea First of all, attention must be called to the fact that merely closing the external meatus of the ear not under examination so poorly excludes it from participation in the 1 DISK ASK* OF THE LABYR1MII act of hearing that results obtained by this method are not at all reliable. The recognition of this element of uncertainty has led to the suggestion of various aids, particularly for the diagnosis of unilateral deafness (the Lucae-Denuert test, conversation tube, etc.). These, at the present time, have all become superfluous through the invention of the so- called exclusion apparatus. Hnraiiii. by means of a loud intra-aural noise, has entirely excluded the ear not under examination. We now employ his exclusion apparatus (Laermapparat). Other forms have been devised by Voss and NeunniHH. (See Fig. 15A on page 27.) If, on applying this apparatus to the ear not being tested, the loud voice next to the ear (ad concham) is not heard, we may assume that the examined ear is deaf for speech. Deafness for speech alone, however, is not suffi- cient to prove that the cochlea has completely lost its func- tion. For this purpose we must also ascertain what is the perception for tuning forks. Our common tuning fork tests often give very useful clues, even though they are not suffi- cient to prove the presence of complete unilateral deaf- ness. If, in Weber's test, there is lateralization to the healthy side, if at the same time Rinne is oo (infinitely negative), that is, if the tuning fork is perceived only by bone conduction; if the deep tones (d) are not heard and there is present a shortening for high tones (C 4 ), then the diagnosis of a unilateral total deafness is very likely. The cardinal tests (Weber, Rinne and Schwabach) are made with a fork of medium pitch (e). More exact than tke ordinary test is the examination according to Bezold's method by means of the continuous tone series of Edelmann. This combination of tuning forks aad whistles includes the entire limit of perception of the human ear and permits of the determination of an unal- tered or altered power to perceive each tone. But this pro- cedure is not practical of execution clinically, for it con- sumes too much time. Bezold has himself shortened the procedure by exam- FUNCTIONAL EXAMINATION 3 ining up to C 2 only by octaves, and from there on by quints. But in order to prove with certainty a unilateral deafness, it is necessary to construct a so-called tone relief, or curve ; that is to say, the tones are projected upon the abscissa and their duration upon the ordinate. The diagram thus ob- tained is compared with that of the normal ear. The hear- ing curve for a person with unilateral deafness begins with a 1 (if the other ear is normal) and shows a rise in the dura- tion with the pitch; that is, a relation opposite to that which is found in the normal ear. Since this procedure is also too bothersome, Wanner has proposed that we use the unweighted a 1 fork with a duration of ninety seconds. According to his assertion, if this fork is not heard by air conduction by the ear under examina- tion, we may assume total deafness for this side. Another very simple procedure has been proposed by h'ardny. If we touch the promontory (of course, through a perforation in the membrane) with a probe whose end is in contact with a vibrating tuning fork, a person with even a very high degree of deafness will perceive the sound of the fork. One who is totally deaf will not react, for this tone is not transmitted to the opposite side. Further, Neintnunt has endeavored to utilize bone con- duction to determine unilateral total deafness. The sound of a vibrating tuning fork placed upon the mastoid of the tested ear is influenced both as to intensity and timbre by closure of the external meatus of the sound side, but not when the meatus of the affected side is closed. 2. Examination of the Vestibular Apparatus The vestibular apparatus reacts to the movement of its lymph by a reflex movement of the eyes which we call nystagmus. A. DEFINITION Nystagmus is a rhythmic, associated movement of both eyeballs; rhythmic, because it consists of two regular com- 4 DISEASES OF THE LABYKIXTH ponents, following each other in sequence, the one quick, the other slow; associated, because both eyeballs regularly participate in the movement. We said a quick and a slow movement, though it would be more correct to say a slow and a quick movement. Haniny demonstrated that the slow component is the vestibular, the quick component is the opposing movement of central origin. Let us assume that my right vestibular apparatus, in consequence of a stimulus (irrigation with cold water, for example), would have the tendency to draw my eyes to the right ; then the eyeballs would move from position a to position b. Right Left FIG. 1 This occurs in the case of an unconscious person or one under general anaesthesia. In the conscious individual, as soon as the labyrinth sends out its reflex impulse which causes the changed position of the eyeball, the centers are notified, whereupon these centers send out an energetic im- pulse to counteract the impulse from the labyrinth, the re- sult of which is to turn the eyeball quickly in the opposite direction. The slow labyrinthine movement was not observed (be- cause of its slowness), and we assume the quick movement of central origin to be the first. But since the labyrinthine stimulus continues, the same action and corresponding counter movement are repeated. This struggle between labyrinthine and central impulses continues in a to and fro movement as long as the labyrinth FUNCTIONAL EXAMINATION 5 irritation exists and finds its expression in the continuous rhythmic exchange of a quick and a slow eye movement. The greater conspicuousness of the quick component was the reason for originally designating the direction of the nystagmus according to the direction of the quick com- ponent, although it would be more logical to designate it by the direction of the slow component. Thus we have come to speak of a nystagmus whose quick component is directed to the left, as a nystagmus to the left, and a nystagmus whose quick component is to the right, as a right nystagmus. B. DIRECTION OF THE NYSTAGMUS From the suspension (Cartesian) of the eyeball, it fol- lows that the eye is capable of free movement in the three planes of space. The three semicircular canals are like- wise placed approximately in the three planes of space. Flour ens discovered the remarkable fact that each semi- circular canal has the power to provoke reflex movements of the eye in a direction corresponding to its own plane as situated within the cranium ; that is, the horizontal canal produces horizontal nystagmus, the frontal, frontal, and the sagittal canal, sagittal nystagmus. The horizontal nystagmus, for example, to the left, ap- pears as a quick movement to the left and a slow move- ment toward the right. Right Left FIG. 2 The smooth arrow indicates the quick movement; the feathered arrow, the slow movement. The rotatory nystagmus, for example, to the left, ap- pears to us as a quick movement of the eyes in the frontal plane, with inclination of the meridian to the left and a slower movement backwards. 6 DISEASES OF Till-: LMiYIflXTH Nystagmus in the frontal plane, however, is not called frontal, but rotatory nystagmus. Nystagmus in the sagittal plane, for example, upward, appeal's as a quick movement of the eyeballs upward with a slow downward movement. Right Left a a represents the meridian ; 5, its inclination. The arrows indicate the nystagmus as in the preceding cut. Right Left FIG. 4 The arrows have the same meaning as in the two preceding cuts. C. DEGREE OF THE NYSTAGMUS We must assume that there exists a certain relationship between the stimulus and the degree of the nystagmus; that is, the extent of the movement of the eyeball. The formula for this relationship we do not know, though we may as- sume, in general, the greater the stimulus, the greater the nystagmus. Inasmuch as all attempts to make a direct measurement of the nystagmus have failed,* we have for a long time em- * Efforts to do so were made by Beck, Kiproff and Bruenings. A pro- cedure which serves to show and to simultaneously record details in the kind of nystagmus which cannot be recognized with the naked eye, is the so-called nystagmography ( Wojatschek, Buys). FCXCTIOXAL EXAMINATION 1 ployed an empirical division of nystagmus into three grades. This classification is based upon the law that a nystagmus is increased in intensity by having the subject look in the direction of the quick component and is de- creased by fixing the gaze in the direction of the slow com- ponent. That is to say, if we allow a patient with, for ex- ample, a right nystagmus, to look to the right, then the nystagmus becomes more pronounced than when he looks straight ahead; and if we have him look to the left, the nystagmus becomes less or entirely disappears. Con- versely, we may conclude, when we are able to recognize a nystagmus to the right only when it is accentuated by hav- ing the patient look to the right, that this is a very mild nystagmus, i.e. of the first degree. If, however, there ex- ists a readily noticeable nystagmus to the right when the patient looks directly forwards, then this must be stronger than the preceding, for we do not need to reinforce it by having the subject look in the direction of the quick com- ponent in order to make it visible. This constitutes a nystagmus of the second degree. This grade disappears when the subject looks to the left. Still more pronounced must be a nystagmus to the right which is still apparent even when the subject is caused to direct his eyes to the left; that is, in the direction of the slow component, in which case we are opposing the nystag- mus. Such a marked nystagmus is known as one of the third grade. In the course of an examination with our stimuli (caloric, or rotation), we know in advance the direction of the nystagmus we are to expect, and so can at once recognize it by intensifying it by having the patient fix his eyes in the proper direction. On the contrary, in the case of a spon- taneous nystagmus, we know nothing in advance as to its direction, and so we are obliged to test the patient by hav- ing him look alternately to the right and left, upwards and downwards. The finger employed for fixation should be held about one-half meter from the patient's eyes, and 8 DISEASES OF THE LABYRINTH should be moved only so far to the side and backwards as to be comfortably followed. Sometimes there exists a nystagmus of the second grade, which, however, cannot be observed because the patient in looking straight forwards chances to fix his gaze upon a near object, which act is sufficient to suppress a nystagmus of moderate grade. For such cases, we employ, according to the suggestion of Bdrdny-Abel, opaque spectacles;* or, following Bruenings, a small mirror is attached by a head- band and held before the eyes; this causes the eyes to ac- commodate for infinity and fixation is avoided. D. PRODUCTION OF NYSTAGMUS BY PHYSIO- LOGICAL STIMULI We are able to produce movements of the lymph by means of different stimuli. These are : 1. Caloric. 2. Rotation, or turning. 3. Mechanical violence (fistula test). These are the stimuli at our disposal in the order of the intensity with which they work. This difference in their effect has been deduced from the observation that, in patho- logical cases, the caloric reaction is lost in cases relatively more slightly affected than is the rotation reaction; and the reaction to the fistula test is lost only in the most se- verely altered labyrinths. 1. Rotation, or Turning Stimulus According to Ewald's experiments, for the details of which we have not the space, we must assume that in the horizontal semicircular canal the movement of the endo- lymph from the small or smooth end to the ampullated end is the more effective ; and such movement causes a nystag- mus to the same .side ; whereas the movement from the am- * Bartels uses strong convex lenses instead of opaque spectacles, accom- plishing the same result, with the added advantage of enabling the observer to see the patient's eyes considerably magnified. (Editor.) FUNCTIONAL EXAMINATION 9 pulla toward the small end is the less effective and produces a nystagmus to the opposite side. Let us assume that we rotate ourself in the horizontal plane; i.e. about our longitudinal axis to the right,* then the lymph in the two horizontal canals, by virtue of its in- ertia, moves toward the left;f that is, in the right horizontal canal there results a current from the small end toward the ampulla. Rear Right Left In the left horizontal canal the current moves from the ampulla, toward the small end and causes a nystagmus to the opposite side, which is also to the right side. We there- fore obtain a horizontal nystagmus to the right, which is stimulated by impulses coming from the horizontal semi- circular canals of both sides. The same deduction holds good for rotation to the left. During the turning in the horizontal plane no apprecia- ble movement of the lymph takes place in the other semi- circular canals, for they occupy a position perpendicular to the plane of rotation.* * We designate turning to the right that movement which corresponds in direction to the movement of the hands of the clock. fThis naturally is the case only in the beginning of the rotation, but the hairs of the crista ampullaris remain deviated for some time, until, because of their elasticity, they return to the position of rest. For the sake of simplicity we assume that it is not the bending of the hairs, but the move- ment of the lymph which causes the bending, which is the cause of the nystagmus. I wish here to state that the first portion of this work covering the physi- ology ha> l>een written particularly in response to the wish of my students, for which reason, upon didactic grounds. I have at certain points simplified the too complicated features at the cost of scientific exactm-". 10 DISEASES OF THE LABYRINTH Since in each canal the maximum movement of the lymph takes place when the canal lies in the plane of the turning, and since we make our investigation by means of the turn- ing chair (w r hose axis is vertical to the floor) and conse- quently the plane of movement is always horizontal, it fol- lows that in testing the other semicircular canals, these should be placed in approximately the horizontal position. Accordingly, in testing the frontal semicircular canal, the head should be held bent forward or to the rear, and in test- ing the sagittal canals, the head should be inclined toward the right or left shoulder. Rear Right If we turn ourself to the right, for instance, with the head bent forward, then, in the right frontal canal, the lymph current flows from the ampulla toward the smooth end, and in the left frontal semicircular canal, from the smooth end toward the ampulla. According to Eivald, we must assume that in the case of both vertical semicircular canals (the frontal and sagit- tal), contrary to what occurs in the horizontal canals, the movement from the ampulla to the smooth end causes nystagmus. to the same side, and from the smooth end (or small end) toward the ampulla, a nystagmus to the opposite side. * For the sake of simplicity we make the assumption, which is not scien- tifically true, that the three semicircular canals are placed in the three planes of space. FUNCTIONAL EXAMINATION 11 Thus we now also obtain, analogously to the rotation with head erect, a nystagmus originating in both sides and di- rected toward the right. The movement in the right frontal semicircular canal is the more effective and gives a strong stimulus for nystag- mus to the right ; at the same time, the less effective move- ment of lymph in the left frontal semicircular canal pro- duces a weaker impulse, likewise for nystagmus to the right. In this case we again obtain a nystagmus to the right, hav- ing its origin in both frontal semicircular canals, but the greater stimulus coming from the right. If now we rotate to the right with the head inclined back- ward, there results in the right frontal canal a current Rear Right / / / r\ \ Left from the smooth end toward the ampulla, that is, a less ef- fective impulse, exciting a weak impulse for nystagmus to the opposite side, i.e. a nystagmus to the left. At the same time there occurs in the left frontal semicircular canal a lymph current from the ampulla toward the smooth end, a more effective movement, producing a strong impulse for nystagmus to the same side, which is likewise the left side. We thus obtain through rotation to the left, with the head inclined backward, nystagmus to the left. In like manner we may deduce the fact that for turning to the left, with head inclined forward, we have nystagmus to the left, and with head inclined backward, we get nystagmus to the right. Nystagmus produced by turning with the head inclined backward or forward is always a rotatory nystagmus, in- 12 DISEASES OF THE LABYKIXTH asmuch as it is produced by the frontal semicircular canal. The sagittal semicircular canal is brought into the hori- zontal plane of rotation by inclining the head toward the right or left shoulder. Here we must point out one difference from the preced- ing illustrations, i.e. the two semicircular canals in this po- sition, during rotation, lie not like the two horizontal and frontal canals, which are on opposite sides of the axis of turning, but they are both upon the same side, and, in con- sequence, in both canals there follows a movement of lymph in the same direction. Front Left Right If we are turned, for example, to the right, with the head inclined to the right side, there occurs in both canals a cur- rent from the ampulla toward the smooth end, the more effective movement, which should call forth a nystagmus to the same side; but since the sagittal canal can produce a nystagmus only in the sagittal plane, that is, upward or downward, there occurs a vertical nystagmus, and, corre- sponding to the more effective movement, the nystagmus is directed upward. FUXCT10SAL EX AM IX A TIOX 13 Again, if we are turned, for example, to the right, with head inclined to the left, there follows i'n both vertical semi- circular canals a lymph current from the smooth end to- ward the ampulla ; that is, the less effective movement, which calls forth a nystagmus in the opposite direction from that called forth by the more effective movement, conse- quently a nystagmus directed downward. Left Right Everything which has thus far been stated is valid only for nystagmus during the act of rotation. If we suddenly arrest the turning, there follows a lymph current in the direction opposite to that which existed during turning,* with the result that we get also a nystagmus in the opposite direction. This we call the after-nystagmus. If we wish to formulate rules for the after-nystagmus, then it is only necessary to reverse the rules above given. For example, let us consider the case of turning to the right with head erect. * We take this for granted for the sake of simplicity. In reality the lymph continues to move in the direction of the rotation in consequence of its inertia: tlu-reby, however, the cupula is displaced in the opposite direction from that which it occupied during the turning. 14 DISEASES OF THE LABYRIXTII During the turning, in the right horizontal semicircular canal we have movement of lymph from the small end to- ward the ampulla, hence the more effective movement, call- ing forth horizontal nystagmus to the right; simulta- neously, movement of lymph in the left horizontal canal from the ampulla toward the smooth end, which is less ef- fective, giving nystagmus to the opposite side (also to the right), therefore producing nystagmus to the right. Rear Right{ ( __ . _ ^ ) | Left Front FIG. 10 The smooth arrow indicates the direction of the lymph current upon stopping the turning. If the turning be suddenly arrested, there follows a move- ment of lymph in the right horizontal canal from the am- pulla (smooth arrow) toward the smooth end. This is the less effective movement and calls forth a nystagmus to the opposite or left side. Simultaneously, there occurs in the left semicircular horizontal canal a movement toward the ampulla, which is the more effective impulse, a nystag- mus to the same side, which is the left, and there results a horizontal nystagmus to the left. In the same manner we can deduce the results for all the other semicircular canals. For convenience, we give here the results of such deductions: Rotation to right and arresting motion, head upright: Horizontal nystagmus to the left. Rotation to left and arresting motion, head upright: Horizontal nystagmus to the right. Rotation to right and arresting motion, head bent forward : Rotatory nystagmus to the left. FUNCTIONAL EXAMINATION 15 Rotation to left and arresting motion, head bent forward: Rotatory nystagmus to the right. Rotation to right and arresting motion, head bent back- ward : Rotatory nystagmus to the right. Rotation to left and arresting motion, head bent back- ward : Rotatory nystagmus to the left. Rotation to right and arresting motion, head inclined to- ward right shoulder: Nystagmus downward. Rotation to right and arresting motion, head inclined to- ward left shoulder : Nystagmus upward. Rotation to left and arresting motion, head inclined toward left shoulder : Nystagmus downward. Rotation to left and arresting motion, head inclined toward right shoulder : Nystagmus upward. Very naturally the nystagmus which we can observe after rotation is more practically useful than nystagmus during turning. Therefore, in practice, we observe only the after- nystagmus, and here we greatly simplify the whole matter. We are interested in knowing whether or not a labyrinth is destroyed. For this purpose it is quite enough to de- termine the nystagmus of one semicircular canal. For the patients, the least unpleasant test is that with the head erect, for reaction symptoms (vertigo, nausea, etc.) are the least pronounced. Accordingly we regularly make only this test. Bdrdny proved that the most reliable test is at- tained by ten revolutions; and that then the duration of the after-nystagmus is twenty to forty seconds in the nor- mal subject. Accordingly we make the practical examination as fol- lows : The patient is placed upon the turning chair,* with head erect and wearing opaque spectacles. He is turned ten times to the right, then, after suddenly arresting the turning, the duration of the nystagmus is measured accu- *In the absence of a specially constructed chair for the rotation test, one may be improvised by utilizing the ordinary revolving office desk chair with arms, adjusting it to" the maximum height and tightening the spring of the tilting mechanism. A board 4" x 1" x 30" placed between the patient's back and the back of the chair will aid in supporting the head. (Editor.) 16 DISEASES OF THE LABYRINTH rately with a stop-watch. Next, the patient is turned ten times to the left, and again the duration of the after- nystagmus noted. The normal individual gives the follow- ing result: FIG. Sketch of a Special Revolving Chair. 10 revolutions to the right produce horizontal after- nystagmus to left, duration 20" 40". 10 revolutions to the left produce horizontal after- nystagmus to right, duration 20" - 40". If, on the contrary, one labyrinth is destroyed, for in- stance, the right, then we may get the following result. 10 revolutions to the right give an after-nystagmus to the left, duration 20" 40". 10 revolutions to the left give an after-nystagmus to the right, duration 5" 15". This result speaks for a probable destruction of the right labyrinth. No nystagmus at all to the right, after turning to the left, must not be expected even in the case of com- FUNCTIONAL EXAMINATION 17 plete destruction of the right labyrinth, for we know that the left labyrinth, through rotation to the left and stopping, produces some nystagmus to the right in consequence of the less effective lymph current in the left horizontal semi- circular canal. Further, this fact is often still 'more signifi- cant; and the differences are also still less noticeable in cases of total destruction of a labyrinth; positive conclu- sions, therefore, cannot then be drawn, especially because it has been proved by Bdrdny that even in normal subjects great differences may exist in the duration of nystagmus from the two sides. Furthermore, it is possible that in a case with total de- struction of one labyrinth the nystagmus after turning to the right and left is quite equal, wlien the so-called com- pensation has become established. I have pointed out that in cases of long standing destruction of one labyrinth (ossifi- cation or sequestration) the nystagmus after turning may be alike for both sides. More will be said ab.out this phe- nomenon later. From the degree of the difference, when the same is not the noticeable difference which is characteristic for a total destruction of the labyrinth, it is impossible to draw con- clusions as to the greater or lesser irritability of the patho- logically inflamed labyrinth, even if we have found in cir- cumscribed and diffuse labyrinthitis in general diminished values for the duration of the after-nystagmus. We can- not properly speak of a hyper-irritability toward physiolog- ical stimuli in the case of an inflamed labyrinth, as I have proved for the caloric* stimulus. I wish to call attention to certain sources of error in the rotation test.f First, the duration of the after-nystagmus may be difficult to determine when there exists a sponta- neous nystagmus. Then we use the fixation apparatus of Bar an if. * Deutsche Otol. Cos.. May. 1909, Basel. T.\ ( a-e of complete absence of rotation nystapnins without explainable i-au-r was described by Lcidlcr (Z. f. O. Bd. 56, H. 4). 18 DISEASES OF THE LABYRISTH The small rod with the fixation point is so adjusted as to cause the nystagmus to disappear. After rotation, the sub- ject is again asked to look at the fixation point, when a nystagmus is observed which did not exist before. FIG. 11 Further, strabismus may be a source of error in our ob- servations. I have found that the squinting eye during and after turning may often be forcibly and rigidly turned to- ward the inner or outer canthus, and we then get the im- pression that only the non-squinting eye shows nystagmus. 2. Caloric Irritation Bdrdny discovered that syringing an ear with cold water produces a nystagmus to the opposite side and syringing with hot water results in a nystagmus to the same (its own) side. This is explained by the physical fact that contact of cold water with the labyrinth wall produces a lymph cur- rent directed downward, while contact with warm water causes a current upward. If we consider this explanation in the light of Eivald's laws, it is easy to deduce the kind of nystagmus produced. In bringing heat or cold to bear upon the labyrinth wall, we have to consider only those parts lying next the outer wall ; i.e. the outer bend and the ampulla of the vertical and horizontal semicircular canals. FUNCTIONAL EXAMINATION 19 If we inject cold water against the labyrinth wall there follows a current from above downward (Fig. 12, smooth arrow), that is, in the frontal semicircular canal, a move- ment from the smooth end to the ampulla, the less effective movement, which causes nystagmus to the opposite side; and since it is a frontal semicircular canal, the nystagmus is rotatory. FIG. 12 Right frontal and horizontal semicircular canals. In the horizontal semicircular canal there results a movement which is from the ampulla to the smooth end (Fig. 12, smooth arrow), that is, for the horizontal semi- circular canal, the less effective movement, which also causes a nystagmus to the opposite side (also to the left). Accordingly there results a rotatory and horizontal nystag- mus to the left. Naturally the rotatory nystagmus is stronger than the horizontal, since the hydrostatic fall is greater, and therefore the current is decidedly greater. The horizontal nystagmus is only very limited; it would not be present at all were the horizontal canal absolutely horizontal in its position, for then there would be no cur- rent produced. If we syringe hot water against the laby- rinth wall, for example, of the right ear, there follows a current from below upward (Fig. 12, feathered arrow), that is, in the frontal semicircular canal, a current from the ampulla toward the smooth end, i.e. the more effective movement, which produces a movement to the same side, L>D D/NAMNA'N or ////: LABYRINTH which, since it originates in the frontal canal, is rotatory. In the horizontal semicircular canal, there results a move- ment of the lymph from the smooth end toward the am- pulla (Fig. 1:2, feathered arrow), which, for the horizontal semicircular canal, is the more effective one, calling forth a nystagmus to the same side. Therefore, we get a hori- zontal nystagmus to the same side. The rotatory is, as above noted, stronger than the horizontal. Let us imagine now that the canals occupy a reversed position; that is, the ampulla above; then we should obtain a reversed nystagmus; that is, with cold water we would get a rotatory and a horizontal nystagmus to the same side, and with hot water, to the opposite side. This, as Bdrdny has proved, is, in fact, the case when the head is inclined forward 180. If the head is inclined toward the left shoulder and cold water is injected into the right ear, we obtain a horizontal nystagmus to the right, for now the horizontal canal occu- pies a position such that its smooth end is higher than the ampulla, and the current flows toward the ampulla, causing the more effective movement, which produces a horizontal nystagmus to the same side. By inclination of the head we get results as follows : Cold water into right ear, head inclined toward left = hori- zontal nystagmus to right. Cold water into left ear, head inclined to right = horizontal nystagmus to left. Hot water into right ear, head inclined to left = horizontal nystagmus to left. Hot water into left ear, head inclined to right horizontal nystagmus to right. According to Hofer (Verh. d. D. otol. Ges., Frankfurt, li'll), in most cases we get the same results if we carry out the sy ringing with head erect, but immediately there- after have the head inclined in the various positions. This must be kept in mind in making the caloric test, and n \CTIOXAL EXAMIXATION 21 therefore during the test we must see to it that the head is held strictly in the upright position. In making the caloric test we use cold water at a tem- perature of 20 - - 30 C. (68 - 86 F.). Water which is too cold (below 20 C. or 68 F.) is not desirable, for the accompanying symptoms (vertigo, nausea and emesis) ordinarily are more severe the stronger the nystagmus. The nystagmus is more intense the colder the water and the longer it is injected. Naturally, in those cases in which water of 20 does not yield a definite reaction, we would employ colder water without fear of severe associated symptoms. FIG. 13 Similarly, in the presence of acute otitis, in consequence of the presence of secretion and of the increased blood sup- ply of the tympanic membrane and the mucous membrane of the tympanic cavity, the action of the water is dimin- ished. This fact is supported by the experiment of Berk, who, by applications of adrenalin, was able to obtain the 22 DISEASES OF THE LABYRIXTH caloric reaction in half the time required under ordinary conditions. The time required for the caloric reaction to appear de- pends upon the accessibility of the labyrinth wall to the fluid employed. According to Kallmann (Passow's Beitriige Bd. V, H. 2), the caloric reaction appears in normal indi- viduals in thirty-six seconds ; in the presence of chronic sup- puration, in forty seconds ; while in cases of total destruc- tion of the drum, and after the radical mastoid operation, in ten seconds. FIG. 14 FIG. 15 The electric heating element a is inserted into the hose and covered with asbestos. Turning the switch over one contact gives a cool current of air, and turning it to the second point puts the heating element into the circuit, and a current of hot air is produced. The tips d and e make it possible to easily introduce the air into the meatus. Granulations, cholesteatomatous masses, etc., lying be- fore the labyrinth wall may retard the action of the caloric test. In general, we consider it a proof that the power to respond is lost, when, after the injection of three liters of water at 16 18 C. (60.8 64.4 F.), there is no reaction. The test is best carried out by'means of the irrigating ap- paratus I have devised (Fig. 13). FUNCTIONAL EXAMINATION 23 The water is caught in a rubber pocket having a drain pipe. In some cases it is wise, even with chronic purulent dis- charge or cholesteatomatous masses, to avoid irrigation, be- cause of the risk of too severe a reaction or of spreading an infection. In such cases the reaction may be brought about by the insufflation of a spray of air, cooled by pass- ing the current through ether (Fig. 14). Other devices for introducing cold air have been de- scribed by Block and Aspissoff. Most recently I have so modified the Foen air apparatus that it appears to be especially well adapted for the caloric test with cold and hot air. 3. Mechanical Irritation In the fistula test we must naturally have for a reaction a fistula into the labyrinth. "We must assume that all cases which give a positive reaction to the rotation and caloric tests would give the fistula reaction were an opening artifi- cially made into the labyrinth. The fistula test is carried out with a small, elastic, thick- walled rubber bag or bulb (ordinarily a small Politzer bag, without valve), to which is attached a tube and an olive tip. The tip is inserted into the canal of the ear under ex- amination in such a manner as to prevent leakage of air, and the result of compression and aspiration of the air is observed as it affects the eyes. In those cases in which there is a very patent Eusta- chian tube, the air escapes so rapidly that the compression is not great enough to elicit the fistula symptom. In such cases I have suggested that at the very moment of com- pression the patient perform inflation by the Valsalva method to counteract the loss by the Eustachian tubes, when the fistula reaction may be made to appear. In cases in which there is a postauricular fistula or large operative wound, we employ, as suggested by Bar any, in- stead of the olive tip, a bell (such as is used for cupping 24 DISEASES OF THE LABYRIXTII or for hyperaemia treatments), covering the entire region of the ear. The effect of the compression is, in typical cases, a nys- t; minus toward the affected side, or a slow movement of the eyes toward the non-affected side. Aspiration has the opposite effect; i.e. a nystagmus toward the normal side, or a slow eye movement toward the diseased side. The explanation as to why we call this result the typical reaction and designate any other as atypical rests entirely upon an empirical basis; for, from experience, we know that the great majority of labyrinth fistulae behave in thi? way. By reversing our conclusion we are able to explain the phenomenon. Assuming that there is a fistula in the horizontal semicircular canal, then we must conclude that compression, if it provokes a nystagmus to the same side, sets up a lymph current from the smooth end to the am- pulla, and aspiration must produce the opposite effect. E. RELATIVE VALUE OF THE STIMULI A few words concerning the relative quantitative strength of the stimuli employed in the above tests. I have* in the light of Fechner's law, divided the stimuli into adequate and inadequate, classifying those which are ef fective by virtue of producing lymph currents, as "ade- quate," whereas those which work directly upon the nerve, as the galvanic stimulus, as " inadequate, "f As a result of our experience with labyrinthitis, we must arrange the stimuli employed according to their strength of action in the following order: Caloric stimulus, ' ( ..nccrning the Differential Diagnosis of Diseases of the Vestihular Apparatus, tin- Yestibular Nerve and its Central Tract-. V.-rh. d. Deut-ch. otol. Gessellsch., May, 1909, Basel. tReccntly Knn-nin linifiii/ii/s' view, theii. \\e should also classify the galvanic stimulus a- adequate." This is not Hi- place to go into the detail- <>f this problem, especially since thus far the galvanic test has proved of little clinical value in studying lahvrinthine inflammations. FUNCTIONAL EXAMINATION 25 Turning or rotation stimulus, Mechanical stimulus (fistula test), the caloric being the weakest, the mechanical the strongest. This conception we must hold therefore, because in cases of serous labyrinthitis only the effectiveness of the caloric stimulus is first lost, more seldom the effectiveness of the rotation stimulus. Finally, cases in which the caloric, turn- ing and fistula tests all excite no reaction are either cases characterized by a sudden total obliteration of the labyrinth function, or cases of old labyrinth destruction. In spite of this difference in the quantitative value of the different stimuli, we must still conceive of them as of the same nature; for I was able to show by the following experiment that the nystagmus produced by one of these stimuli can he completely arrested by another. In a pa- tient with a readily demonstrable fistula symptom on the right side, by syringing with cold water, I produced a ro- tatory nystagmus to the right side. In the midst of this marked rotatory nystagmus I was able, by compression of the air in the meatus, that is, by a stimulus for nystagmus to the left (this compression being of a given strength), to immediately arrest the rotatory nystagmus. The same phe- nomenon resulted also when, by turning to the left with the head bent forward and with an arrest of the motion, a ro- tatory nystagmus to the right was produced, and the com- pression was made. The similarity between the caloric and turning stimuli could not be demonstrated because the turn- ing and calorie tests cannot be made to act similarly upon the same semicircular canal.* F. DISTURBANCES OF EQUILIBRIUM The disturbances of equilibrium produced by the laby- rinth are dependent upon the nystagmus (by way of dis- tinction from others of central or hysterical origin) and follow the direction of the slow component; that is, if there * Concerning the details of procedure and results of this experiment I will report later. 26 DISEASES OF THE LABYRINTH exists a rotatory nystagmus to the left, then the body has the tendency to fall toward the right. The explanation for this phenomenon we might perhaps seek in this: that the apparent motion of external objects follows in the direc- tion of the quick component of the nystagmus, that is, the subject believes himself, with relation to space, to be moved to the left and away (from the object). The reaction to this apparent movement is an opposed movement of the body; that is, a movement to the right, in the frontal plane, a movement which causes the body, which is in reality at rest, to be toppled toward the right. Rotatory nystagmus toward the right, therefore, pro- duces disturbances of equilibrium, with the tendency to fall toward the left; and rotatory nystagmus toward the left calls forth equilibrium disturbances with a tendency to fall toward the right. The direction of the fall must immediately change itself with an alteration of the position of the head. For exam- ple, if, with an existing rotatory nystagmus toward the left, the head be turned through 90 to the left, the tendency is to fall forward. Relative to the body axis, the nystagmus .now is to the rear, that is, the slower component is turned forward. If we turn the head 90 to the right, with a nystagmus to the left, then it follows that the falling is toward the rear, for now, with regard to the body axis, the nystagmus is for- ward, and the slow component is directed backward. In a simple horizontal nystagmus there follows only an apparent movement of space and its objects in the direc- tion of the nystagmus; there is no tendency to falling, for there is only a movement in the horizontal plane. The dependence of the direction of the falling upon the nystagmus is to such a degree typical that, when the di- rection of the falling does not correspond to the slow com- ponent of the nystagmus, then we must assume that there is a non-labyrinthine cause (of central origin, hysteria). The disturbances of equilibrium do not have much FUNCTIONAL EXAMINATION 27 significance in the inflammatory and purulent diseases of the labyrinth. In circumscribed labyrinthitis there is usu- ally an indefinite swaying, corresponding to the limited nystagmus which is often directed to both sides or is alternating.* In diffuse serous and in diffuse purulent manifest laby- rinthitis, the tendency to fall toward the diseased side is very pronounced, but the patients are usually immediately confined to bed, so that the observation of this phenome- non at once becomes difficult. On the other hand, however, there is also another manifestation, which does not cause Fig. Ion. Lacrinapparat (see page 2) the patient any particular unpleasantness and which is easily observed. This is the forced position taken by the patient for his comfort. This corresponds to the quick com- ponent of the nystagmus; for example, a patient with a right diffuse manifest labyrinthitis lies by preference upon his left side. This is manifestly to be explained by the fact that in this position he reduces his field of vision, and thereby lessens the extent of the apparent movements. Conscious of his position, he feels no need of a correcting movement, but he has only the unpleasant sensation of the diminished apparent movement. * We cannot consider here the complicated experiment of von Stein. CHAPTER II CIRCUMSCRIBED DIFFUSE SEROUS SECONDARY AND DIFFUSE PURULENT LABYRINTHITIS I M LAMMAS IONS of the labyrinth occurring after chronic middle ear suppurations we divide into the following grades:* 1. Circumscribed labyrinthitis. '2. Diffuse serous secondary labyrintlritis.f 3. Diffuse purulent labyrinthitis. For purposes of diagnosis and treatment, we consider these urades of one and the same process as separate clin- ical pictures. Each of these three forms may be manifest or latent. The stage of being manifest or latent expresses itself in the presence or absence of symptoms which, in brief, we designate as labyrinth symptoms. By the term labyrinth symptoms we understand, besides diminution of the hearing, also tinnitus, as a symptom on the part of the cochlear apparatus; and nystagmus, vertigo, vomiting and disturbances of equilibrium as symptoms on the part of the vestjbular apparatus. A. PATHOLOGY In the circumscribed labyrinthitis, we are dealing either with only a defect in tbe wall, or with an inflammation lim- ited to the immediate vicinity of this defect, be it of a serous, sero-fibrinous or purulent nature. (We are well aware that the defect in the labyrinth wall, strictly speak- ing, does not always mean a labyrinthitis, but we are as * After acute otitis media these forms of labyrinthitis occur only oxeep- tinnally: on tin- other hand. another form of Ial>\ i inthitis. an inflammation extending directly through the labyrinth wall, which we de-i^nate l>y the name "dill'n-e M-ron* induced lahvi iutliiti-," we will later eoii.-idcr in detail. t\Ve understand liy serous also sero-libriii<>u-. 28 PATHOLOGY ) yet unable to clinically differentiate such a defect from a circumscribed labyrinthitis.) In the diffuse serous secondary labyrinthitis, we have an extension of such a circumscribed inflammation into the labyrinth. In the diffuse purulent labyrinthitis, the entire labyrinth is filled with pus, or, if the process is already an old one, then with the organized residuum of a purulent inflamma- tion, that is, with granulations, connective tissue or even newly formed bone. In the circumscribed or diffuse serous secondary laby- rinthitis, we find almost always but a single point of en- trance, while in the purulent labyrinthitis, the point of en- trance, because of the extensive destruction of the walls, is no longer to lie determined; often there are two or more points of entrance which occurred at different times. Some authors ( /'Y/Y'/r/V//. Ldiif/c) regard these as secondarily oc- curring points of egress from the labyrinth. In the circumscribed or diffuse serous secondary laby- rinthitis, the horizontal semicircular canal is by far the most frequent portal of entrance: in purulent labyrinthitis, the invasions through the oval window predominate. The reason for this we must look for in the fact that th,e likeli- hood of an extension into the entire labyrinth is greater from the oval window than from the horizontal semicircular canal. Invasion through the round window, contrary to other writers (Fried rich, Mci/er), we found less often. In our fifty cases of circumscribed labyrinthitis, the point of invasion occurred thirty-one times in the hori- zontal semicircular canal, three times through the oval window, once through the horizontal semi- circular canal and oval window, once the frontal -einicircular canal, once the promontory; once there was an extensive sequestrum so that the point of en- trance could not be determined; in three cases the fis- 30 DISEASES OF THE LABYRINTH tula was not found, five cases were not operated and in three cases the fistula developed after a radical operation. Of the twenty purulent manifest labyrinthites, the site of the fistula was not recorded five times, four times no fistula was found, four times the fistula oc- curred in the horizontal semicircular canal, four times in the oval window; twice the labyrinth wall was de- stroyed, one case was a suppuration after a gun- shot wound, in which the ball lay in the region of the oval window. Of twenty-six cases of purulent latent labyrmthitis, the fistula occurred nine times in the horizontal semicir- cular canal, five times no fistula was found, four times it was found in the oval window, three times nothing was observed (by way of a fistulous opening), twice it was found to be in the horizontal canal and the oval window, once in the horizontal and sagittal semicircu- lar canals, once in the horizontal and frontal semicircu- lar canals, and once there was destruction of the laby- rinth wall. When we consider all of the ninety-six cases to- gether, the fistula occurred forty-four times in the hori- zontal semicircular canal, eleven times in the oval win- dow, once in the frontal semicircular canal ; once it was localized in the promontory, five times there was a double fistula, three times occurring in the horizontal semicircular canal and in the oval window, once in the horizontal and sagittal canals, once in the horizontal and frontal canals; twelve times no fistula was found, eight times no fistula was noted, five cases were not operated, so nothing can be said regarding the loca- tion of the fistula ; three times the fistula occurred after a radical operation, and so in these cases also the loca- tion of the fistula is undesignated, and one case was a jmnshot wound. ETIOLOGY 31 From these figures we see the tendency of fistulae to be located in the horizontal semicircular canal. This is rela- tively greatest in the circumscribed suppurations (thirty- one times in fifty cases), but for the diffuse purulent forms less, namely, thirteen out of forty-six cases. The relative frequency of the fistula in the oval window in the diffuse purulent labyrinthitis (eight out of forty-six cases), com- pared with the circumscribed labyrinthitis (three out of fifty cases), as well as the frequency of the double fistulae in diffuse purulent labyrinthitis (four out of forty-six cases), compared with the circumscribed labyrinthitis (one out of fifty cases), is easily accounted for by the above. That we were unable to find a fistula in twelve cases in spite of search after aspirating the blood with the Tonogen pump is no proof that a fistula was not present, but only proves how difficult it is to discover small breaks of continuity. They are especially easily overlooked when they do not lie in the horizontal semicircular canal, but are localized at some other point in the labyrinthine wall. B. ETIOLOGY Nearly all circumscribed and the diffuse purulent laby- rinthites have their cause in chronic middle ear suppuration. Seldom do they occur in consequence of an acute otitis.* Of our ninety-six labyrinthites, eighty-one occurred in chronic otitis, ten in subacute otitis ,and five in pro- nounced acute otitis. Of the subacute suppurations, eight were of the circumscribed type and two cases were of the diffuse purulent manifest labyrinthitis. The five cases of labyrinthitis growing out of an acute otitis were all of the diffuse purulent manifest type. * In a case reported by me previously the fistula in the semicircular canal without doubt appeared in the course of an acute otitis. In a case of E. Urbantschitsch. there occurred on the thirty-ninth day, in the course of an acute traumatic otitis, a labyrinthine fistula. .;_> Disi-:.[sf-:s or Till-: LABYRINTH On the other hand, the circumscribed labyrinthitis appear- frequently as the consequence of subacute or chronic tubercular suppuration. At least, we must so interpret it, when out of eight cases of circumscribed labyrinthitis occurring after subacute suppuration, SIX were the subjects of advanced phthisis. The figures of Goerke, who reports tuberculosis as the cause in five cases out of sixteen, corroborate the s.-iine conclusion.* Cholesteatoma also appears to play an important role in the etiology. Of the ninety-six cases, it was positively observed during operation thirty-one times, fifty-four times it was not noted, nor was tuberculosis. But of these fifty-four cases, some might still have been reckoned with those that were cholesteatomatous, and surely some belonged to the tubercular. There remain >ix cases that were not operated, and therefore could not be controlled. Four of these were tubercular in an advanced stage. The role which cholesteatoma and tuberculosis play in cir- cumscribed and diffuse latent labyrinthitis, and, on the other hand, which acute otitis plays in diffuse purulent manifest labyrinthitis, is easily explained. For the formation of both of the first forms there is necessary a slowly pro- gressive bone-destroying tendency on the part of the primary suppurative disease in the ear. (See the Histo louical Finding of rlif :ci\-\- Hutting Ilrt/cnn:^) The genuine acute otiti- has not at all such a marked bone- destroying tendency as to break through the labyrinthine capsule. At most, it would be expected to force a way through the labyrinth window. In such an acute form there occurs a sudden breaking through, and the pus of the acute *The Inflammatory Diseases of the Labyrinth. Arch. f. O. 80. tLabyrintli Findings in Chronic Middle Kar Suppuration, .\n-li. f. O. L.\Y. i'ii tin- Histology of Labyrinth Suppuration-; l';i o\\ '* ll-|.ort-. \ ,l. I, H. 5 & 6. Labyrinthitis and Bruin Diseases. Passow's Reports, Vol. II. ETIOLOGY :K otitis contains uerms of such virulent activity that we can only conceive of a rapid dehming of the labyrinth with pus (with rapid destruction). Only in the suppuration of scar- let fever have we observed rapid bone destruction in acute stages (Scheibe) ; but then there also naturally results a >udden invasion of the labyrinth. On the other hand, we can a>crihe to cholesteatoma and tuberculosis a slow bone destruction. A chronic purulent otitis which leads to a labyrinthine disease is ordinarily of long duration, the longest (Case 38) thirty-six years. The original illness leading to an otitis could for the most part not be ascertained; most often, however, scarlet fever and measles were reported. It is of great interest that in certain cases (4, 7 and 9) the fistula into the labyrinth formed not until a consid- erable period after the radical operation, in the stage when the wound was covered with granulations. In Case 4 it is remarkable that seventeen days aftei\ the operation, in spite of the fact that the cavity was covered with granula- tions, the semicircular canal was bare, though no fistula could be discovered. Not until six months later was the pa- tient again admitted and operated, after which the fistula symptom could be observed. At the operation there ap- peared in fact a fistula in the horizontal semicircular canal. In Case 7, not until four months later, though the region of the lateral semicircular canal was epidermized, was the listnla symptom demonstrable. In Case 9, the fistula symp- tom was plain, though at the time of the operation, which was performed with avoidance of the tympanic membrane, the operator remarked especially that the semicircular canal was healthy. It would appear that here the belated fistula had devel- oped at a point in the labyrinth wall which had formed a Ion. a 1 a tract before the operation. This knowledge, that a labyrinthine fistula is capable of slowly developing in the course of months after the radical 34 DISEASES OF THE LABYRINTH operation, along a tract already preformed, appears to us of moment for the prognosis of the radical operation. Prob- ably such cases of chronic middle ear suppuration with at- tacks of vertigo, in which we are in no way able to prove a positive labyrinthine disease, in consideration of what has been said above, should warn us to think of the possi- bility of disease of the labyrinth wall of a progressive character, which we may designate diaguostically under the somewhat uncertain clinical term paralabyriutlntis. Particularly worthy of notice is Case 6, in which the fis- tula symptom was demonstrable with a non-perforated, non- inflamed tympanic membrane. We can never forget the possibility that such a case is to be counted among the puru- lent ones. How perfectly an attic perforation, for instance, is capable of healing is illustrated by the following exam- ple: A girl from whom I removed a long pedicled attic polyp which reached to the external canal, and in whom I demonstrated in my course the attic perforation, passed from under our observation and months later returned to the clinic, by chance, in the course of my colleague, Dr. Bondy. He was unwilling to believe the girl when she said I had removed a polyp until I had myself confirmed her statement, so completely had the membrane healed. Indeed, it is perhaps exceptionally permissible to assume the occur- rence of a spontaneous dehiscence in the semicircular canal. C. SYMPTOMS In circumscribed labyrinthitis the transitions from the latent to the manifest stage are so variable and so indis- tinct that we are unable to make a clinical distinction be- tween these two stages. The labyrinthine symptoms (tin- nitus, vertigo, emesis, disturbances of equilibrium, nystag- mus) may at the time of examination be present or absent. They may, however, Curing the entire progress of the dis- ease appear at any time in the form of attacks, so that a patient, free from all symptoms dnrinu- the examination, a >hort time thereafter may present severe symptoms. SYMPTOMS 35 In the diffuse serous secondary labyrinthitis, only the manifest stage comes into consideration, for we can no longer consider as latent a serous labyrinthitis which has once run its course. On the contrary, in the purulent labyrinthitis the mani- fest and latent stages are very sharply defined. In the manifest stage there are abruptly appearing but slowly diminishing labyrinthine symptoms (nystagmus to the non- affected side, vertigo, emesis, equilibrium disturbances). In the latent stage there are no symptoms, except occa- sionally a slight nystagmus ordinarily directed to both sides, that is, according to whether the eyes are turned toward the left or right. The differential diagnosis, therefore, must consist in distinguishing between : (a) 1. Circumscribed labyrinthitis. (a) 2. Diffuse serous secondary labyrinthitis. (b) 3. Diffuse purulent manifest labyrinthitis. (b) 4. Diffuse purulent latent labyrinthitis. (a) differentiates itself from (b) by the presence of some remnant of function demonstrable by our labyrinthine tests (hearing, caloric reaction, rotation reaction, fistula symp- tom) ; 1 from 2 by the absence of the so-called (Vestibular- aussclialtungsymptom] symptom of vestibular inactivity (= nystagmus toward the healthy side, vertigo, emesis, dis- turbances of equilibrium) ; while in 1 regularly both divi- sions of the labyrinth functionate, i.e. both hearing and vestibular reaction remain; in 2 the hearing is often lost, more seldom also the caloric reaction and the rotation re- action. 3 is to be distinguished from 4 by the failure of the vestibular apparatus to functionate (= nystagmus to the healthy side, vertigo, emesis, disturbances of equi- librium). Let us consider the picture of each of these diseases by itself: Circumscribed Labyrinthitis. A patient with chronic purulent otitis complains for some Di si: A >/> or THI-: I.M:YI;I.\TH time of having attacks of vertigo, perhaps also of tinnitus. Kxaiifniation >hows a .urcater or lesser diminution of hear- ing, hut this function is hy no means lost; the fistula symp- tom is positive, the caloric reaction present, spontaneous nystagmus exists, generally to both sides, according to the direction of fixation. Diffuse Serous Secondary Labyrinthitis. A patient who has for some time been under our obser- vation with circumscribed labyrinthitis suddenly is taken with severe vertigo, has marked rotatory spontaneous nys- tagmus toward the healthy side, his hearing on the diseased side has become markedly worse, often is entirely lost or there remains only a very slight degree of hearing (for loud speech), the caloric reaction is still demonstrable or is entirely lost. (In the last case the patient is totally deaf on the affected side.) Still, the fistula symptom is demonstrable. Diffuse Purulent Manifest Labyrinthitis. A patient with chronic middle ear suppuration suddenly has the most severe vestibular symptoms marked vertigo, extensive rotatory nystagmus toward the healthy side, emesis, disturbances of equilibrium. The functional test shows him to be totally deaf on the affected side; he does not react to the caloric, turning or fistula tests; in short, no functional activity of the labyrinth can be shown. Diffuse Purulent Latent A patient who for some time has suffered from a chronic suppurative otitis, relates that months or years ago he had vertigo. At the present time there are no symptoms ; at the most, some spontaneous ny-taumus, accordingly as his fixa- tion is to the right or left. The functional test shows com- plete obliteration of the labyrinth, total deafness, no caloric reaction, no turning reaction, no fistula symptom demon- Arable. SYMPTOMS 37 If a diffuse purulent latent labyrinthitis has existed very long, so that there is a complete ossification of the laby- rinth, then the turning test may apparently have been pre- served: that is, there appears a manifestation which I have designated as com^'ii.^iitnni, for which the following expla- nation may be given : AVhen a labyrinth has been for a long period destroyed, so that there remains not the slightest remnant of its sensory cells or nerve endings, then the other labyrinth takes up a certain compensatory function. That is to say. for example, if the right labyrinth is destroyed, but a compensation has not yet appeared, then we would have, after rotating to the right, with head erect, an after- nystagmus to the left, with a duration of 15"- -30", after turning to the left, an after-nystagmus to the right with a duration of 5". Here the nystagmus to the right as well as to the left in this case originates in the left labyrinth; but the impulse for nystagmus to the right through movement of the endolymph in the left horizontal semicircular canal is from the small end toward the ampulla (the effective movement ). but the nystagmus to the right is caused by the movement of the endolymph from the ampulla to the small end (the less effective). If, however, compensation has already taken place, then we have, for example, if the right labyrinth is destroyed, an after-nystagmus to the right or to the left lasting 10" 15", according to the direction of rotation, but in the propor- tion of 10" for the left and 15" to the right. And in this case the nystagmus can originate only in the left horizontal semicircular canal, but we must assume that the movement of endolymph from the smooth end to the ampulla is now equally effective with the movement from the ampulla to the smooth end. According to my observations, which I have made in part after the completion of this book, for which reason I am unable to introduce the case histories, this compensation occurs only in cases in which the com- plete labyrinth destruction has existed a long time; for in- stance, with ossification or sequestration. It is demonstra- 38 DISEASES OF THE ble equally well for horizontal and rotatory nystagmus, this corresponding with the position of the head.* On the other hand, a series of cases with labyrinth opera- tions and other cases in which we could not assume that there was a complete destruction of all nerve endings did not show this compensation even after several years. It is to be noted that the diffuse purulent latent laby- rinthitis sometimes occurs with necrosis and sequestration of the labyrinth.! As a rule, in sequestration of the labyrinth the following symptom triad occurs in the diseased ear : Total deafness, loss of irritability of the vestibular apparatus for the ca- loric, turning and mechanical stimuli, and facial paralysis. Yet it is possible that the turning reaction may have ap- parently returned, inasmuch as compensation may have taken place. Whether this will be the case apparently de- pends upon the duration of the process and the complete- ness of the destruction of the nervous elements. That in spite of almost complete necrosis or sequestration of the labyrinth, the soft parts of the labyrinth must not neces- sarily be destroyed is proved by Cases 12 and 29, in which, notwithstanding the extensive necrosis of the labyrinth con- taining bone with sequestration, the fistula symptom was still present. Two more cases of this type are -reported in the literature (Ruttin,E. Urbantschitscli). The facial paresis or paralysis need not always be pres- ent, but is a very frequent symptom (according to Bezold, in 83% of the cases; according to Gerber, in 11%}. It is generally caused by the fact that the necrosis also involves the facial canal lying in such proximity to the labyrinth, * Concerning the relation of the sagittal semicircular canal in these cases I will report later. tRegarding the formation of necrosis and sequestration, I am unable to express myself further here. See the works of Bezold*, Gerber- (with extensive references), Hegener*, Siebenniami-Xin/cr*, Fricdrich^, Longe 9 , ~\\'liittnniacki. 1. Labyrinth Necrosis and Paralysis of the Facial Nerve. Wiesbaden, 1886. 2. Arch. f. O. Bd. 60. 3. Labyrinthitis and Brain Abscess. Passow's Beitraege, Bd. II. 4. Z. f. O. 53. 5. Suppurations of the Laby- rinth. Wiesbaden, 1905. 6. Quoted from Hegener. 7. Z. f. 0. Bd. 47. SYMPTOMS 39 but may also be caused by pressure of the sequestrum upon the facial (Neumann). The determination whether or not there has been formed a sequestrum may, under certain conditions, be of the greatest importance. We have already stated that in case of diffuse purulent latent labyrinthitis the so-called compensation may be present; that is, with a completely destroyed labyrinth, the nystagmus after turn- ing may be equal toward both sides, and that this is an in- dication of a long existing labyrinthine destruction, such as is caused by bony invasion of the labyrinth or by a sequestrum. Let us arrange these clinical forms, for the sake of a clearer oversight, in a table: Anamnesis Present Symptoms Nystagmus to E 03 m .g| li - -. Fistula Symptom Circumscribed Attacks of + I + + + + Labyrinthitis Vertigo Diseased side or 1 Healthy side or Diffuse serous Vertigo for * secondary Labyrinthitis some time or attacks Healthy side + Diffuse Purulent Vertigo 1 Manifest Labyrinth'tis present or absent + Healthy side Diffuse Purulent Vertigo some _ _ _ + on _ Latent Labyrinthitis time ago or * * Com- pensa- tion Rote: v ^Xystagnnis to right, on looking toward right, and nystagmus to left on looking to left. r 7V//-; /. It' it i> a ca.-c of bony healing of the labyrinthitis, then naturally ;m operation would be superfluous. If, on the con- trary, it is a ca>e of a sequestrum, then a labyrinth opera- tion is naturally indicate;!. Here the facial paralysis may uive the correct indication, for in a case of facial paresis of not too long standing we may as>ume with considerable cer- tainty that a necrosis or sequestrum exists. \Ye will now look more closely at the diagnostic symp- toms and results of the functional tests in the order as arranged. *is. Vertigo appearing in attacks is peculiar to circumscribed labyrinthitis, though this must naturally also be given in the history of the diffuse secondary labyrinthitis, since this i> preceded by the circumscribed form. As a rule, the vertigo occurs very suddenly, and from this time there come attacks of vertigo at intervals which finally, bring the patient to the physician. These attacks of vertigo may exist for years. In one case (Case 11) the at- tacks of vertigo were referred back five years. As a rule. the period varies between five weeks and two days. In one case (Case 41) we were able to note the invasion into the labyrinth before our very eyes. The patient, was at th<> clinic waiting for operation; the examination for labyrinthine disease wa- negative. One day he was taken with severe vertigo; the previously negative fistula symp- tom was now decidedly positive. In our fifty cases of circumscribed or diffuse serous sec- ondary labyrinthitis, only nine gave no attacks of vertigo in the anamne>is. ;md of these nine, five were advanced 88 of tuberculosis. In these the absence of vertigo is to 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 >! 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- sionally demonstrable, as well as that in which compression is alone effective, seems to be an indication that the fistula is extremely small or that it is protected by an intervening hindrance (cholesteatoma, polyp) from the compressing or aspirating air current. The fistula symptom may be unusually noticeable or easily provoked. Often even light pressure upon the tragus is sufficient to produce severe nystagmus with vertigo and falling movements. In one case of V. Urbantschitsch, with fistula in the hori- zontal canal, on whom the radical operation was performed under local anaesthesia, there appeared during the removal of a sequestrum, which was wedged in between the dura and the pyramidal bone toward the middle cranial fossa, vio- lent vertigo and nystagmus, which completely ceased after removal of the sequestrum. Urbantschitsch ascribed this manifestation to a second fistula, in the upper semicircular canal, which had been closed by the sequestrum. At this point it would be well to call attention to one consideration. That is, the necessity of very careful ex- amination and observation and also the possibility of error. First, it is possible to confuse the fistula nystagmus with the caloric, if one does not most carefully avoid pressure during the syringing. (This is best done by keeping the irrigator relatively low, i.e. only sufficiently above the meatus to cause a flow.) First, we may have in the be- ginning of the test a fistula nystagmus, which we mistake for a caloric reaction. But we notice that the cold water nystagmus is directed toward the healthy side; therefore, cold water nystagmus could be confused only with a re- versed compression nystagmus. Contrarily, upon syring- ing with hot water, it would be possible only to confuse the nystagmus produced by the hot water with typical com- pression nystagmus, for both are directed toward the ex- amined side. But we may, on the other hand, also confuse the caloric FEVER 55 nystagmus with the fistula symptom. For instance, it is possible in making the fistula test to produce by the air cur- rent employed a sufficient cooling of the labyrinth wall as to cause thereby a caloric nystagmus. According to Bdrany, this is particularly apt to be the case when the olive tip is not inserted tightly into the meatus. Further, the confusion is possible only in a case of re- versed fistula nystagmus, for in compression the typical fis- tula nystagmus is to the same side, the caloric (cold) to the opposite side. But confusion with the reversed fistula nystagmus can be avoided if one will observe that in most cases in fistula nys- tagmus not only is compression effective, but a nystagmus is also produced by aspiration, and this is in the opposite direction. Further, it is possible to confuse the fistula nystagmus with the associated nystagmus of Stransky. This is an un- dulating nystagmus sometimes occurring in neuropathic in- dividuals, when, on having them tightly close the eyes, we forcibly resist the effort with our fingers. D. FEVER In order to obtain a general idea of the significance of fever in labyrinth diseases, I have divided the cases into groups, as follows : I. Before the operation under 37 C . (afebrile) After the operation under 37 C (afebrile) II. Before the operation under 37 C. . After the operation 37 C.-38 C. III. Before the operation under 37 C. . After the operation over 38 C . (afebrile) ( subf ebrile ) (afebrile) ( febrile ) IV. Before the operation 37 C.-38 C. After the operation under 37 C. . V. Before the operation 37 C.-38 C (subf ebrile) (afebrile) (subfebrile) After the operation 37 C.-38 C VI. Before the operation 37 C.-38 C (subfebrile) ( subfebrile ) \ftcr the operation over 38 C (febrile) VII. Before the operation over 38 C . (febrile) After the operation under 37 C. . (afebrile) VIII. Before the operation over 38 C After the operation 37 C.-38 C. . . . IX. Before the operation over 38 C . . (febrile) (subfebrile) (febrile) After the operation over 38 C. , (febrile) 56 DISEASES OF THE LABYRINTH A -cries of cases not operated must be eliminated.* In the first group, that is, with normal temperature be- fore and after the operation, were thirteen casesf. Of these, two cases were circumscribed labyrinthitis (Xos. 19 and 49) ; one case of circumscribed labyrinthitis, followed by a secondary diffuse serous labyrinthitis (Xo. 32); one a circumscribed labyrinthitis, with a purulent manifest labyrinthitis following. (No. 10); two cases of serous in- duced labyrinthitis (Nos. 98 and 104) ; two cases of trauma- ti>m of the labyrinth (Nos. 105 and 107) ; four cases of puru- lent latent labyrinthitis (Nos. 72, 89, 92, 93), and one case of purulent manifest labyrinthitis (Xo. 65). We see that all forms of inflammatory labyrinth disease may proceed with- out fever, a fact already emphasized by Friedrich.% Seven of these cases underwent the labyrinth operation, the re- maining six had only the radical operation. This proves that neither after the radical operation nor after the laby- rinth operation is it at all necessary that we have fever; but it appears that the occurrence of a subfebrile tempera- ture is very frequent after the radical and labyrinth opera- tions in circumscribed and diffuse labyrinthitis, as a con- sideration of the following group II teaches. To this group (free from fever before the operation, with a subfebrile tem- perature after operation) belong twenty-three cases. These cases are partly circumscribed (Nos. 1-50), partly diffuse purulent manifest or latent labyrinthitis ( Xos. 50-96). One case (No. 100) is an induced labyrinthi- tis. The subfebrile temperatures may have existed before operation, both in the radical operation and in the laby- rinth operation, and may have continued after the opera- tion, as shown by group V, to which belong fourteen cases.|| Cases 5, 6, 13, 24, 28, 97, 102, 103. -eg 10, 19, 32, 48, 65, 72, 89, 92. 93. 98, 104. 105, 107. Wrivili -i, -h : Suppuration of the Labyrinth. Wiesbaden, 1905, in Korner's Ohrenheilkunde der Gegemvart. SCases 1. 25, 30, 31, 35, 36, 37, 42, 44, 47, 49, 50, 51, 60, 64, 66, 75. 77. 84, 88, 91, 96, 100. ||Cases 2, 9, 14, 16, 17, 18, 27, 40, 46, 59, 62, 79, 80, 82. FEVER 57 In both groups there were no deaths. In connection with group I, and since these subfebrile temperatures appear quite regularly in all forms of labyrinthitis, we are unable to attach any diagnostic importance to the temperature. Let us now consider group III, afebrile before the opera- tion, with post-operative fever. To this group belong eigh- teen cases.* In six cases the cause of the fever is certainly not to be found in the labyrinthine disease, for three cases had a cerebellar abscess (Xos. 11, 12, 70), one case (No. 43) is unexplained, one case (No. 15) had severe tubercu- losis, and one case a carcinoma with suppurating localized metastasis. There remain twelve cases in this group. In these cases there occurred a temperature after the operation, which was not to be ascribed to any special labyrinthine cause. Certainly, we know that after the radical operation in un- complicated chronic middle ear suppuration it is not rare to have an elevation of temperature of not over 38 C. It is noteworthy, however, that the fever, in the two cases which died of post-operative meningitis, appeared not until five days after the operation (Cases 33 and 56). This would seemingly indicate that a post-operative meningitis of laby- rinthine origin requires five days for its development. One fact thus brought out should warn the operator in cases of labyrinth disease in which only the radical operation is undertaken, and that is that the prognosis should not be made too favorable. On the other hand, this knowledge should serve to give support to our indications for opera- tive interference. Labyrinthine symptoms make their appearance immedi- ately after the radical operation in those cases in which the labyrinth has been injured. In the development of dif- fuse labyrinthitis following directly a previously existing circumscribed labyrinthine disease, they appear, as a rule, within three days. Inasmuch as a meningitis ordinarily *Cases 11, 12, 15, 26, 33. 39, 43, 45, 56, 57, 63, 70, 83, 86, 87, 95, 106, 108. 58 DISEASES OF THE LABYRIXTH develops from a fully developed labyrinthitis, we are often still able to anticipate the meningitis and block the way to the cranial cavity by means of a labyrinth operation, pro- vided we promptly take active measures on noticing the final positive indications of the progress of a labyrinthitis, that is, sudden, complete loss of labyrinth function. If we allow this indication to go by unheeded, then the prospects of mastering the meningitis are indeed slight. One exception is apparently given by a case of Bondy's, in which a meningitis developed directly from a serous labyrinthitis. The cases under group IV*, in which the subfebrile or febrile temperature before the operation fell immediately after the operation, belong to the exceptions. On the other hand, a more or less gradual defervescence, when there was fever before the labyrinth operation, probably signifies that the labyrinthitis had already caused a circumscribed or serous meningitis in the posterior cerebral fossa, and that after the primary purulent focus had been taken care of this meningitis spontaneously healed. This would be con- firmed by the cases (Nos. 52 and 73) in group VIILf Case 52, a pronounced meningitis with turbid cerebrospinal fluid, healed completely after the labyrinth operation, at first with a rapid fall in temperature, then gradual deferves- cence. Case 72 is particularly important, inasmuch as it involved the differential diagnosis between meningitis of the posterior fossa and brain abscess. This diagnosis is not to be made from the temperature curve, for such de- clines in temperature occur also in brain abscess. The case was permanently cured, so that the diagnosis which we made upon other grounds, to be later referred to, was very likely correct. A fall in temperature before the labyrinth operation would be naturally observed in cases in which the labyrinth disease is combined with a sinus infection (of course, pro- Cases 41, 55, 67. fCases 23, 34, 38, 52, 71, 73, 90. INDICATIONS FOR OPERATION 59 vided the sinus disease were also relieved by operation). In this class belong Cases 7, 23, 34, 38, 90. Looking at group IX,* composed of cases which had a continuously high temperature before and after the laby- rinth operation, we find that they are for the most part cases of meningitis, or of meningitis complicated with brain ab- scess, existing before the labyrinth operation. From these considerations concerning the fever, we may draw the following conclusions : 1. Subfebrile temperature immediately before and after the radical or the labyrinth operation has no significance regarding the diagnosis or the operative procedure. 2. A single elevation of temperature immediately after the labyrinth operation or at the time of the first change of dressing is usually no ground for anxiety and does not indicate any complication. 3. An elevation of temperature continuing several days after the radical or the labyrinth operation, when not oc- casioned by a co-existing disease elsewhere, is always the sign of an intracranial complication, either proceeding from a labyrinth disease, or existing independently. E. THERAPY, OR INDICATIONS FOR THE RADICAL AND THE LABYRINTH OPERATIONS Disease of the labyrinth, with the exception of the diffuse purulent manifest labyrinthitis, does not of itself signify the necessity of an operative procedure. The question now arises: Does the labyrinth disease make it necessary to relieve operatively the causal disease (an acute or chronic middle ear suppuration)? "We may, above all, take into consideration as the causal disease only the chronic middle ear suppuration. For an acute otitis practically never gives rise to a circumscribed or a diffuse serous secondary labyrinthitis, and only exceptionally to a purulent labyrinthitis. On the other hand, another com- * Cases 7, 20, 22, 54, 58, 61, 69, 81. 60 DISEASES OF THE LABYKIXTII plication is not rare, i.e. the induced serous labyrinthitis. These cases we will consider later. But we do not take the ground that we should operate the moment we discover a diseased labyrinth, for, sooner or later, because of the uncertainty of our conservative treatment, we will be forced to consider the question of a radical or a labyrinth operation. Here also the adage j>ninmn nil noccre applies; and in dealing with labyrinth diseases, with the exception of the diffuse purulent mani- fest form, operation is not urgent. So the question, "How shall we operate?" is more Important than "When shall we operate?" The guiding principle for answering this question must be along the following lines : If the labyrinth responds to only one of our tests (hear- ing, caloric test, turning test, fistula symptom), then the radical operation is sufficient; at least, it does not endan- ger the life of the patient. For an extension of the disease may be recognized in time, by the further appearance of labyrinth symptoms and by the complete loss of irritabil- ity of the labyrinth to our known stimuli ; and thus by a sec- ondary labyrinth operation this may be arrested. However, in case the labyrinth has already been com- pletely destroyed and no longer responds to our known stimuli, then, if there is an extension of the disease, we have no danger signal from the labyrinth. For the next stage of development does not take place in the labyrinth, but within the cranium ; that is, we recognize it by the onset of meningitis symptoms. Therefore, in those cases in which the labyrinth is entirely unresponsive, we must perform the labyrinth operation in combination with the radical operation. Circumscribed Labyrinthitis . In the circumscribed form of labyrinthitis, according to the above, we perform only the radical operation. If, after the operation, as a rule, on the second or third day, which is the critical time for the appearance of a diffuse second- INDICATIONS FOR OPERATION 61 ary labyrinthitis, the symptoms of a unilateral discontinu- ance of function of the labyrinth (nystagmus to the healthy side, vertigo, emesis, disturbances of equilibrium) appear, we have to deal with a diffuse secondary or a diffuse puru- lent labyrinthitis. These are differentiated by the func- tional tests. We examine the hearing through the dressing while applying the exclusion apparatus to the healthy ear. If loud conversation is perceived by this test through the dressing, further examination is unnecessary, for a diffuse purulent labyrinthitis is excluded. If the patient is deaf upon the operated side in this test, then the dressings must be removed and the hearing test made again in the same manner. . If the patient again in this examination proves to be deaf, then we take up the caloric test. If the existing spontaneous nystagmus toward the healthy side is only of the first or second grade, so that we are able to recognize an increase in its intensity, then we make the test with cold sterile saline solution. But should there be spontaneous nystagmus of the third degree to the healthy side, so that we would be unable to recognize any increase of the nys- tagmus produced by syringing with cold saline solu- tion, then we must use hot water (48 C.). If the vestibular apparatus is still irritable to caloric stimuli, then the nys- tagmus to the healthy side either entirely disappears or becomes decidedly weaker, and there appears a nystagmus toward the diseased side. If in this manner the irritabil- ity of the labyrinth to caloric changes can be proven, then there can likewise be as yet no purulent labyrinthitis. But if the labyrinth does not respond to the caloric test, then we are obliged to apply the fistula test. This is done in operated cases with a retro-auricular opening by the em- ployment of Bdnuit/'s rubber bell, which hermetically cov- ers the entire operated field. If the fistula symptom is present, then we may again wait until this symptom is extinguished. But if the patient is deaf on the operated side, is unresponsive to the caloric test, and the fistula symptom has disappeared, then we must DISEASES OF THE LABYRINTH assume that a purulent labyrinthitis has appeared, and the labyrinth operation must be at once performed. For now we have passed the point beyond which an extension of the process may still be recognized and may without danger be watched step by step. Of the thirty-two cases of circumscribed labyrinthitis,* there occurred fifteen times after the radical operation a diffuse serous secondary labyrinthitis.f Since in every case this subsided again, and the labyrinth never entirely failed to respond, there never developed, according to our experi- ence, a purulent labyrinthitis, and we had no reason for performing the labyrinth operation. However, this opera- tion was performed in three cases,:}: but twice when there was at the same time a cerebellar abscess (an indication concerning which more will be said), and once because of severe, trying attacks of vertigo, on account of which the patient urged operation. In the forty-one cases which we must regard as healed diffuse serous secondary labyrinthitis, four cases of ad- vanced phthisis were not operated; upon three cases the radical operation was performed, and upon four the laby- rinth operation was performed. Of the last four, because of deep extradural abscess, the labyrinth, no longer intact, was not avoided. In the other two cases the labyrinth opera- tion was performed without real justification (as we now know), for a remnant of irritability of the labyrinth re- mained; in the one case (No. 2) the fistula reaction, in the other (No. 33) the caloric reaction, could be elicited. "We should state that in the beginning cases like No. 2, that is, with complete loss of hearing and of the caloric reaction, and with the fistula symptom present, we regarded as ex- ceptions, and we did not rightly understand the relative o 1 ' ' *' 6 ' 7 ' 8 ' 9 ' 10 > 12 > 14 ' 17 > 18 ' 19 > 25 > 26 27, 30, 31, 34, 35, 36, 38, 39, 40, 41, 42, 43, 44, 45, 47, 48, 50. tCasea 1, 3, 10, 12, 25, 26, 30, 31, 34, 39, 40, 43, 44, 47, 50. tCases 4, 10, 12. 2, 5, 13, 15, 20, 21, 22, 24, 28, 33, 44. INDICATIONS FOR OPERATION 63 value of the individual reactions and the sequence of their destruction. Therefore, we were inclined to treat these cases as if they were completely destroyed labyrinths ; that is, to operate the labyrinth. On the other hand, the only justification for the labyrinth operation in Case 33 might be the fact that the patient had a year before undergone a radical operation, and that we could promise him a defi- nite healing, with cessation of the suppuration of the laby- rinth wall only by means of a labyrinth operation. Finally, the violation of the strict rule for operating brought sad consequences. The case died of a meningitis six days after the labyrinth operation. At the postmortem section I looked carefully for a wound of the dura, but could find none, and the path of the suppuration must have been through the internal auditory meatus, so that the blame for the results must be assigned to the operation. This, however, is the only case in which we can take upon our- self the blame for the fatal outcome in a labyrinth operation. Diffuse Serous Secondary Labyrinthitis. When a patient with diffuse serous secondary labyrinthi- tis comes under observation, we wait for its termination. It runs its course, generally in a few days, during which, however, we regularly watch the function of the labyrinth. If, after the termination of active manifestations, there re- mains any remnant of labyrinth function (hearing, caloric reaction, turning reaction or fistula symptom), then we per- form the radical operation, naturally, under the same pre- cautions as in the circumscribed labyrinthitis ; that is, we wait, so to speak, with knife in hand, in order that in case of a recurrence of labyrinth symptoms and the loss of all labyrinth reaction, we may at once, on the assump- tion of a purulent labyrinthitis, perform the labyrinth operation. It is indeed possible that a diffuse serous secondary labyrinthitis might cause a complete loss of labyrinthine function ; but these cases we are able to recognize only very 64 DISK ASK* OK THE LABYh'IMH seldom, and so they must be treated like the diffuse puru- lent labyrinthitis; that is, they must be given the labyrinth operation. In seven cases* there existed at the time of admis- mis>ion a diffuse serous secondary labyrinthitis. Of these, three had the radical operation and recovered completely without further loss of function than existed before the operation. Four had the labyrinth opera- tion, one case (No. 10) because a diffuse purulent labyrinthitis developed before our eyes (complete loss of labyrinth reaction) ; one case (No. 29) already showfd symptoms of meningitis, and died soon after of meningitis. A third case (No. 32), because of the likelihood of a cerebellar abscess, had the labyrinth operation. The fourth (No. 16) was operated with not altogether definite indications, in view of the uncer- tainty of the indications in cases with loss of hearing and of the caloric reaction, but with demonstrable fis- tula symptoms. \\V awaited the subsidence of the acute stage in two cases (37 and 39) ; in the third case (23) we were forced by the presence of the pyaemia to operate earlier. Diffuse Purulent Manifest Labyrinthitis. In this form, according to our already stated rule, we must .perform the radical and the labyrinth operation in one act, for the labyrinth is completely destroyed, and we an no longer expect any further information from the laby- rinth concerning the course of the suppuration. We also consider it imperative to perform the operation as quickly as possible, even though many authors do not dare to do so, inasmuch as they prefer to wait for the formation of adhesions. We, however, believe in the principle ubi pus ibi evacua, and that it is necessary to attack the labyrinth Caw* 10, 16, 23, 29, 32, 37, 49. INDICATIONS FOR OPERATION 65 at once, because we are unable to see whether the labyrinth suppuration is inclined to produce adhesions or to set up a meningitis. In the latter event, we cannot operate any too early. Against this procedure we might at the most raise the objection that perhaps the meningitis might be caused by the operation. A glance at our cases is sufficient to dis- pel this doubt. Of the twenty diffuse purulent manifest labyrinthites* which were operated, eight died and twelve were cured. Of those who died, five were received with the most pronounced symptoms of meningitis (unconscious, or with purulent cerebrospinal fluid), one died of cerebellar abscess, one of pyaemia, with thrombosis of the cavernous sinus, and only one died of meningitis which did not exist before admission to the hospital. This case, however, in particular, justifies our indication, for he was without doubt operated too late. Although, even on the day after the radical operation, there appeared nystagmus to the healthy side, and on the third day, by functional testing, the purulent labyrinthitis was proven beyond doubt, not until the sixth day, when the lum- bar puncture showed turbid cerebrospinal fluid, did we succeed in getting consent to perform the labyrinth opera- tion. Here we must report that in one case (No. 52) the cere- brospinal fluid at the time of operation was already turbid, but still the patient was saved by the labyrinth operation. Diffuse Purulent Latent Labyrinthitis. Here there is no need for haste with the operation, but when it is performed we can only conceive of the radical and the labyrinth operations performed at one time; for the labyrinthine function is completely destroyed and an eventual extension of the process can no longer be recog- nized by the labyrinth tests. It is in these cases, in particu- lar, that we have attained the best results with the laby- Cases 51 to 70. 66 DISEASES OF THE LABYRINTH rinth operation. AVe have only to recall the series of Zeroni and those of our own cases, which we formerly saw die every year of meningitis, for which we could find no cause. To-day we have no longer to fear the sword of Damocles in the form of meningitis which hung over every patient in whom a radical operation was necessary. Of twenty-five diffuse purulent latent labyrinthites, in which the labyrinth operation was performed, twenty-one were cured,* four died, one (No. 78) in consequence of an abscess in the parietal lobe, one (No. 81) as a result of a meningitis already pronounced before the operation (puru- lent cerebro spinal fluid), two of meningitis which was not in evidence before the operation. These two cases are worthy of discussion. The one (No. 74) had severe head- ache before the operation and a temperature of 37.8 C., but we could ascribe the cause to a tear in the dura made at the time of operation. The other case (No. 71) dates back to the year 1907 and belongs more to our experimental series, but I include it because it presents a good example of a labyrinth opera- tion performed too late. The functional test showed con- versational voice well heard by the speaking tube (the ex- clusion apparatus was not then in use), caloric reaction negative; but, on the other hand, the turning test showed the significant difference of five seconds for the diseased side, compared with thirty seconds for the healthy ear ; no fistula symptom. In performing the radical operation there was found a softening of the bone extending into the laby- rinth nucleus, and yet only the radical operation was per- formed. The very next day, because symptoms of a begin- ning meningitis were recognized, the labyrinth operation was performed, but too late. For the sake of a better grasp of the indications for operation, we will arrange them in a table : * One case (Xo. 76) died shortly after admittance, in consequence of an abscess in the parietal lobe, which broke into the ventricle before we could operate. This case was not included in these twenty-five. OPERATIVE TECHNIC 67 Circumscribed Laby- rintliitis : Diffuse serous second- ary labyrinthitis : Diffuse purulent mani- fest labyrinthitis : Diffuse purulent la- tent labyrinthitis : First : Eadical operation. In case of labyrinth symptoms and loss of function after the radical operation : Labyrinth operation. (Labyrinth operation in two stages.) First : Radical operation. With loss of function after the radi- cal operation: Labyrinth opera- tion. (Labyrinth operation in two stages.) Radical and labyrinth operation at once. ( Labyrinth operation in one stage.) Radical and labyrinth operations together. (Labyrinth operation in one stage.) FIG. 17 Teclmic of the Labyrinth Operation. The credit of having pointed out to otology the way to the labvrinth belongs to Jansen. 68 OF THE LABYRINTH The method which I regularly employ is essentially that of Neumann, but I do not on principle go as far as the internal meatus, but am satisfied with the opening of the votiluile from behind, and of the cochlea from in front. I proceed in the following manner : 1. The typical radical operation. '2. Exposure of Trautmann's triangle (between the sinus, facial ridge and middle cranial fossa). (Fig. 17 shows it in a case with the sinus extending forward, Fig. 18 with the sinus lying well backward.) The pictures are made entirely after preparations belonging to the author, :il-c Fix. -1. which, however, was already printed in advam-e in V. Urbant- schnitsch's text-book. Here in cases in which the sinus lies very far back it is not always necessary to expose the dura (Frcy and Ham- merschlag), though I do not regard its exposure as a dis- advantage nor have I experienced any bad consequences from its exposure. In the cases reported, the dura was in- deed torn once, but out of so many cases a single mishap cannot count for much; for this has been reported by nu- OPERATIVE TEC EMC 69 merous writers even in the radical operation. It is proper to report here one case observed by myself, in which three years after the labyrinth operation there appeared a men- ingocele. Thus far this case has remained the onlyone reported. FIG. 19 3. Undermining the facial ridge and the horizontal semi- circular canal. In so doing we must confine ourselves to the area behind the semicircular canal and the upper third of the facial ridge (Fig. 19). The depth to which we must restrict ourselves in the process of undermining amounts to about one centimeter; for the posterior vestibular wall, reckoned from the prominence of the horizontal canal, is 70 DISEASES OF THE LABYRINTH on the average between nine and eleven millimeters thick. 4. During the chiseling, we introduce from time to time into the oval window my very pliable labyrinth probe (Fig. 20). If this is freely movable behind the facial ridge, then the vestibnlum is already opened posteriorly (Fig. 21). FIG. 20 FIG. 21 5. Opening the cochlea from the front. AVe apply the chisel perpendicularly in front of and as close as possible to the facial ridge, and remove the promontory with one blow. (In practice on the cadaver, it is advisable to place the chisel upon the subiculum promontorii.) (Fig. 22.) 6. Plastic after Panse. 7. Introduction of a wick drain in front of the facial ridge into the tympanic cavity and another behind the facial ridge. 8. The usual treatment of the wound. The dressing, as a rule, is left six days. If severe head- ache or fever appears, the dressing must be changed and OPERATIVE TECHNIC 71 the wound examined, in order that retained matter, decom- posed secretion, overlooked bony fragments, etc., may be properly taken care of. In general, we have operated in the manner above out- lined. Only in a few individual cases from external causes FIG. 22 (such as the difficulty of the operation, lack of time on ac- count of narcosis) has the operator preferred the method of Hinsberg. According to our earlier experiences, it would appear that, in general, under this method, the vertigo and other manifestations of a reaction disappear later than 72 DISEASES OF THE LABYR1XTH when Neumann's method is used (see also V. Urbaiit- schitsch's text-book). We keep the patient in bed from eight to ten clays after the operation, for severe vertigo seldom continues longer. Alexander prolongs the rest in bed as long as six weeks. Generally there results under this operative method no flow of cerebrospinal fluid. On FIG. 23 Fig. 23 shows the completed labyrinth operation. the contrary, if we go as deep as the internal meatus, we must expect from this opening a flow of fluid for three to five days. TERMIXATIOX 73 F. TERMINATION Regarding the Circumscribed Labynntliitis we know, first of all, that a fistula may exist unchanged during a period of years. In Case 66 the fistula symptom could be produced during three years. After the radical operation the fistula may remain a long time without pro- ducing any symptoms, or, at the most, very slight symp- toms ; for the retention of pus, always giving rise to severe attacks of vertigo, drains into the antrum or the middle ear. At the present time I have under treatment a private case in whom I diagnosed a large, dry cholesteatoma more than a year ago. This had destroyed the attic and antrum wall and posterior meatal wall, and, as demonstrated by the probe and by the Roentgen findings, had partially de- stroyed the mastoid. In short, it is a perfect picture of a radical operation performed by nature, yet with preserva- tion of the drum membrane, excepting Shr a pn ell's membrane. The head of the hammer and the body of the incus are ab- sent. The fistula symptom was very pronounced. The pa- tient objected very strongly to an operation, so that I de- cided to remove the cholesteatoma with a curved curette. This I did in several sittings through the external meatus, through which. I could go with a sharp spoon well into the depths of the mastoid. After cleaning out the cholestea- toma, the frequent attacks of vertigo spontaneously ceased, especially those attacks produced by movements of the head. The patient is to-day still entirely free from sub- jective symptoms, though the fistula symptom is typically present, and, besides, we can now see quite plainly the epi- dermized prominence of the lateral semicircular canal (cholesteatoma matrix), in which one point shines through somewhat darker. If this spot is touched with a probe, the patient has a typical fistula symptom accompanied with severe vertigo. The fistula may, however, heal completely, either with con- 7-4 D/NAMNA'S' OF THE LABYRINTH nective tissue (Case 19) or, indeed, with a bony formation (Case 1). Frequently (fifteen times in thirty-two cases) the cir- cumscribed labyrinthitis develops into a diffuse serous sec- ondary labyrinthitis. But this is in itself usually not dan- gerous, though it may develop into a purulent labyrinthitis, and this is to be regarded as dangerous only through being the connecting link between a circumscribed labyrinthitis and a meningitis. On the other hand, a diffuse serous sec- ondary labyrinthitis frequently affects seriously the func- tion of the labyrinth. There may be marked diminution of the sense of hearing or even complete loss of hearing in the affected ear, with sometimes loss of the caloric and turning reactions. In a case of E. Urbantschitsch, in which the fistula was healed by connective tissue, there was a recurrence after three years, with bulging of the membrane, which closed the fistula, and a reappearance of the fistula symptom. Diffuse Serous Secondary Labyrinthitis. This can undoubtedly heal spontaneously either without loss of function or with loss of hearing and sometimes with loss of the caloric and turning reactions. In this last case it is no longer to be differentiated from a diffuse purulent latent labyrinthitis. Karely it may also be directly trans- formed into a purulent labyrinthitis (Case 19*). The prog- nosis is, therefore, on the whole, good. Of our twelve cases, four died, though two of these were of temporal lobe abscess (Xos. 22 and 29). One died of meningitis, prob- ably not caused by the labyrinth (No. 29) ; and in one (Xo. 33) we have laid the blame for the meningitis upon the laby- rinth operation, which was not absolutely indicated. Diffuse Purulent Manifest Labyrinthitis. Of all the labyrinth diseases, this presents the very worst prognosis for the life of the patient. * We must imapine that as a matter of fact more often a diffuse purulent latent labyrinthitis develops from a circumscribed form, going intermediately through the form of a diffuse serous secondary labyrinthitis. TERMINATION 75 Of twenty cases, eight died, though we can look upon only six of these cases as resulting directly from the labyrinthi- tis. For these six died of meningitis. Of the other two, one died of meningitis and thrombosis of the cavernous sinus, the former probably proceeding from the latter ; the other, of a cerebellar abscess. The labyrinth operation is surely a life-saving measure, for of the twenty cases, twelve were cured, among them one with turbid cerebrospinal fluid. Of the cases which died, five upon admission to the hospital already had symptoms of meningitis, one was operated late, as has already been stated (No. 56). It is noteworthy that the labyrinth suppurations originat- ing in acute otitis apparently led to an early meningitis, in- asmuch as all four cases were brought in with a meningitis already present. This corresponds with the experience of other authors (Scheibe, Wanner) regarding the danger in labyrinthitis originating in acute otitis. Diffuse Purulent Latent Labyrinthitis. Here naturally the end result may be complete healing, with organization of the exudate or of the granulations. Indeed, it may result in complete bony destruction of the diseased labyrinth. Politzer has described such a case, as is well known. Recently I operated a case in which I found a similar condition. There was absolutely no semicircular canal to be found, the probe could be introduced a short dis- tance into the oval window, but soon inet with a bony re- sistance. On removing the promontory, there was found no cavity, only bone. But, as a rule, the disease extends slowly and steadily to- ward the cranial cavity, and finally results in some compli- cation, most frequently in a cerebellar abscess and menin- gitis. Rarely it extends through the upper semicircular canal, resulting in a temporal lobe abscess, unless the dis- eased focus is removed by a labyrinth operation. The rad- ical operation, as we have already stated at full length, 76 DISEASES OF THE LABYRINTH may only hasten the meningitis, for it does not remove the focus of pus, but, by the traumatism involved, may cause irritation, as Brieger has observed. Of twenty-six cases, twenty-one were cured; three died of meningitis, two of temporal lobe abscess. In the last two cases the labyrinth suppuration apparently was not the cause of the abscess. Of the oases of meningitis, one was caused by a tear in the dura, the two others plainly origi- nated in the labyrinth. The one case (No. 71), as we have already clearly shown, was operated too late ; the other had a meningitis before the operation. We see that the prog- nosis in a diffuse purulent latent labyrinthitis, when the labyrinth operation is performed sufficiently early, is very good. CHAPTER III INJURIES OF THE LABYRINTH As a rule, an operative injury of the labyrinth is recog- nized by the immediate appearance upon awakening from the anaesthetic of symptoms of a diffuse labyrinthitis, i.e. marked rotatory nystagmus of the third degree to the healthy side, vertigo, ernesis and disturbances of equilib- rium; and the patient is deaf or nearly deaf on the oper- ated side. (If the promptness of the appearance of these symptoms is not always clearly expressed in case his- tories 105 to 108, it is because sometimes the patients were not always examined immediately after awaking from the anaesthetic, and vertigo and emesis were ascribed by both the patient and the attendant to the anaesthetic.) Traumatic injury of the labyrinth naturally does not con- stitute any reason for at once further opening the laby- rinth, whether we have a luxation of the stapes or an in- jury of the semicircular canal or of the promontory. On the contrary, with the relative mildness which character- izes these injuries, according to various observations, and particularly after a fine pathological-anatomical study of Goerke, our chief duty after such injuries consists in the most careful observation of the patient. As a rule, the nystagmus and the accompanying symptoms disappear within a few days, and the injury gives rise to no further results. In our cases the labyrinth symptoms lasted ten days in Case 105, fourteen days in Case 106, eight days in Case 107 and six days in Case 108. As regards the nystagmus, injuries of the labyrinth do not give symptoms that are always the same. Theoreti- cally, immediately after awakening from the anaesthetic there should be a marked rotatory nystagmus toward the healthy side; for the opening of the labyrinth is accom- 77 78 DISEASES OF THE LABYRINTH panied by a loss of fluid, if only perilymph, which would also probably cause a complete temporary arrest of func- tion of the wounded ear. This behavior was also present in Cases 106, 107 and 108. In Case 105. on the contrary, there were present (though not observed until the next day), besides attacks of nystag- mus toward the healthy side, also a slow rolling of the eyes with a horizontal movement to and fro. This atypical behavior is perhaps to be ascribed to a cir- cumscribed labyrinthitis setting in early. The assumption that a circumscribed labyrinthitis may have its origin in a traumatism of the labyrinth seems reasonable, when we consider that after an injury of the labyrinth there may be for months attacks of vertigo of the type which char- acterize a circumscribed labyrinthitis ; that is, provoked by movements of the head, severe muscular efforts, etc. In this connection, a case of Kiimmel's is very instructive. In this case, after an operation on the nose, there followed an acute otitis with finally a mastoiditis on the right side. An antrotomy was performed on May 12, 1903, when the horizontal semicircular canal was injured. Immediately there was severe vertigo and marked horizontal nystagmus to the left. Five days later there is noted in the case his- tory, "The nystagmus disappears in a few days." Then, "until the close of 1903 there were often severe attacks of vertigo, particularly after physical effort, but also during ordinary work about the house. These entirely disap- peared by the end of the following May, but some uncer- tainty of variable degree occurs upon physical strain, that is, upon suddenly turning in a direction contrary to the movement of the hands of the clock. ' ' In the beginning of 1904 Kurnmel saw the patient again, and observed total deafness in the injured ear (tested ac- cording to the principles of Bezold*}. In Case 105 the hearing was not tested after the injury; * Concerning Infectious Labyrinth Diseases, Arch. f. Klin. Med. Vol. 55 u. Ref. Hinsberg, Z. f. O. Vol. 51, page 311. INJURIES OF THE LABYRINTH 79 in Case 106 it was practically zero before the operation; in Case 107 it diminished from three and a half meters for the spoken voice (tested with the exclusion apparatus) so that the patient, on the following day, could only hear words spoken at the external ear. In Case 108 it fell from one meter for the spoken voice (examined with the exclu- sion apparatus) to one-quarter meter, and remained there until the appearance of a purulent labyrinthitis, nine days later, which totally destroyed the hearing. In Kummel's case deafness also occurred, though later. On the other hand, this did not occur in a single case of Bezold's nor in Neumann's case. In the last case the hear- ing was completely restored. In general, we may, therefore, expect a diminution of hearing immediately after an injury of the labyrinth, amounting to deafness for the spoken voice, or to a percep- tion of a loud voice close to the ear, in favorable cases even one-fourth meter for the conversational voice. Just how the hearing will behave, naturally, depends upon the pathological changes which take place. In a sim- ple closure of the supposed opening by a callus or con- nective tissue formation without severe inflammatory symptoms, as we may assume them to be formed histologi- cally, according to the investigations of Marx* there is possible an almost complete restoration of hearing, as in Neumann's case, for example. But since the injury practically always occurs in operat- ing for purulent middle ear disease, as a rule, it is hardly likely that it would run its course in the labyrinth without inflammatory symptoms, even though they are not always those dependent upon a purulent condition. For this rea- son we have in the majority of cases the permanent and severe damage to the hearing. Indeed, the infection may also come later, as undoubtedly is shown by Case 108. In this case the injury of the labyrinth produced marked ves- * Concerning Labyrinthitis in Acute Middle Ear Suppuration, Z. f. 0. Bd. 60, 3 & 4 H., page '221. 80 DISEASES OF THE LABYRINTH tibular symptoms with diminution of hearing from one meter to one- fourth meter for the conversation voice, but nine days later there followed a sudden labyrinth suppura- tion which entirely destroyed the hearing. Nor is it immaterial where the trauma tism is localized. In injury of the oval window (stapes luxation) only the peri- lymphatic space is opened; whereas, in the horizontal semicircular canal, should a section be cut away (as in Neumann's case), the membranous semicircular canal and the endolymphatic space are both opened at the same time. The immediate effect, according to our conception,* must be the same for the hearing; whereas, in case of an infec- tion, injury of the semicircular canal offers fewer chances for the extension of the suppuration than does the opening of the oval window. The caloric test was not made in Case 105; in Case 106 the caloric reaction was lost; in Cases 107 and 108, as well as in Neumann's case, it remained present. It would seem that it is more likely to be preserved than to be destroyed. The turning test was made in Case 107, and was present likewise in Neumann's case. Practically the most important feature is the onset of vestibular symptoms immediately after the operation, while the serous labyrinthitis, which alone has to be considered in the differential diagnosis, appears, according to our ex- perience, at the earliest, twelve hours after operation. Of further importance is the question as to whether or not a labyrinth injury is followed by infection. This can only be answered by the course of the symptoms. In a non- infected labyrinth injury, the manifestations continuously diminish from the day of operation during the succeeding days ; in an infected injury of the labyrinth, the symptoms reach a second period of intense severity, or recur sud- denly after they have run their course. A classic example * Ruttin: Contributions to the Pathology of Deafmutism, together with Observations on the Physiology and Pathology of the Peri- and Endolymph. Transactions of the German OtologicaJ Society, Dresden, 1910. STATISTICS 81 of this last possibility is afforded by our Case No. 108. After practically all vestibular symptoms had disappeared, the symptoms suddenly returned with renewed severity, with complete loss of the labyrinth function. The nystag- mus in this case is hardly to be explained as of labyrinth- ine origin ; it is far more likely to be explained by a begin- ning disease of the posterior cranial fossa (serous menin- gitis) ; for, with a complete loss of function on the part of the labyrinth, the marked nystagmus was directed to- ward the diseased side. We must explicitly state that the fever gives us no point for the differential diagnosis between simple trauma of the labyrinth without subsequent infection and injury of the labyrinth with later infection. G. STATISTICS Cured 83 not operated radical operation rad. op. later labyr. op. labyr. op. 7 38 4 34 Died not operated radical operation rad. op. later labyr. op. labyr. op. 1 5 7 12 par. men. other causes pur. men. other causes pur. men. other causes pur. men. other causes 1 05*) 3 4t ) 9 3J ) arising arising arising arising arising arising before after before after before after op. op. op. op. op. op. 00038 1 Xote: rad. op. = radical operation; men. = meningitis ; pur. = purulent. Even if we do not attach too high a value to the statis- tics, we must at least, from the relatively large number of observed cases and from the manner of their grouping, ex- * Two of phthisis, one unknown cause, no post mortem, two abscesses of the temporal lobe. tThree of cerebellar abscess, one of cavernous sinus thrombosis. JOne of carcinoma, two of temporal lobe abscess. 82 DISEASES or THE LABYRINTH pect some light upon the question as to the danger of opera- tive procedures in diseases of the labyrinth. Eighty-three cured cases stand in contrast with twenty-five fatal cases. Of the eighty-three cured cases, seven were not operated, thirty-eight had the radical operation, and thirty-eight the lahyrinth operation; four in one stage and thirty- four in two stages. Of the twenty-five fatal cases, one died of tu- berculosis without operation, five had the radical opera- tion, of whom none died of a meningitis of labyrinthine origin (the doubtful case, No. 43, we must leave out). Seven had the labyrinth operation in two stages, of whom only three died of a meningitis of labyrinthine origin. All three cases (Nos. 56, 71, 101) presented labyrinth symp- toms only after the radical operation; in two cases (Nos. 56 and 71) there is no doubt that, according to our indi- cations for operating, the labyrinth operation was decided upon too late. Only Case 101 was operated promptly, but nevertheless died. Twelve fatal cases were operated upon in one stage, of whom three died of other causes, and nine of meningitis of labyrinthine origin. Of these nine cases, eight had well-defined clinical symptoms of a meningitis before the operation, with purulent cerebrospinal fluid. Only in one case (No. 33) could the meningitis of labyrinth- ine origin be said to have been caused by the labyrinth operation, inasmuch as the patient showed no evi- dence of meningitis before the operation; for the men- ingitis appeared not until five days after the labyrinth operation. And in this very case our indications for operating were not strictly observed, inasmuch as the caloric reaction was still present. Now let us look at our figures from another point of view. In all, just one hundred cases of labyrinth diseases were operated. In forty- three the radical operation was performed. In eleven the labyrinth operation in two stages was per- formed; that is, first the radical, and later the labyrinth. STATISTICS 83 In forty-six the radical and labyrinth operations were performed at the same time. Of the forty- three having only the radical operation, none died of a meningitis of labyrinthine origin. These cases were decidedly circumscribed and not purulent diffuse laby- riuthites; in short, cases in which the labyrinth function was not blotted out. Therefore, we may conclude that the radical operation is not dangerous in these cases. Of the eleven cases operated in two stages, three died of menin- gitis of labyrinthine origin which appeared after the radical operation. Before the operation all three had no positive symptom of labyrinthine disease; they belong, therefore, in the group of post-operative labyrinthitis, since, without doubt, in two of these cases the labyrinth operation came too late; this is the more significant when we compare them with Cases 64 and 108, in which the labyrinth operation was performed in time and the patients were saved.* Considering in comparison the forty-six cases which were operated in one stage, we see that nine died of a meningitis of labyrinthine origin. Of the nine, eight had a meningitis before the operation, and only one developed it after the labyrinth operation. The majority of these cases were diffuse purulent labyrinthites. The large proportion of meningitis cases which these labyrinthites present proves their dangerous character in and for themselves. The cir- cumstances that only a single fatal case (and that one truly not properly belonging in this group and operated without justifiable indications) may be laid at the door of the laby- rinth operation, while out of thirty-four cases operated in one stage at the proper time with all indications for oper- ating present, not a single case ending fatally these cir- cumstances show best of all what an active procedure upon the labyrinth can accomplish, assuming careful observance of all the indications and proper operative technic. According to these figures the mortality may be said to * Compare also a case of mine previously reported by Neumann. Austrian Otol. Society, 1907. 84 DISEASES OF THE LABYRINTH be 2.2 per cent. Neumann had seven deaths out of twenty- seven labyrinth operations, but not caused by the opera- tion. Freitag, from the literature, estimates the mortality at 4.5 per cent, for the labyrinth operation, but gives the mortality of the Breslau clinic, according to the reports of Hinsberg, as zero. By comparison, Freitag finds that the figures for non-operated cases of labyrinth suppuration to be, for Jansen, 10 per cent. ; for Whitehead, 33 per cent. ; for Friedrich, 50 per cent. ; for Gerber, 16.6 per cent. Naturally we cannot expect that the labyrinth operation is capable of saving hopeless cases of meningitis, such as the eight cases in which there was present a meningitis be- fore the operation. Even if in such cases we still advise operation (for, with- out it, the fight is absolutely lost), it sometimes happens that the courageous operator gets a remarkable result, by way of an unexpected cure, which compensates him for the trouble and disappointment of operations performed in vain. CHAPTER IV SEROUS INDUCED LABYRINTHITIS ALEXANDER called attention to the fact that nonpurulent (serous) inflammations of the labyrinth sometimes occur with violent labyrinth symptoms. For a comprehension of this disease it is necessary to separate the "serous labyrinthitis," originating in a fistula and known as a diffuse serous secondaiy form, from the "induced labyrinthitis,"* which proceeds directly through the labyrinth wall. The first is only a stage in the slow advancement of the suppuration from the tympanic cavity upon the labyrinth. But the last is a suddenly appearing nonpurulent inflam- mation of the labyrinth perhaps often only a collateral (concomitant) oedema of the labyrinth. It may occur : 1. In the course of acute otitis. 2. In the course of chronic otitis. 3. In cases of unhealed radical operation. 4. A short time after the radical operation. Of our eleven cases, there belonged : To the first group, no case; To the second group, no case; To the third group, four cases; To the fourth group, seven cases. Cases of the first group we have certainly observed, but we have no case records of such, for the acute otites which we receive at the clinic as bed patients arrive in too ad- * Rtittin: Concerning the Question of an Ectasia of the Dnctus Cochlearis. Transactions of the German Otological Society, Heidelberg, 1908. 85 86 DISEASES OF THE LABYRINTH vanced a stage.* But Voss has reported a series of such ca>es. The picture is, on the whole, the same, whether the serous induced labyrinthitis grows directly out of an acute otitis or out of a chronic otitis. The symptoms are en- tirely those of the diffuse purulent manifest labyrinthitis : marked rotatory nystagmus to the healthy side, vertigo, emesis, disturbances of equilibrium and impairment of hearing, and even absence of hearing. The complete clin- ical picture often appears suddenly, without any reference in the history to vertigo. The differentiation from the diffuse purulent manifest form, when it is at all possible to make it with certainty, is made by the functional test. As long as a remnant of functional activity of the labyrinth (hearing, caloric and turning reactions) can be demonstrated, so long must we assume that we are dealing with a disease not yet of the purulent diffuse form, that is, with a serous induced labyrinthitis. We already know from the cases of Voss that undoubt- edly such a serous induced labyrinthitis may proceed with complete loss of function. It seems, on comparing our cases with those of Voss, that the serous induced labyrinthitis is more frequent among the labyrinthites following an acute otitis than among those occurring in the course of a chronic middle ear suppuration or after the radical operation. It is quite possible for a purulent inflammation of the labyrinth to occur without any breaking through of the labyrinth wall, in consequence of a transmigration of bac- teria through the annular ligament or through the round window. Substantiating the first possibility, we have the * Since completing the manuscript for this book I have reported (Austrian Otol. Soc., 1911) a case of particular interest which belongs in this series. Simultaneously with the otitis, which was still in the serous stage, there appeared a very severe serous labyrinthitis. Here belong also the observa- tions of Alt and Politzer (vide Politzer's Text-book). Of interest is also the report of Otto Meyer, to the effect that a serous labyrinthitis may also arise haematogenetically. In the case reported by him there was simultaneously with a purulent otitis and meningitis, a serofibrinous labyrinthitis produced by an accumulation of cocci in the blood vessels of the labyrinth. SEROUS INDUCED LABYEIXTHITIS 87 investigations of Gruenbery* the second possible path is substantiated by the findings of 0. Meyer and Uffenorde.-\ To the labyrinth suppuration arising in the course of an acute otitis, we must ascribe a special seriousness, a special tendency to meningitis. The question, therefore, arises: Shall we open the labyrinth, or not, in a diffuse labyrinthitis with complete loss of function! For we do not yet know if we are dealing with a purulent or only with a serous labyrinthitis. Unfortunately, the number of cases observed is not yet sufficiently great; but we would per- sonally advise waiting to see if the symptoms increase or decrease in severity, keeping the patient under the closest scrutiny. As a rule, a labyrinthitis arising in the course of an acute otitis appears to be only serous. That even a labyrinth suppuration arising in the course of an acute otitis may heal spontaneously is proved by the carefully observed case of Marx% and the panotitis of Politzer. In fact, the possibility of a spontaneous cure of purulent mastoiditis is not to be denied, yet no otologist would in these days wait for this eventuality. Further, we do not often see cases of the second group in their most acute stage, for the duration of the dis- turbance is short. But we do, without doubt, see many cases which are to be interpreted as cases of induced serous labyrinthitis which have run their course. These constitute a large number of those chronic suppurations in the course of which the patients become deaf without having lost the vestibular reaction. The histological demonstration of such cases of serous labyrinthitis which have run their course is to be sought in the cases of Herzog and in the cholesteatoma deafness of Siebenmann-Nager. The rela- tive frequency of the third, and particularly of the fourth, group is striking. The third group can be explained by the * Griinbcrg: Contribution? to the Knowledge of Labyrinth Diseases II, Zeitschrift f. 0. Bd. 58, 1909. Transact. German Otol. Soc., Dresden, 1910. , Zeitschrift f. Otology, Bd. LX, H and 4. 88 DISEASES OF THE LABYRINTH fact that in unhealed radical operations we are doubtless often dealing with migratory labyrinth diseases, which, in- vading the labyrinth more or less deeply, sooner or later lead to a clinical labyrinthine inflammation. Thus are to be explained the undoubtedly correct find- ings of Ah'.rtinder, to the effect that after radical opera- tions deafness of the affected ear often follows. Here is to be mentioned a case of Wojatscheks* in which, seven weeks after the operation for an acute mastoiditis, there developed a serous labyrinthitis with loss of hearing and of the caloric reaction. Two weeks later the labyrinth function was again almost fully restored. Still more interesting is the case of Herzfeld.\ In an acute otitis, fourteen days after the onset, the mas- toid was opened. Because of pains, oedema over the zygoma, diminution of hearing to the perception of the whispered voice only at the meatus, and horizontal nystag- mus to the diseased side, the radical operation was per- formed twelve days later. Twenty-six days later there oc- curred vertigo, emesis, small intermittent pulse, tremor of the entire body, nystagmus on looking straight forward and to both sides, and complete deafness of the right side. On account of the severe symptoms, the labyrinth was opened the next day, but nothing of a pathological nature was found either in the vestibulum or in the cochlea. How- ever, the labyrinth symptoms disappeared. We can hardly wonder at the frequent occurrence of cases of the fourth group when we realize that the radical operation undoubtedly means more or less traumatism for the labyrinth wall, following which it is natural that there should be a severe reaction inflammation. With its rela- tive closeness, the labyrinth can very easily be within the area of this inflammation. * Russian Monatschr. f. 0. 1909, ref. Z. f. 0. Bd. 60. W." Presentation of a man with but one labyrinth. Report of the meeting of the Berlin Otolog. Soc., Nov. 5, 1909, reported by Claus, Z. f. O. Bd. 60. SEROUS INDUCED LABYRINTHITI8 89 The fourth group is the most important, not only because it occurs most frequently, but also because of its post- operative character, which fact imposes upon us special care in judging this clinical manifestation. In general, the induced serous labyrinthitis appears in from one to three days after the radical operation. Most frequently the symptoms appear suddenly, when the patient is feeling unusually well, having recovered from the un- pleasant effects of the anesthetic and the operative shock. These symptoms are nystagmus to the healthy side, vertigo, einesis, disturbances of equilibrium (lying upon the well side). The functional test shows a marked diminution of hearing or total deafness on the diseased side, with retained caloric reaction. In our cases the hearing was diminished while the ca- loric reaction was retained nine times; the hearing was en- tirely absent while the caloric reaction was retained three times. Naturally, from the analogy with the diffuse serous sec- ondary labyrinthitis, and in consideration of the cases of Voss, we must assume that there are cases of serous laby- rinthitis with obliterated hearing and obliterated caloric reaction. But such cases we have been obliged to class with the diffuse purulent form, inasmuch as we are usually un- able to differentiate them clinically. In the serous labyrinthitis sometimes, but really very seldom, do we see nystagmus to the diseased side. Accord- ing to Alexander, this would represent a stage of irrita- tion ; but we are more inclined to believe that in these cases it is a matter of an undeveloped serous labyrinthitis, or it is the production of attacks of nystagmus by head movements. We must come to this conclusion after the observation of labyrinth fistulae. In these, since the circumscribed focus is already within the labyrinth, the serous labyrinthi- tis appears very rapidly after the operation, and we are in a position to observe even the very beginning of the proc- 90 DISEASES OF THE LABYRINTH ess, for our attention is already directed to the labyrinth. In these cases we were almost always able to notice that the nystagmus at its onset is regularly directed toward the healthy side. We can imagine that the induced serous laby- rinthitis is sometimes preceded by a sort of circumscribed inflammation, especially when it is a case of migratory laby- rinth disease. The induced serous labyrinthitis may develop into a dif- fuse purulent labyrinthitis. This we are forced to conclude when the labyrinth function is completely lost (Cases 101, 70, 68, 63). In such a case the indication for a labyrinth operation is clear. It remains to be mentioned that simultaneously with the milder affections with complete loss of function, and also in both the induced and in the secondary diffuse serous labyrinthitis, a facial paresis may appear. This we must assume to be caused by the same inflammatory exudative process in the facial canal. Compare the cases of Bondy* and of Ernst U rb ants chit sc/i.f The duration of the severe symptoms is generally three to eight days, when a continuous diminution is the rule. * Austrian Otol. Soc., Oct., 1908, M. f. O. XLIII, Heft 3. t Austrian Otol. Soc., Oct., 1909, M. f. 0. XLIII, Heft 11. CHAPTER V LABYRINTHITIS AND BRAIN ABSCESS WE find eight of our cases combined with brain abscess. There occur in the literature a large number of such cases. Of our cases, four were temporal lobe abscesses and four were cerebellar abscesses. In addition, there are two cases of cured cerebellar abscess proceeding from labyrinth sup- puration, which are reported separately. So we have six cases of cerebellar abscess in connection with labyrinth suppuration ; that is, we must assume this with the observa- tion that, although it is not entirely impossible, one or more cases are less likely to have proceeded from the laby- rinth suppuration as such (i.e. through the internal audi- tory meatus) than from the destruction of bone about the labyrinth. Wagener has beautifully shown how difficult it is to differentiate between such cases. In a cerebellar abscess not of labyrinthine origin the course of the infec- tion is not always as clear as in a case which I reported.* Often there may be extensive destruction of the paralaby- rinthine bone, but the labyrinth itself may be quite intact. On the other hand, the four cases of temporal lobe abscess, as shown by the postmortem, were certainly not de- pendent upon labyrinth suppuration, but were caused by destruction of the tegmen antri or tympani and the con- secutive pachymeningitis externa and interna. Of the six cases, four occurred in connection with puru- lent and two in connection with serous labyrinthitis. The combination of a labyrinthitis and a cerebellar abscess is not a rare one, but one in which the diagnosis and treatment are especially difficult. The symptoms in both may be entirely similar and the differential diagnosis may be quite impossible. But many cases do permit of MI. f. 0. Xr. 4, 43rd year. 91 92 DISEASES OF THE LABYRINTH a fairly certain differential diagnosis, that is, those cases in which the symptom given by Neumann and Barany, i.e. nystagmus to the diseased side, is present when the laby- rinth is wholly destroyed. We are able to diagnose with certainty a brain abscess by the nystagmus to the diseased side when there is positively a labyrinth suppuration (com- plete deafness with loss of reaction of the labyrinth for all tests: caloric, turning and fistula tests), provided that the other labyrinth is not affected. We know that in complete destruction of the labyrinth there is either nystagmus to the healthy side (that is, for a short time after the destruc- tion), or there is no nystagmus (that is, some little time after the destruction has taken place). Nystagmus to the diseased side in such a case can only result from retrolaby- rinthine causes ; namely, from a meningitis in the posterior cranial fossa, or from a cerebellar abscess. In purulent meningitis the nystagmus will increase, as shown by Xcu- mann; but in serous meningitis, as I have pointed out, it will decrease. With cerebellar abscess the nystagmus will either remain constant (more often, though, it varies sud- denly and it is quite characteristic for us to see in the course of a day periods in which the patient is entirely free from nystagmus, these periods alternating with severe nys- tagmus to the diseased side), or the nystagmus changes its direction; that is, if we examine the patient, for instance, in the forenoon, we may find nystagmus to the diseased side ; in the afternoon, the nystagmus is to the healthy side. Naturally, other symptoms may appear besides. Ver- tigo, emesis, equilibrium disturbances are then only of sig- nificance in diagnosing a cerebellar abscess, if we know positively that the labyrinth is completely without function.. As long as this is not the case, it is doubtful whether this symptom is produced by the labyrinth or has its origin within the cranium. On the other hand, slowing of the pulse is not naturally occasioned by the labyrinth, and, besides, the nystagmus points most surely to an abscess. Likewise, fever is never LABYBINTHITIS AXD BBAIX ABSCESS 93 to be ascribed to a simple labyrinth disease, but suggests a complication., Should the cerebellar abscess be combined with a circumscribed or a serous labyrinthitis, the diagno- sis becomes even more difficult. In circumscribed laby- rinthitis the nystagmus is quite as likely to be directed to- ward the healthy side as toward the diseased side, and thus it is not to be distinguished from a cerebellar nystagmus. And in the serous labyrinthitis, as long as the labyrinth still performs any of its functions, we are not at all sure of the matter. If a serous labyrinthitis has run its course and the labyrinth retains its functions, then attacks of nys- tagmus to the diseased side would still be possible. In such cases, therefore, as I have already proposed, we must first exclude the labyrinth by the labyrinth operation. Then we may utilize for the diagnosis of a cerebellar abscess a spontaneous nystagmus still persisting after the labyrinth operation, if it is toward the diseased side, or is alternately directed to the healthy and to the diseased side. Naturally, the operation must completely destroy the labyrinth, for which reason nothing short of the opening anteriorly and posteriorly, that is, Neumann's method, is to be recom- mended. Opening the labyrinth simply from in front is not sufficient, for nerve elements might be left, which, after the labyrinth operation, could produce nystagmus to the operated side, as in Case 4. In a case of suspected cerebellar abscess or of meningitis, our procedure accordingly is as follows: In a case with spontaneous nystagmus to the diseased side, when the laby- rinth is entirely excluded, we perform the labyrinth opera- tion with exposure of the dura of the posterior fossa ac- cording to rule. If we find the dura pathologically altered, we incise it and look for the abscess. If the dura is normal, we wait a while, in order that we may positively exclude any other disease (tuberculosis, tumor, etc.), and make the incision only after no other possibility remains, except an otogenous abscess or meningitis. 94 DISEASES OF THE LABYRINTH If there is spontaneous nystagmus to the affected side in a case in which the labyrinth has not been entirely ex- cluded, then we first perform the labyrinth operation with exposure of the dura of the posterior fossa, and, at all events, wait to see if the nystagmus, after having thus excluded the labyrinth, still remains of the same degree or is of changing intensity. If this is the case, we make the in- cision and look for the abscess. In these cases, a nystag- mus directed to the diseased side is more significant, for, by the very opening of a labyrinth which is not completely destroyed, a nystagmus toward the healthy side is called forth. \\V will now examine our cases more closely. In Case 11 there was a circumscribed labyrinthitis, which, after the operation, was transformed into a diffuse secondary or a purulent manifest labyrinthitis. Unfortunately the fistula test was not made after the operation, which would have differentiated between these two forms. This, however, would have been only of theoretical interest, for, practi- cally, we were obliged to open the labyrinth, for fever, head- ache, slight rigidity of the neck, namely, the symptoms of an intracranial complication, were present, besides the dif- fuse labyrinthitis. After the operation there appeared the typical nystagmus to the well side, and for six days every- thing seemed to go well, with diminution of the fever. It is all the more noteworthy that on the seventh day, as the first symptom of a cerebellar abscess, there appeared nys- tagmus to the diseased side, emesis and headache, though the temperature remained normal. During the following days the nystagmus changed, alternating from the diseased to the well side, varying also in intensity. Both of these symptoms must cause us to think of cerebellar abscess, had the other symptoms (apathy, occipital headache, stiffness of the neck) not been present. In Case 12 there was a circumscribed labyrinthitis. After the radical operation there came on a typical diffuse serous secondary labyrinthitis, with marked spontaneous LABTBIXTH1TIS AXD BBAIX ABSCESS 95 nystagmus to the healthy side, which destroyed the hear- ing but left the caloric reaction. Within three days this nystagmus subsided in the typical manner; on the third day there was left only nystagmus of the first degree to the healthy side. All the more suspicious was the appear- ance on the fourth day of a nystagmus to the diseased side ; since there was present not another symptom of cerebellar abscess, and the neurological and ophthalmological exami- nations were entirely negative, we made the mistake of waiting. The patient surprised us the next day by loss of consciousness and contractions on the opposite side of his body. Immediately the labyrinth operation was per- formed with opening of the cerebellar abscess, but the pa- tient died three days later of meningitis. It is interesting that in Case 11 there was fever, but Case 12 was continuously free from fever until one day before death. Likewise, in both cases there was no slowing of the pulse. In Case 70 there also occurred at first a serous labyrinthi- tis following the radical operation, which, not until four- teen days later (the exact time of its appearance could not be established), became purulent. The nystagmus during the entire time was directed to the healthy side. Even one day after the labyrinth operation the nystagmus still con- tinued unchanged. But on the second day, in addition to the nystagmus to the healthy side, which now changed its character and became decidedly horizontal, there appeared a distinctly rotatory nystagmus to the diseased side, and also a vertical nystagmus. Even before the labyrinth operation, because of the temperature and the headache, there was reason to suspect an intracranial complication. Inasmuch as upon operating, the dura behind the opened vestibule was found to be greatly changed, the suspicion of cerebellar abscess was so strong that search was made for it. But the incision was in vain. Because, two days later, the above-mentioned, I may say, exaggerated or "ex- traordinary" nystagmus appeared, our earlier diagnosis, 96 DISEASES OF THE LABYRINTH in spite of the negative result of our incision, was con- firmed, and we explored once more and found the abscess. And here again the nystagmus was a very important symp- tom. I wish to again call attention to the fact that every 11 extraordinary" nystagmus points to an intracranial com- plication. I should designate as "extraordinary" every nystagmus which does not fall within the type character- istic of a circumscribed or diffuse labyrinthitis. The type for the circumscribed labyrinthitis, as we have already seen, is a rotatory or a horizontal nystagmus to the healthy or to the diseased side, or to both sides. The type for the diffuse labyrinthitis (that is, for a diffuse serous or a dif- fuse purulent manifest labyrinthitis, or for any sudden labyrinth exclusion or destruction) is severe rotatory nys- tagmus to the healthy side. Any other nystagmus, as, for instance, a vertical or diagonal nystagmus, points to an in- tracranial origin, which we. are not only able to conclude from the observed abscesses, but also from a large num- ber of cerebellar tumors, cerebellar tubercles, tumors of the pons and acusticus tumors. Case 68 on the third day (characteristic) after the radi- cal operation complained of vertigo. On this day the laby- rinth, which even before the operation appeared not to be intact, yet showed no definite lesion (hearing present only for loud voice at the external ear, caloric reaction plain, but weak, and not associated with vertigo, some spontaneous nystagmus to the healthy side, as the functional test showed), was in the same state as before the operation. Since the hearing remained the same and no other symp- toms appeared, there was no occasion for any further operative procedure. Not until after eight days did there appear headache, nausea and elevation of temperature and an extraordinary nystagmus (horizontal on looking to the left, rotatory on looking to the right), which was also in part directed to the diseased side. The functional test now showed total failure of labyrinthine function (deafness, no caloric reaction, no turning reaction, no fistula symptom). LABYRINTH1TIS AND BRAIN ABSCESS 97 At once we made the positive diagnosis of labyrinth sup- puration with probable diagnosis of cerebellar abscess. The patient, however, refused any further operation, until four days later he had a chill. We then performed the labyrinth operation with exposure of the dura of the posterior fossa. As the dura appeared normal, we waited. Another internal and neurological examination proving negative, and the fever in the meantime having become pyaemic in character, I swerved from my diagnosis and only tied off the jugular vein and cleaned out the sinus, which was, in fact, thrombosed. This course seemed the more justifiable, for any special headache and slowing of the pulse were entirely absent and the patient insisted that he was doing well. But the signs of a thrombosis of the cavernous sinus increased more and more, and finally the patient died. The postmortem showed, besides a cavernous sinus thrombosis extending' from the petrosal sinus and a basal meningitis, also a cerebellar abscess. CASE HISTORIES Abbreviations R.e. = Right ear. L.e. = Left ear. Con.v. Conversational voice. AVhisp.v. = Whispered voice. W. - Weber. R. = Rinne. Sch. = Schwabach. F.t. = Fistula test. C.r., or cal. react. = Caloric reaction. a.c. = Ad concham. Xy. = Nystagmus. Ny. r. = Nystagmus to the right. Ny. 1. = Nystagmus to the left. Short. = Shortened. Rotat. = Rotatory. Leng. = Lengthened. R.tr. = Turning to the right and arresting the motion. L.tr. = Turning (rotation) to the left and arresting the motion. B.s. syr. al. = Both sides syringed alike. = Mark for seconds. = Sign for minutes. O.P. Dept. = Out Patient Department. Temp. = Temperature. 1. L. H. Thirty- three years old. Bronzeworker. Ad- mitted July 10, 1907. Anamnesis: Patient visited the clinic one year ago on account of pain in r. ear. Polyps were removed, after which there followed a discharge, which ceased after five weeks of treatment. During the past four weeks the discharge has 98 CASE HISTORIES 99 returned, with pain. Sensitive to pressure over tragus and mastoid. Since removal of polyps, hearing is less acute. Occasional severe vertigo. Status praesens: R.e. : Thick, non-smelling secretion, with many scales of epidermis (no cholesterin). Upper posterior ineatal wall bulging. Large polyp from above, filling entire uieatus. Mastoid not sensitive to pressure. L.e. : Membrane retracted, cloudy and atrophic. Functional test: Con.v., 1. 8 m., r. i/o m. ; Whisp.v., 1. 3 m., r. 1/2 m. AV. 1. ; R. - - b.s. Bone conduction, r. shortened, 1. lengthened, d b.s. shortened, C 4 r. shortened; 1. normal. Caloric ny. to r. normal. Pressure in the external auditory meatus produces ver- tigo and rotatory ny. to r. R.tr. == Xy. 1/20". L.tr. == Ny. r. 20". Temperature: Before operation, normal. After opera- tionJuly 28 (second day), 37.5; July 29, 37.7; July 30, 36.7 ; July 31, 37.8 ; Aug. 1, 37.5. Thereafter, below 36.0. Operation: Typical radical operation. Cholesteatoma fills antrum and tympanum ; oval fistula in horizontal semi- circular canal. Dura of middle fossa exposed over an area the size of a bean. July 26: Two hours after the operation patient had ny. to both sides. Severe rotatory ny. to 1., even on looking straight forward. July 27 : Since the operation yesterday, patient has vom- ited every ten minutes. Has not slept. Vertigo only upon raising his head. Slight rotatory ny. to 1. on looking for- ward, more pronounced on looking to 1. On looking to r., only a slow, large horizontal ny. to r. July 28: No emesis since yesterday. Rotat. ny. to 1., slight horizontal ny. to r. Temp. 37.5. July 29 : Vertigo only on standing. Eotat. ny. to 1., slight or no ny. to r. Temp. 37.7. July 30 : Patient feels decidedly better. Vertigo only on standing. Ny. diminished. Rotat. ny. to 1., no ny. to r. Temp. 36.737.4. 100 DISEASES OF THE LABYRIXTH July 31 : No vertigo. Kotat. ny. to 1. 37.8. Aug. 1 : No vertigo. No ny. 37.5. Aug. 3 : First dressing. Wound shows no reaction. No vertigo, no ny. Temp, normal. Aug. 5 : Second dressing. Wound shows no reaction. No vertigo, no ny. Aug. 7: Patient feels well. Transferred to out-patient department. Aug. 11: Dressed. Few granulations. Whisp.v. well heard with conversation tube. No vertigo, ny. with large movement of eyes to both sides, stronger to the 1. than to the r. Aug. 13: Dressed. No vertigo. Slight rotat. ny. to r. Wound without reaction. Aug. 30: W T ith conversation tube hears Whisp.v. without error. No vertigo or ny. Sept. 1 : No vertigo, no spontaneous ny. With conversa- tion tube hears Whisp.v. repeated without mistakes. With cold water, slight if any reaction. Turning to r. = = rotat. after-ny. to 1. Duration, looking forward = 15". Sept. 14: No vertigo, no spontaneous ny. With conver- sation tube Whisp.v. repeated with few mistakes. Turning to 1. = horizontal after-ny. to r. 12". Turning to r. = hori- zontal after-ny. to 1. 12". 10 revolutions to 1., head forward, = rotat. after-ny. to r., 13". 10 revolutions to r., head forward, = rotat. after-ny. to 1., 13". The horizontal ny. after rotation is alike on both sides and consists of small movements. The rotat. ny. after turn- ing is likewise equal, but of coarser movements of the eyes. Both sides react aHke after cold water irrigation. Sept. 20: Hears less than before. With conversation tube, con.v. heard with mistakes ; small spontaneous rotat. ny. to both sides. Turning to 1. : Horizontal after-ny. to r., 11". Turning to r. : Horizontal after-ny. to 1., 19". Head inclined forward, after 10 revolutions to 1., rotat. ny. to r., 13". CASE HISTORIES 101 Head inclined forward, after 10 revolutions to r., rotat. ny. to 1., 18". Second admission to hospital Mch. 8, 1909. Anamnesis: Nine months after the operation, discharge from ear returned. Local treatment caused cessation for a while, but discharge soon began again. Patient states that he had vertigo only four weeks after first operation; none since. No emesis, and headache only when the dis- charge ceases. Never has fever. Status praesens: L. ear: membrane normal. R. ear: Retro-auricular scar. Granulations fill antrum and tym- panic cavity. No fever. L. ear normal; r. ear deaf for speech and tuning forks. "VT. in the head. E. bone conduc- tion shortened, d = 0. C 4 = 0. F.t. negative. C.r. prompt, with vertigo. Operation, Mch. 13 (Tint tin] : Skin incision through the old scar. Periosteum, altered by scar, pushed aside. Sinus and dura of posterior cerebral fossa at the level of the upper bend of the sinus as large as a heller piece lies ex- posed, and this area is drawn by scar tissue into the cavity. In the opened antrum and tympanic cavity, abundant cholesteatomatous masses. After curetting these away, there is visible, on the horizontal semicircular canal, a cap- like, yellow, sharply defined exostosis, which plainly closed the former fistula. Facial prominence smoothed. Eusta- chian tube curetted. A typical plastic retro-auricular closure of the wound. Dressing. After the operation no ny. except the narcosis ny. Very carefully watched for sev- eral days. No vertigo. Mch. 14, 37.6; Mch. 15, 36.7; Mch. 16, 36.0; Mch. 17, 37.5. First change of dressing. Cavity shows granulations, some discharge. C.r. typical. Total deafness. Temp, is normal. 2, K. V. Age 29. Admitted Dec. 5, 1907. Anamnesis: Occasional discharge for fifteen years. Suf- fers often from vertigo. Status praesens: L.e. : A large polyp fills the lower part of the external meatus. Abundant discharge. At present 102 DISEASES OF THE LABYB1XTII the patient suffers little pain, though previously she had severe headache, particularly over the I.e. R.e. is normal. Functional test: R.e. normal. L.e. deaf for speech and tuning forks. AV. lateralized to 1. R. . Sch. shortened. Ci 0, C 4 0, spoilt, ny. rotatory to 1. C.r., after prolonged syringing, 0. After tr. r., ny. 1. = 12", after tr. 1., ny. r. = 12". The fistula symptom was easily demonstrated yes- terday. Ny. rotat. 1. Now no vertigo, according to pa- tient's statement. But only two days ago, when she was urged to enter the hospital, which she tried to avoid, she stated that she frequently had severe vertigo. She has also lately been forgetful. Neurological findings: Patellar reflex absent. Sugges- tion of ataxia in r. arm. Fundus normal. Operation, Dec. 6 (Prof. Urbantschitsch) : Typical radi- cal operation. Sinus lies far forward. It is exposed about 2 cm., showing its wall to be normal. Exposure of the dura of the posterior fossa in front of the sinus, and of the mid- dle fossa the size of a heller. The dura of the middle fossa covered with slight exudate. The dura of the posterior fossa normal. Typical labyrinth operation.* Abundant discharge of fluid from the labyrinth. In the horizontal semicircular canal at the juncture of the lateral and median portions there is a fistula, discolored brownish black, about 1 mm. long, whose patency is demonstrated with a probe. Plastic; dressing. After the operation, ny. rotatory r., large and rolling; vertigo, emesis, patient lies on her right side. Dec. 7: Temp. 37.7. Dec. 8 : Ny. not so marked. Temp, normal until Dec. 12. Dec. 12 : Temp, rises to 38.0. Dec. 13 : First dressing. Ny. diminished, but quite marked on looking toward the healthy side. Dressing some- what permeated by the liquid. No secretion. Beginning discharge. Temp. 38. *Here, as in all the following case histories, we understand by "\\ pit -;il laby- rinth operation" the method of Neumann, but, upon principle, not extending to the internal auditory nieatus. CASE HISTORIES 103 Dec. 15: Second dressing. Slight discharge. Tempera- ture normal. Dec. 17: Dressed. Transferred to out-patient depart- ment. 3. M. U. Age 58. Admitted Jan. 3, 1908. Anamnesis: R.e. diseased for two years. For a time, discharge. Two months ago severe discharge again came on, together with vomiting and severe vertigo, and very severe pains in the head on the right side. Status praesens: R.e., large perforation in posterior quadrant into the antrum and attic. Mucus membrane granulating. Lower portions preserved; short process of hammer visible. L.e. normal. Temperature: 37.2. Functional test: L. normal. E. Con.v. ad concham. "\V. rt., E. + G! +, C 4 -f- ; spontaneous ny. horizontal to both sides, with rotatory component on looking to 1. Fistula test -)-, with vertigo and nausea. Caloric reaction +. Operation, Jan. 4, 1908 (Prof. Urbantschitsch) : Typical radical operation. Cholesteatoma in the widened antrum. In the horizontal semicircular canal at an angle of 45 with its axis a fistula about 4 mm. by 1 mm. The dura of the middle fossa lies low. It was exposed for an area the size of a heller, and is normal. Sinus not exposed; no ossicles. Temperature: Jan. 4, 38; Jan. 5, 37.6 and 36.4. Jan. 6: Ny. toward healthy side. Temp. 37.1. Jan. 7 : Temp. 37.3 ; Jan. 8, 36.4, 37.4. Jan. 9 : Dressing changed because of temp, of 38.2. Deaf when tested with exclusion apparatus. Labyrinth does not respond (syringed at 24). Xy. to healthy side unchanged. Fistula still demonstrable. Jan. 10 : Temp. 36.8, 38.0. Jan. 11, 37.5, from which date it is practically normal. Feb. 2, 1908: Xo. ny. Condition good. Transferred to out-patient department. 4. M. H. Age 30. Cashier. Admitted Jan. 28, 1909. 104 DISEASES OF THE LABYRIXTH Anamnesis: Discharging ear one year ago, with pains on both sides, improved under treatment. A few days ago, following a coryza, severe pain behind left ear. More re- cently also continuous tinnitus, vertigo and attacks of faint- ing. Previously she had from time to time vertigo with apparent movement of objects, nausea, anorexia. Status praesens: L. : Griesinger's symptom. Jugular re- gion sensitive to pressure. Internal and neurological con- dition normal. B.e. normal. L.e. chronic suppuration. Functional test: Con.v. 2 m. Whisp.v. ad concham; buzzing noise in jugular audible. AV. 1., E. . Bone con- duction scarcely lengthened, d 0, C 4 , when struck hard. Vertigo. No spont. ny., no fistula symptom. Caloric ny. prompt. Operation, Feb. 1 (Prof. Urbantschitsch) : Pneumatic mastoid. Exposed sinus normal, only at one small point adherent to the bone; attempt at removing this caused bleeding. Feb. 2 : Pain in 1. arm. Eotatory ny. to r. and 1. about equal. Feb. 3: Pain in 1. shoulder. Better 'in the arm. Ny. equal. 37.0, 39.1. Feb. 4: Headache, ny. equal; 38.8. Emesis. Dressing changed. The sinus, where exposed, yellow. Diagnostic puncture of sinus. Circulation in sinus diminished. Liga- tion of jugular vein. Thrombus cleared out. Excision of outer wall of sinus after packing. (During anaesthesia, the caloric test was made. Typical result.) Feb. 5: Headache less. Ny. as before. Emesis slight. 36.5, 37.7. From now on temp, normal, except for occa- sional elevations to 37.4. Feb. 6: Headache. Neck sensitive. Dressing changed. Packing removed from sinus. No bleeding. Cal. react, typical. Hears con.v. (with exclusion test and conversation tube) perfectly. "VV. 1. Middle fork not heard near ear. C t 0, C 4 0. Feb. 7 : Feels well, slight headache. Feb. 8, same. Feb. 9: Evening, headache. Ice cap. Morphine. CASE HISTORIES 105 Feb. 10: Severe headache at vertex and occiput. Pulse 64. Pupils small and react poorly. Suggestion of ataxia of the upper and lower extremities. Eeflexes exaggerated. Skin somewhat hyperesthetic. 'Spine sensitive to pressure. Kernig negative. Feb. 11 to 12 : Alternating periods of headache and free- dom from headache. Pains are controlled by morphine. Urine negative. Wassermann negative. Thrombus, sterile. Feb. 13 : Pulse 96. Patient lies more upon right side, and says she has headache and vertigo on standing or lying on left side. Xy. rotat. r. = ny. rotat. 1. Neurological exam, negative, except for ataxia of upper extremities. Dressing changed. Inner wall of sinus heavily covered with exudate. Feb. 14 to 17: Patient feels well. Slight vertigo, still present on standing. Dressing changed. Eminence of lateral canal not granulating. Median wall of sinus in re- gion of the resection of the lateral wall stretched and dis- colored. Mch. 4: The deposit in the sinus gradually clears and the patient feels better from day to day. Headache gradually less. Mch. 11: Transferred to out-patient department. June 24, 1909 : Patient again admitted because of vertigo coming on, often so severely as to make her believe she might fall upon the street. The vertigo persists in the hospital, appearing especially upon suddenly moving the head; occasional headache. Sensation of dullness in head. Marked vertigo on changing dressing. Fistula symptom present with typical ny. to diseased side on compression. C.r. prompt. Spontaneous ny. to both sides. Operation, July 8, 1909 (Prof. Urbantschitsch) : Granu- lations over lateral semicircular canal and in the tympanic cavity. Fistula plainly visible in horizontal canal. Semi- circular canal at site of fistula and the promontory opened. As the latter was opened, a drop of pus appeared in the labyrinth. Immediately .following the operation there is noticeable rotat. ny. to r. side, and a much quicker, smaller nv. to the 1. 106 DISEASES OF THE LABYRISTH July 8: 7 P.M. Xy. unchanged. Vertigo on turning. Pulse irregular, 82. July 9 : Kotat. ny. r. perhaps more marked than yester- day. Pulse strong, regular, -84. July 10: Rotat. ny. r. quite marked. Smaller ny. to 1. still present, July 12: ny. r. weaker; 1. only occasional. July 13 : Condition the same. Patient gets up. July 14 : At change of dressing, very minute quantity of pus present. Patient has severe pain on touching the inner tympanic cavity ever so lightly. After dressing, marked rotat. ny. to diseased side. No ny. to well side. July 15 : Ny. only upon looking to 1. and down, and to r. upward of about equal strength. On walking, vertigo, ap- parent rotation of objects to the r. and downward. Head- ache chiefly in the 1. parietal region. July 17: Dressing changed. Wound in good condition. After dressing, decided rotat. ny. 1., slow rotat. ny. r. Feels relatively well. July 21 : Condition the same. Headache. July 24 : Ny. to diseased side very marked after dressing. July 28: Dressed. Patient complains of pains in parie- tal region and occiput. Small rotat. ny. to both sides. July 30 : Transferred to out-patient department. Three weeks later there is still vertigo, which gradually diminishes. Patient able to walk upon street with greater confidence than before. While before she had vertigo even while lying down, now this is felt only when she moves suddenly and objects seem to turn to the 1. Since early in August, vertigo appeared quite seldom, and since early September, even after rapid movements, she is free from vertigo. No emesis since July 30. Now there is only headache, irregular in its appearance and without special cause, radiating from both sides into the occipital region. Such an attack lasts one to two hours. Oct. 27: Entirely free from vertigo, even on sudden movement of head. CASE HISTORIES 107 5. Z. Admitted Nov. 26, 1907. Anamnesis: Discharge from r. ear one year ago. Then vertigo for two weeks; since then no vertigo. Occasional tinnitus. For past three months no tinnitus. Severe phthisis. Status praesens: R.e., total destruction, foetid suppura- tion, polyps. L.e. opaque and retracted. Functional test: L. normal. E. deaf for speech and tun- ing forks. W. r., R. . Rotat. ny. 1., Sch. 20", shortened ; caloric ny. prompt (little vertigo) ; fistula' symptom -{-, and ny. to 1. on compression. Feb. 16, 1908: Same findings, except reversed fistula symptom. Compression ny. to r. 6. W. J. Age 40. Mason's helper. Admitted Aug. 24, 1908. Anamnesis: Three years ago, discharge 1. R.e. healthy. Vertigo, particularly on bending forward. No fever, no other symptoms. Status praesens: R.e., normal. L.e., membrane cloudy and retracted, in places thickened; around the umbo, a semi- lunar scar. No perforation visible. Functional^ examination: Con.v. 2 -- 3 m. W. 1., R. ; d +, C 4 +, both sides requiring a heavy blow to the fork to make it audible. No spontaneous ny. Fistula symp- tom +, reversed, on compression, ny. rotat. r. ; on aspira- tion, ny. rotat. 1. Aug. 31 : Patient, upon his request, dismissed without operatiop. 7. A. Z. Age 21. Waiter. Admitted Oct. 10, 1908. Anamnesis: Ten years ago, following scarlet fever, dis-r charge from 1. ear, lasting about one year. Treated as out- patient. Two weeks ago, severe, foetid discharge again ap- peared. Headache for four days. Yesterday, emesis seven times, with attacks of vertigo. To-day, chills. Status praesens: R.e., normal. L.e., drumhead totally destroyed; cholesteatoma. Functional test: Con.v. 0, Whisp.v. 0, no tinnitus, W. r., 108 DISEASES OF THE LABYRINTH E. . Bone conduction shortened, d 0, c 4 0; no fistula symptom. Cal. react, present, with vertigo. Temp. 40.2. Chills. Operation, Oct. 11 (Prof. Urbautschitsch) : Typical radi- cal. Mastoid sclerotic. From the region of the sinus, gray- ish-green, foetid pus, mixed with gas and under heavy pressure. Exposure of sinus, which is discolored a green- ish-yellow, and is perforated at one point. Ligation of jugular. Exposure of the sinus to where it is healthy, and of the dura in front of and hehind the sinus. The thrombosed sinus opened and cleaned out until there is severe bleeding from above and moderate hemorrhage from below. Dressing. Until Oct. 15, temp, normal and condition good. Oct. 15 : Chills. Temp. 38.9. Packing removed, no hem- orrhage. Jugular sewed after Alexander's method. Irri- gation. Dura of posterior fossa covered with exudate. Sinus groove, visible. Median sinus wall discolored yellow. Oct. 16: Temp. 38.1. Oct. 17: Temp. 37.5. Dressing. Temp, from now on normal. Nov. 6 : Transferred to O.P. Dept. Feb. 12, 1909 : Again admitted. Anamnesis: After the operation, the discharge ceased for six weeks. Eight days ago, recurrence of the discharge, with pain in 1. ear and vertigo. Status praesens: Abundant granulations in the wound cavity, but they do not prevent a view of the deeper parts. Region of the semicircular canal epidermized. Functional test: Con.v. 3 m., whisp.v. 1 m., tested with exclusion apparatus; I.e. deaf for speech. W. 1., E. . Bone conduction somewhat lengthened. Ci and c 4 slightly perceived. Past two days no vertigo. Spont. ny. 0. Fis- tula symptom -4- and reversed, i.e. on compression, rotat. ny. 1. Cal. ny. typical. Both sides equally syringed 25, ny. 1. after y 2 ', and after continuing the syringing 5' no change in the 1. ny. Patient says he is not dizzy except on looking to the 1. On stop- CASE HISTORIES 109 ping the syringing, vertigo. The ny. lasts about I 1 // longer. Temp, normal. Feb. 13: Temp, normal. Feb. 14, Temp. 38.2; Feb. 15, 38.1; Feb. 16, 36.2; Feb. 17, 38.1. Granulations removed. Anaesthesia with '20% cocain. Because of pain, complete removal impossible. Feb. 18, Temp. 36.8; Feb. 19, 38.4; Feb. 20, 37.7; Feb. 21, 36.0; Feb. 22, 38.0; Feb. 23, 36.6; Feb. 24, 37.3; Feb. 25, 38.2; Feb. 26, 36.1; Feb. 27, 37.7; Feb. 28, 37.1. From then on normal, until Mch. 4, 37.8, when there was an angina. M.-li. 22: Transferred to O.P. Dept. 8. J. V. Age 24. Servant. Admitted Oct. 15, 1908. Anamnesis: E.e. discharged in childhood, but not re- cently. Seven weeks ago, patient was taken with pains and noises in r.e., but without discharge. Two weeks later a swelling appeared behind the r.e., which was opened by his physician. One week later, discharge appeared from ear. Status praesens: L.e., normal. R.e., behind the ear an adherent scar about one cm. long. No swelling. Quite abundant creamy, bad smelling discharge. Large perfora- tion in ShrapneU's membrane; the rest of the drumhead intact. Functional test: Hearing distance 6 m. (exclusion ap- paratus left). W. in head, R. . Sch. lengthened, d short- ened, c 4 shortened, rotat. ny. 1. on looking to 1. Fistula symptom +, typical. Xo vertigo, no tinnitus. Oct. 20, Operation (Bondy) : Fistula of mastoid. Choles- teatoma. Dura of both fossae extensively exposed and cov- ered with granulations. Tip, filled with granulations, is resected. Posterior meatal wall removed up to annulus tyinpaniciis. Lateral attic wall removed. Attic cleaned, but ossicles left. Xow there is visible at the ampulla of the horizontal semicircular canal a small circular opening with black discolored walls. Upon pressing at this point with a sponge, there follows a slow, rolling movement of the eyes to the healthy side. Plastic after Panse. 110 DISEASES OF THE LABYRINTH Afternoon: Temp. 36.8. Patient feels comfortable. No emesis or vertigo ; slight spontaneous ny. to both sides. Pa- tient hears con.v. perfectly. Oct. 21 : No pain, vertigo or ny. ; afebrile. Con.v. well heard with exclusion apparatus in healthy ear. Oct. 22: Temp. 38.8. First dressing. Wound normal. Pressure on fistula gives active ny. to diseased side. Con.v. perfectly heard. Oct. 26: Dressing. Abundant discharge, somewhat foetid. Wound shows granulation begun. Details of the tympanic cavity are lost. No spontaneous ny. ; no vertigo ; hearing perfect. Fistula symptom plainly shown by pres- sure. Light packing. Nov. 4: Fistula symptom still present. Cal. react, typi- cal. Some spontaneous rotat. ny. to both sides. Whisp.v. 4 m. Nov. 10: Discharged. Nov. 30 : Inspected. Attic and antrum epidermized. Fa- cial prominence granulating. Small granulations in the horizontal semicircular canal. Prompt cal. react. Hear- ing: Whisp.v. 8 m., con.v. 12 m. Fistula sympt. still typical. 9. R. O. Age 20. Admitted Oct. 17, 1908. Anamnesis: Chronic suppuration; increased discharge during past eight days. Pains in head and mastoid region at intervals. Status praesens: L.e., normal. R.e., cholesteatoma in attic. Functional test: Con.v. 2y 2 m., whisp.v. 1 m. W. r. ; R. . Bone conduction shortened. No spent, ny. ; no ny. on mov- ing head. No fist. symp. Cal. ny. typical. Temp, normal. Operation, Oct. 17 (Bar any] : Opening of antrum, but preserving the tympanic cavity. Cholesteatoma in the antrum. No fistula in the horizontal canal. Oct. 18 : Temp. 38.2. Dressing. Oct. 20: No fistula symp.; no more vertigo. Slight ny. to diseased side. CASE HISTORIES 111 Xov. 3: Daily dressing until now. Much discharge. Transferred to his physician. Xov. 10: Marked fistula symptom; occasionally slight vertigo. Jan. 31, 1909: "Wound, cavity entirely epidermized. Xo fistula symptom. Whisp.v. 6 m. Xo spontaneous vertigo. Temp, normal since first change of dressing. 10. J. G. Age 17. Anamnesis: Scarlet fever at age four. In eighth year parents first noticed that child did not hear well, particu- larly on r. side. Oct., 1908, pain in 1. ear, and there was an "abscess." Kxumined recently as a private case by Dr. Neumann. who diagnosed normal caloric reaction and turning reac- tion on both sides. Total deafness r. Greatly diminished hearing 1. Nov. 15, 1908: I Admitted patient, and found the fol- lowing. R. drumhead cloudy and retracted, scar in poste- rior superior quadrant. L., external diffuse otitis. Abundant purulent secretion. Membrane not visible. Con.v. : r. 0, 1. 0. E. totally deaf with exclusion apparatus and conversation tube. L., words shouted ad concham were heard. Also loud words through the conversation tube. "W. 1. ; d not heard next to r. ear, but heard a few seconds 1. Bone conduction transmitted from r. to 1. side, and greatly shortened ; c 4 , both sides + when the fork is heavily struck. Tested with the continuous tone series, c 3 and d 3 heard posi- tively; but tested with Urbantschitsch's harmonica, all tones (six octaves) are heard 1. Absolute deafness r. Very marked rotat. ny. r. Cal. r. O (carefully tested for heat and cold). The ny. increased by head movements; severe vertigo with every movement. Cannot stand without help, and has to be held in chair. L. typical fistula symptom with quick component 1. and slow component r. Turning ny. not demonstrable. 112 DISEASES OF THE LABYRINTH Because of vertigo, patient has to be tied to chair for turning test. Complains of constant tinnitus. Nov. 6: Rotat. ny. to r. changes in intensity. Severe vertigo with every movement. Patient lies more upon his right side. On attempting to get out of bed, rotat. ny. r. ceases a short time, and for a moment severe rotat. ny. 1. appears, soon giving way to rotat. ny. r., as before. Repetition of tests gives result as yesterday. Equilib- rium test also made as follows: With head straight, falls to 1. With head held to r., falls forward. With head held to 1., falls backward. Fistula symptom present like yesterday, but, upon pres- sure, there occurs a ny. to 1. lasting longer than the pressure. Galvanic Ny. : Anode to r. ear, kathode in r. hand, no noticeable effect upon the spontaneous ny. Kathode to r. ear, anode in r. hand, no noticeable effect upon the spontaneous ny. Anode to 1. ear, kathode in 1. hand, no noticeable effect upon the spontaneous ny. Kathode to 1. ear, anode in 1. hand, very noticeable rotat. ny. to 1. Divided anode to both ears, kathode in hand, no visible effect upon spontaneous ny. Divided kathode to both ears, anode in the hand, very plain ny. to 1. Direct transmission, kathode to r. ear, anode to 1. ear. rotat. ny. r. apparently stronger even with eyes directed forward. Anode to r. ear, kathode fo 1. ear, rotat. ny. very distinctly to 1. Current up to 8 M.A. Nov. 17: Totally deaf for exclusion apparatus, for con- versation tube and for all tones of the continuous series and for the harmonica. Fistula symptom no longer demon- strable. Severe spont. ny. to r., which no longer changes, and remains the same in all positions of the head. Patient does CASE HISTORIES 113 not complain that movements of the head cause vertigo, as on the first day. Cal. react, both sides 0. Turning reaction both sides 0. Galvanic reaction 0. 8 M.A. Nov. 18: Totally deaf. Rotat. ny. as before. Vertigo decidedly less. Can walk, eats without nausea or emesis. Frequently lies upon his back. Previously wa$ inclined to lie on right side. Equilibrium disturbances typical, i.e. falls to 1. with head forward. With head to 1., falls backward; falls forward with head turned 90 to r. Nov. 19: From bass f to c 3 (harmonica) traces of hear- ing remain. The same Nov. 20. Nov. 21 : Totally deaf. Cal. react, lost. Spontaneous ny. r. still large. Typical equilibrium disturbances, but less marked. Prefers no special position in bed. Complains of head noises. Nov. 23 : Deaf. No reaction. Galvanic test yields no re- sponse. Spontaneous ny. r. decidedly diminished. Dis- turbances of equilibrium now only slight but typical. Typical labyrinth operation 1. Immediately after opera- tion, no severe disturbances. Moderate emesis, no vertigo, only pains. Until 4 P.M. (operation was at 12 M.), anaes- thesia ny. r. and 1. Then ny. r. 11. I. M. Age 18. Butcher's helper. Admitted Nov. 4, 1908. Anamnesis: For eight years occasional discharge 1. Dur- ing past three to four weeks, pain and vertigo. Status praesetts: L., total destruction of drumhead. Granulations and cholesteatoma. Con.v. (with exclusion apparatus) 1 m., whisp. a.c. W. r., R. . Bone conduc- tion shortened, d 0, c 4 0. No spontaneous ny. Bending head backward causes ny. r. Fist, symptom -f-, but re- versed, i.e. compression gives severe horizontal ny. r., and aspiration weaker ny. 1. Cal. react, typical. Temp, normal. Xov. 10: In view of the hearing and reaction, only the radical operation was at first performed. The dura of the middle fossa was very low, a large cholesteatoma occupied the antrum, and there was a fistula in the horizontal semi- 114 DISEASES OF THE LABYFIXTII circular canal. During the following days there was fever, over :->S , headache, marked ny. to the healthy side, some rigidity of the neck and sensitiveness of the spine upon pressure. On change of dressing, patient was found to be totally deaf and the calor. react gone. Thereupon (Nov. 13) the labyrinth operation was performed (Ruttin). Neu- mann's method was followed, and because of the rigidity of the neck, the operation was carried to the internal audi- tory meatus. The operation was especially difficult because of the position of the dura. Owing to the admixture with blood, the labyrinthine fluid could not be examined. The facial nerve after the operation was entirely intact. Dur- ing the following six days, reduction of fever, pulse about 100, subjectively patient was comfortable. Neck no longer sensitive to pressure. Ny. to healthy side. On the seventh day, suddenly headache appeared, with slight ny. to the diseased side. Emesis. Temp, normal, pulse 70. Nov. 20: Patient, in the forenoon, is apathetic; notice- able ny. to diseased and healthy side. In the afternoon, pa- tient is better, sits up and plays cards. Nov. 21 : Pain in occipital region, neck stiffly held with- out special rigidity. Ny. 1. of variable intensity. Nov. 22 : Occipital headache. Head rigidly held. Apathy. Strong ny. 1. Lumbar puncture gives clear cerebro- spinal fluid. Pulse 68. Incision of the cerebellum in the region of the posterior pyramidal surface empties an abscess nearly the size of a plum located in the 1. cerebellar lobe. Counter-incision behind the sinus and drainage. Nov. 25: Death. Postmortem (Prof. Stoerk) : Abscess of 1. cerebellar hemisphere completely drained, oedema of the neighboring cerebellar region, hemorrhagic encephalitis in the corpus callosum, severe chronic internal hydrocephalus, oblitera- tion of convolutions, no meningitis. Streptococcus pyogenes in the pus. 12. H. P. Age 68, Clerk. Admitted Oct. 15, 1908. Anamnesis: Eepeated attacks of discharge from 1. ear CASE HISTORIES 115 during past twenty years. Five months ago a swelling ap- peared behind the 1. ear. Vertigo since last of Sept. Dur- ing past day, emesis and vertigo. Status praesens: Posterior superior meatal wall de- pressed. Membrane red and swollen. Perforation not visi- ble. Con.v. a.c., whisp.v. 0. Middle tuning fork not heard next the ear. Ny. variable, to the r. and 1., regularly rota- tory. On bending head to 1., rotat. ny. to 1., and on inclina- tion to r., weaker ny. to r. Slightest fistula symptom. Cal. ny. very severe and of long duration. Temp, normal. Operation, Oct. 20 (Ruttiu) : Large extradural abscess of posterior fossa extending around the sinus. A fistula could not be found. Oct. 21 : Patient feels comfortable. Temp, normal. Pulse 106, occasionally intermittent. No ny. Oct. 22 : A.M., very marked rotat. ny. to r. with large excursion of eyeball, for all positions of eyes. Patient lies on the r. side. Dressing changed. Patient is totally deaf. W. 1. Middle tuning fork not heard. Low fork not heard; c 4 only when struck hard. Cal. react, elicited plainly by hot saline solution. Marked spontaneous vertigo. Emesis on sitting up. Oct. 22: Dressing changed. Cerebellar dura somewhat covered with exudate. Rotat. ny. r. with eyes to r. and forward. Patient lies on r. side. Vertigo on standing up. Oct. 23 : Ny. to r. on looking to r., but not on looking for- ward or to 1. Slight vertigo on standing. Oct. 24: Dressing changed. Wound as above. Cold saline gives typical reaction. Ny. r. with eyes in every direction. Oct. 25 : Ny. to 1. Gait wavering. Vertigo. Suspect cerebellar abscess. Oct. 26: Neurological examination (Dr. Ekonomo) : Noth- ing definite; perhaps a trace of ataxia of the lower ex- tremities. Fundus normal (Dr. 0. Ruttin). Oct. 27 : Patient suddenly becomes unconscious. "Weak tremor of r. hand, particularly of the fingers. Pupils con- tracted, do not react. No ny., no deviation. Temp, normal, pulse 120. 116 DISEASES OF THE LABYRIXTH Operation, with patient unconscious, without anaesthetic (Ruttin): Typical labyrinth operation. Incision of cere- bellum opposite the posterior surface of the pyramidal bone. Abscess emptied of several tablespoonfuls of thick, yellow, non-fetid pus. Counter-opening back of sinus and drain- age. With the finger in the cavity, a second smaller abscess located more to the rear was opened and drained. About one iiour after the operation the patient returned to con- sciousness. No ny., pulse 104, temp, normal, no paresis. Five hours later (11 P.M.), we have the following: Rotat. ny. to r. Pupils react slowly to light, also to accommoda- tion. Eye muscles intact. Corneal reflex active, hoarse- ness, tongue and palate not coated, laryngosropir exam, im- possible. Thick mucus causes cough. Rough breathing heard over lungs. Temp, normal, pulse 104. Patellar re- flexes very active. Babinski 1. clearly positive. Deep re- flexes not demonstrable. Ataxia of the 1. extremities, par- ticularly of the upper ones; abdominal reflex and cremas- teric reflex 1. not demonstrable, r. prompt. Sensorium clear. Oct. 28: Neurological exam. (Dr. EL'oth sides, 25, rotat. ny. r. after 10", continuing during 5' longer s\ i-inuinu'. Quantity of water used 390 c.c. for each side. CASE HISTORIES 119 Operation, Jan. 27 (Prof. Urbantschitsch) : Mastoid within entirely destroyed. Typical radical operation. Some sequestra removed from antrum. In the horizontal semicircular canal an elongated fistula, several millimeters in length, discolored brownish-red, and having sharp edges. All diseased bone removed. Plastic. Jan. 28 : Patient feels comfortable. Vertigo only upon standing. Rotat. ny. L, large movement on looking to L, small, on looking straight forward, and smallest on looking to r. Slightly increased on sitting up. Patient lies upon back. No emesis. Jan. 29: No ny. lying down. No vertigo, only slight diz- ziness on sitting up. During the entire stay in hospital, regular evening rise in temp, (tuberculosis). 16. E. T. Age 62. Female. Inmate of almshouse. Ad- mitted Feb. 2, 1909. Anamnesis: Discharge during past half year. Frequent headaches. Four weeks ago, blood in discharge from ear. Then patient had vertigo for first time, when objects seemed to move to the r. Fourteen days ago she noticed that in the morning her mouth was one-sided. That morning she had severe vertigo. She staggered on walking, and took to her bed. She vomited, and stated she had the sensation of being in the water. Since then, frequent attacks of vertigo, when objects seem to turn about her. At first, these attacks were less frequent; later, more often. Frequent tinnitus. Status praesens: Internal and neurological findings nor- mal. Facial paresis 1. R.e., normal. L.e., total destruction of the membrane. Polyps in the inner wall of tympanum. Functional test: With exclusion apparatus, deaf. W. r., R. - - (transferred to sound side). Sch. shortened. Xo spontaneous ny. Cal. react. 0. Tr. r. = horizontal ny. 1. lasting a few seconds. Tr. L == horizontal ny. r. 15". Tin- nitus and vertigo. Fistula symptom + ; on pressure, severe rotat. and horizontal ny. to 1., which continues during the succeeding aspiration. Aspiration alone gives no reaction. 1-20 DISEASES OF THE LABYRINTH Xy. produced by simply introducing 1 the tip of apparatus into the ear. On compression, we note this difference from the ordinary : The ny. does not immediately attain its maxi- mum of intensity, but increases for several seconds, then gradually subsides, corresponding to an attack of uy. Temp, normal. Feb. 3, Temp. 38.0; Feb. 4, normal. Feb. 4, Operation (Ruttin) : Mastoid pneumatic, with its cells filled with granulations. The walls in part necrotic. Typical radical operation. In the horizontal semicircular canal, a fistula larger than a pin-head with discolored edges and permitting the passage of the labyrinth sound. Typical labyrinth operation. The sinus lying well posterior, ex- posure of the dura of the posterior fossa is not required. It is sufficient to open the vestibulum from behind, without exposure of the dura. Many cells of the tegmen antri and tympani, filled with granulations, are removed with the chisel. Sinus exposed for 2 cm. Its wall is normal. After the operation, in the evening, emesis, vertigo. Temp, now and later, normal. Feb. 5 : Rotat. ny. r. ; emesis, vertigo, nausea. Feb. 6: Same. Feb. 7 : Eotat. ny. r., less vomiting, headache, lies upon back. Feb. 8: Rotat. ny. r. less, headache better, no emesis, Haematoma 1. lower eyelid. Feb. 9: Rotat. ny. r. quite marked. Haematoma the same. Headache less. Feb. 10: Rotat. ny. r. like yesterday. Feels well. Out of bed. First change of dressing; no discharge. Wound bleeds, slight inflammation of edges of wound. Feb. 19: Ny. practically gone. Facial as before opera- tion. Transferred to O.P. Dept. 17. M. P. Age 29. Servant girl. Admitted Feb. 14, 1909. Anamnesis: Discharge from both ears since scarlet fever at age 3. "Worse recently. Vertigo, with loss of conscious- ness. Patient cannot recall when she first had vertigo. CASE IHSTOEIES 121 Status praesens: R.e., total destruction of the drum mem- brane. Inner wall covered with granulations. Thin fetid secretion from antrum. L.e., polyp obstructing the canal. Functional test: Con.v., r., li/ 2 m. ; 1., y 2 m - AVhisp., r., a.c. ; 1., 0. "W. r., R. . Bone conduction lengthened on both sides; d r. -f ; 1. ; c 4 r. -f-, 1. . Now no vertigo. No. spont. ny. Cal. react, prompt. R. fistula sympt. +, typical on compression, with rotat. ny. r. Aspiration gives no clear reaction. Fistula symptom only at times present. Temp, normal. Operation, Feb. 16 (Prof. V rb ants chit sch) : L. typical radical operation. Nothing of special interest. R. in the antrum granulations and pus. In the horizontal semicircu- lar canal, a small semicircular dehiscence, not admitting a probe. Temp. 37.7. Feb. 17 and 18 : Patient feels well. No vertigo or head- ache. No ny. Temp. 37.7, 37.8. Feb. 19-22: Patient feels entirely well. Temp. 36.2, 37.9, 37.0, 37.4. Feb. 23: Temp. 37.9. Feb. 24: Transferred to O.P. Dept. Temp. 36.7. 18. M. Z. Age 44. Admitted Feb. 16, 1909. Anamnesis: Discharge from r. ear for about fifteen years. 1896, polyps were removed at this clinic. Pains dur- ing past three months. During past month, increased puru- lent discharge and vertigo. The vertigo comes in attacks, when patient always falls to r. Headaches for years, in- creased past two to three months. Hearing reduced re- cently. Patient has always heard poorly with 1. ear. Never any discharge from this ear. Temp. 37.5. Status praesens: Feb. 17, I.e., clouded membrane, greatly retracted. R.e., abundant, fetid, purulent discharge. Ex- tensive destruction of membrane, only upper portion with short process and small part of hammer handle preserved. Functional test: L.e., words shouted heard a.c. W. in the head; R. , Sch. shortened, d and c 4 much shortened; spont. ny. 0; fistula test 0. R.e., deaf, R. ; Sch. short- 122 ened ; Ci 0, c 4 heard only by striking fork with metal. Fis- tula test +. Cal. react, typical. No ny. on moving head; severe tinnitus in both ears. After tr. r., ny. 1. 15". After tr. 1., ny. r. 15". Temp. 36.7. Feb. 18: Syringing both sides, 25, rotat. ny. r. very marked, duration about 2', strong, then decreasing for 5', when syringing is stopped. After 5' some rotat. ny. 1., after 6', again rotat. ny. r., weak; during the syringing, no vertigo. Operation, Feb. 18: Mastoid sclerotic. In the antrum, cholesteatoma size of cherry. In the horizontal semicircu- lar canal, an area 2 3 mm. long, which in its anterior part is a permeable fistula, in its posterior part only thin canal prominence, through which one can see the membranous canal. Middle fossa exposed to less than size of a one heller piece. Plastic. Dressing. Temp. 37.6. Feb. 19 : Eotat. ny. r. and rotat. ny. 1. To the right it is more of a ny., while to the left it is more of a rolling move- ment of the eyes, with equal rolling to and fro. Temp. 37.2. Feb. 20 : Eye movements are still the same. Some ver- tigo. Temp. 36.3. Feb. 21 : No vertigo, except on standing. Temp. 37.3. Feb. 22 : No ny. Temp. 37.5. Normal af ebrile course. Feb. 27 : Transferred to O.P. Dept. June 14, 1909: W. in head. R. ; d 0; c 4 0. Tested with exclusion apparatus, deaf. L. tr. = 0. K. tr. = marked ny. Kathode divided. Anode on forehead = rotat. ny. r., 10 M.A. Anode divided. Kathode on forehead = rotat. ny. 1., 10 M.A. Indisputable and Anode r.e. 4 M.A. Rotat. nv. 1. Kathode r.e. 2 M.A. = Rotat. ny. r. Kathode I.e. 6 M.A. = Rotat. ny. 1. Anode I.e. 6 8 M.A. == Rotat. ny. r. very accurately CASE HISTORIES 123 19. A. K. Age 12. School child. Admitted Mch. 2, 1909. Anamnesis: Not obtainable. Status praesens: L.e. : Membrane totally destroyed. Tympanic cavity mucous membrane granulating. R.e. : Large perforation, cavity wall covered with granulations. Functional test: Con.v., r., 4 m. ; with exclusion appa- ratus, 1., 1 m. ; 1., 4 m. ; with exclusion apparatus, r., 2 m. Whisp., r., 1 m. ; with exclusion apparatus in 1. ear, a.c. ; 1., 1 m. ; with exclusion apparatus, 14 m. W. 1., E. r. + 1. . Bone conduction, 1. shortened, d r. and 1. + ; c 4 r. and 1. -J-. No vertigo. No spont. ny. Fistula sympt. typical. Operation, Mch. 4 (Ruttin) : Mastoid pneumatic. Cells behind antrum discolored. Diseased bone extends into posterior fossa, for the tegmen antri is softened. Typical radical. In the horizontal semicircular canal, a fistula about li/> mm. long, closed with connective tissue. Tympanic cav- ity and tube curetted. No ny. in the evening after the operation. Mch. 5 : No ny., no vertigo. Mch. 11 : Dressed. Primary healing of retro-auricular wound. Sutures removed. Wound bloody. No discharge. Plastic in good order. Hears con.v. ~y 2 m - (exclusion appa- ratus). Prompt cal. react, with vertigo. Up to Mch. 12 : No ny. or vertigo. Mch. 12: Rotat. ny. r. quite large. No vertigo. Mch. 13: As above. Mch. 14 : Rotat. ny. r. less. No vertigo. Mch. 16: Dressing. Neurological exam. Con.v. 1/2 m * (exclusion apparatus). Prompt cal. react, with vertigo. 20. H. P. Age 47. Office helper/Admitted Mch. 15, 1909. Anamnesis: Chronic middle ear suppuration of years' standing. Polyps repeatedly removed. For a long time, attacks of migraine and irritability. Vertigo only during past few days. Status praesens: L.e.: membrane and function normal. 124 DISEASES OF THE LABYRINTH E.e.: fetid, purulent discharge, polyps, cholesteatoma. Posterior superior meatal wall bulging. Functional test: Deaf for speech and tuning forks. W. r., K. . Sch. shortened; d 0, c 4 heard when struck hard. Spont. rotat. ny. == 1 (first degree). Fist, sympt. +, and typical (to diseased side on compression). Caloric test, no response. Temp. 39.1. Operation, Mch. 15 : Typical radical operation. Ichorous cholesteatoma in antrum; elongated fistula in horizontal semicircular canal. From the region of the sinus, pus un- der pressure comes out with pulsations. Jugular ligation. Exposure of sinus, with thorough cleaning of thrombi from the bend to the bulbus jugularis. Typical labyrinth opera- tion. During the succeeding 3-4 days, rotat. ny. 1., emesis and vertigo. Because of a continuance of the fever, on Mch. 20, the sinus was opened further backward, some thrombi were removed until free bleeding was secured. After a further rise of temp., slow defervescence, and patient felt tolerably comfortable. On the 21st day, patient became unconscious during the night and died. 'Postmortem: An old fetid abscess, 4.5 x 4.5 cm., with a pyogenic membrane 2 mm. thick, in the r. frontal lobe im- mediately in front of the precentral fissure. A second old abscess, 2.2 x 1.7 cm., with thinner membrane, in the left parietal lobe. Circumscribed, fetid leptomeningitis in re- gion of abscesses and of the r. Sylvian fissure ; and circum- scribed, in part adhesive, internal pachymeningitis over the larger abscess. Thrombophlebitis of the r. transverse sinus and the sigmoid sinus. Opening of r. transverse sinus in its anterior half and perforation of its inner wall on the border between the opened and unopened portions. Cir- cumscribed, purulent pachymeningitis interim in the region of the perforation in the posterior fossa. Fatty degen. of the parenchyma. Adhesive pleuritis, particularly r. ; cnl- CASE HISTORIES r_>:> careous degeneration of the r. apex. Calcification of the r. tracheo-bronchial glands. In the pus of the abscess, a mix- ture of different germs. 21. A. J. Age 2G. Worker in a factory. Admitted 19, 1909. Anamnesis: In Sept., 1908, pain in ear and tinnitus, fol- lowed in a few days by a tenacious purulent discharge from the 1. ear, which continued until now. From Dec. 1, 1908, until Jan. 1, 1909 ; frequent removal of polyps and curetting of tympanic cavity; since then, frequent vertigo, occipital headache and nausea, especially in the morning. Status praescns: K.e. : membrane and function normal. L.e. : slight swelling of superior meatal wall. Pulsating pus in the bottom of the canal, which is removed. Drum mem- brane red, swelled, perforation in anterior inferior quad- rant. Functional test : Mastoid sensitive to pressure. Deaf for voice and tuning forks. "\V. in head. R. negative (trans- mitted to other side). Slight spont. ny. to both sides. Cal. react, prompt. Fistula sympt. -f- , and on compression the eyes remain in position, but there is a distinct rolling from lower r. to upper 1. of interpalpebral fissure. Now no ver- tigo; continuous tinnitus. Operation, Mch. 20 (Bondy] : Radical. On the promi- nence of the horizontal semicircular canal, an area look- ing suspiciously like a fistula. But pressure here caused no definite eye movement. On the third day after the operation, spont. ny. alternat- ing between the two sides. Vertigo and emesis. Mch. 26 : Dressing changed ; nothing of note. Ny. as be- fore, but weaker. The ny. slowly disappears during the following days. Intermittent and remittent fever, up to 39.7, while in hospital. Patient died Apr. 21. Postmortem (by Prof. Glion] : Showed chr. tuberculosis involving lungs and acute miliary tuberculosis of kidneys 126 DISEASES OF THE LABYRINTH and lungs. Tubercular disease of spine and psoas abscess both sides. Lobar pneumonia, both lower lobes. 22. M. R. Age 41. Cottager. Anamnesis: Slight discharge and tinnitus for four months. During past three months, symptoms have in- creased, pain and greater discharge. One month ago, facial paralysis appeared. Fourteen days ago, sudden vertigo, so that patient found it difficult to avoid falling. Vertigo improved, but still present. Headache only at time of se- vere pains in ears ; no nausea. Status praesens: Apr. 27, 1909. L.e. : membrane and function normal. E.e. : abundant, very fetid discharge. Pulsation. After sponging: Total destruction of the mem- brane. Marked swelling of the superior and posterior meatal wall. Functional test: Deaf for tuning forks and voice. W. 1., spont. rotat. ny. 1. on looking forward. Cal. react. 0. Fis- tula sympt. +, with very severe, large rotat. ny. 1. on greater pressure (reversed fistula symptom), with marked vertigo and fainting lasting y 2 minute ; afterward, headache in the r. parietal region. Turning ny. : Tr. 1. causes no visi- ble change in the spont. ny. ; tr. r., an increase in the ny. lasting at the most 10". Total facial paralysis. Operation, Apr. 27 (Bondy] : Kadical operation. An- trum and mastoid filled with caseous masses, bone greatly softened. Dura of middle fossa lies exposed over an area as large as a heller piece, covered with lardaceous granu- lations. Labyrinth in its entire extent necrotic. Horizon- tal semicircular canal white and uncovered, with a fistula permeable for the labyrinth probe. Stapes lies free in the opening of the oval window, with the niche noticeably widened and deepened. Promontory also uncovered. The granulations of the tympanic cavity extend deep backward into the inner meatal wall. In view of the extensive disease of the facial prominence, all thought of saving the facial is abandoned, and the prominence is removed, and the CASE HISTORIES 127 nerve, imbedded in granulations, is excised. The horizon- tal semicircular canal is removed, the vestibule is widely opened behind, also the lateral labyrinth wall. Cochlea is cleaned. Abundant flow of labyrinthine fluid. Afternoon : Temp. 39.9. Rotat. ny. 1. unchanged. Apr. 28: A.M., temp. = = 38.0; rotat. ny. 1. unchanged. P.M., ny. disappeared. Apr. 30: Patient in a stupor. Temp. 37.3; pulse 60. Spont. rotat. ny. to diseased side. Operation (Bondy} : Further exposure of the dura of the middle fossa, which is incised. Brain substance dis- colored black. Incision. Large amount of thin, brown, fetid, ichorous fluid. The finger introduced shows a smooth-walled abscess, the median and posterior wall reached at a depth of 4 cm., but the anterior wall cannot be felt. Eubber drain. Pulse after operation 120. P.M.: Patient still in stupor, but responds when aroused. Ny. gone. May 1 : Greater stupor. Complains of severe headache. May 2 : Stupor. Restlessness. Rigidity of neck. Coma. 6 P. M., death. Postmortem (Erdheim) : Large r. parietal lobe abscess opened by operation. Pus discolored, bad smelling, con- taining pure culture of micrococcus meningitidis intracellu- laris. Abscess wall limited by pyogenic membrane. Col- lateral inflammatory oedema of the entire r. cerebellum. Free leptomeningitis ; in the left middle fossa there is in the subdural space exudate and blood from the operation. Chr. tuberculosis both lungs, with extensive ecchymosis and tubercles. Degeneration of the parenchyma. Extensive tu- bercular ulcers of the intestines. 23. H. G. Female. Age 21. Helper. Admitted Apr. 4, 1909. Anamnesis: Discharge from 1. ear for six years. Previ- ously treated in Wilhelmina Hospital. The discharge diminished at times, but never ceased. Except for the un- 128 DISEASES OF THE LABYRINTH pleasant discharge, patient has had no symptoms. Four days ago she had, on arising, vertigo and vomiting 1 . Yomitus consisted of mucus only. At the same time she had fever, remained in bed and was afraid to stand up. Her condition became worse on sitting up. This continued four days. Status praesens: L.e. : In the external canal, very fetid discharge with cholesteatoma ; deeper, granulations, which bleed easily. Pus pours out between the granulations. The mastoid region in general, especially over the sinus, is very tender, even without pressure ; also the jugular region. The patient's general* condition is bad; she vomits repeatedly. Pulse 120; temp. 38.8. R.e. : also chr. suppuration. Functional test: L.e.: Con.v. (with exclusion apparatus) 36 40 cm., "\V. 1., R. ; Sch. lengthened (not dependable). Ci and c 4 decidedly shortened. Vertigo lying upon 1. side, very marked on standing or sitting up. Spont. ny. chiefly r. Fistula sympt. +. Cal. react, typical. Irrigating both sides gives rotat. ny. 1. after 1' with no change during 10' flow. 850 c.c. fluid used on each side. Radical operation: Very early in the operation, thin pus is encountered. After opening the antrum, which is filled with granulations and cholesteatomatous masses, pus flows out from behind and below (pernicious abscess). Sinus exposed for a short distance. Since its wall is sur- rounded by pus and is discolored and altered, the jugular and facial veins are ligated. After completion of the radi- cal operation, when a fistula of the horizontal semicircular canal was found, the sinus is followed, and must be exposed to the jugular bulb, and to within three finger breadths of the median line. After reaching healthy sinus wall and healthy dura in the middle and posterior fossae, both being opened over a large area, the sinus is opened. In spite of severe hemorrhage, the sinus is thoroughly inspected and several thrombi removed. After free bleeding, packing. Hemorrhage is arrested. Entire wound cavity is packed with iodoform wick; closure with silk. Plastic postponed. CASE HISTORIES 120 Apr. 5, temp. 36.4 ; Apr. 6, 37.9 ; Apr. 7, 36.6 ; Apr. 8, 37.9 ; Apr. 9 to 12, normal ; Apr. 12, 37.8 ; Apr. 13, 38.1 ; from Apr. 14, normal. In the pus from the mastoid was found bar. proteus (contamination). Apr. 12 : First dressing. Wound granulating. Apr. 14: Dressing, on account of elevation of temp, on 13th, when a bone splinter the size of a heller piece was re- moved from the region of the tip. Temp, fell to normal. Apr. 21 : Discharged. The ligatures of both the central and peripheral stumps were not removed. Eeturns for dressings. June 14, Control test: Con.v. (with exclusion apparatus r.) Vo m., middle fork well heard at the meatus. W. 1., R. -, Sch. lengthened. Spont. ny. rotat. r. == rotat. 1. Cal. react, (cold) gives distinct ny. rotat. r., not very large, with no vertigo. 24. F. S. Age 28. Admitted Apr. 14, 1909. Anamnesis: Advanced pulmonary tuberculosis. L.e. operated Aug., 1908, at the Polikliuik. Then there was dis- charge for three weeks. Did not cease after operation. Tinnitus 1. from beginning of sickness. Vertigo only dur- ing past six weeks, when hearing has also been poor. Functional test: R.e., normal L.e. (tested with exclusion apparatus), deaf. W. in head. R. +. Sch. greatly re- duced. Middle fork at ear, ; d ; c 4 0. Spont. ny. rotat. r. = = rotat. 1. Fistula sympt, +, with large, slow, rolling movement to r. on compression, to 1. on aspiration. Syr. b.s. (25), after V. 2 ' ny. rotat. 1., with severe vertigo, which ceases during syringing, but the rotat. ny. 1. persists during 5' irrigation, variable, but distinct. After irrigation, ver- tigo and ny. increased. Xy. after tr. r. = 1. horizontal 19" ; after tr. 1. = ny. horizontal r. 28". 25. K. G. Age 30. Draftsman. Admitted May 3, 1909. Anamnesis: Discharge both sides, first in 1893, with diminished hearing, so that he was dismissed from military 130 DISEASES OF THE LABYRINTH school. Hearing changed, being poorer, first on one side, then on the other. Says he had no discharge then and is not conscious that he has any now. Tinnitus since 1893. Does not recall previous vertigo. About two years ago had ver- tigo for first time. Then his condition improved, and in 1900 was able to perform his military service for three years. Since 1905, condition worse, i.e. loud tinnitus and attacks of vertigo, chiefly in warm weather and on bicy- cling. Supposedly no discharge, no headache, no emesis. Kecalls no sickness. Family history negative. Examined (as out-patient) Apr. 22, 1909. R.e.: Chr. sup- puration. L.e. : Chr. adhesive process. Functional test: Con.v. r. 1 m. ; 1. 7 m. Whisp: r. 10 cm.; 1. l 1 /^ m. ; with exclusion apparatus to I.e. con.v. r. 10 cm. W. r., R. both sides ; Sch. both sides lengthened. Air conduction for middle fork r. greatly shortened; 1. less so. c 4 r. perceived only on being struck with metal ; 1. on slight stroke. Ci both sides with moderate stroke. Spont. rotat. ny. r. = 1. Fistula symptom : Compression, slow, rolling movement to 1. ; aspiration, slow, rolling move- ment to r. No ny. After the fist, test, spent, ny. is much stronger. Syr. b.s. 25 rotat. ny. r. after l 1 /^ minutes, the irrigation lasting 4^ minutes. No change in ny. 350 c.c. fluid used on each side. Fixator adjusted r. 20 and 1. 35. R.e. alone (25), rotat. ny. r. slight, yet plain, after y 2t and remains nearly constant during 4' irrigation. L.e. alone, after y 2 , plain rotat. ny. r. (stronger than r.), in- creasing in intensity for I 1 /*/, then about the same for 5' irrigation. Divided anode kathode to forehead == rotat. ny. 1. not marked, but plain, 20 M.A. Divided kathode - - anode to forehead = rotat. ny. r. plain, 14 M.A. Kathode r. anode to forehead == rotat. ny. r. 8 M.A. Anode r. kathode to forehead = rotat. ny. 1. 12 M.A. Anode 1. kathode to forehead == rotat. ny. r. 10 M.A. Kathode 1. anode to forehead = rotat. ny. 1. 10 M.A. CASE HISTORIES 131 June 18, 1909: Hearing distance (tested with exclusion apparatus) : Conv.v. 10 cm. W. r.; middle fork near ear, shortened, but heard relatively long. Sch. not shortened, rather lengthened. R. , d with moderate exciting stroke, c 4 when excited with the finger nail. Fistula symptom still present, on compression a slow, rolling movement to the 1. ; on aspiration, slow, rolling movement r. Caloric test made with ether apparatus: Rotat. ny. 1. plain, with vertigo. Status praesens: May 3, 1909. L. e. : membrane greatly retracted. R.e. : meatus large, containing purulent frag- ments. Membrane reddened, atrophic area surrounds the hammer, which is movable (with the pneumatic speculum), but the rest of the membrane appears to be adherent. No perforation visible. Above and posterior to the hammer, masses of epidermis, which are removed with difficulty. Functional test: L.e. : Con.v. 7 m. ; whisp. iy 2 m - W. r.; R. , Sch. lengthened. C, and c 4 shortened. Fist, react. ; Cal. test, prompt. R.e. : Con.v. 5 m. ; whisp. 14 m. ; R. , Sch. lengthened, d and c 4 shortened. Fist, test -f , Cal. react, prompt. Spont. ny. r. on looking to r., 1. on looking to 1. Tinnitus 1. Operation (Ruttin) : Mastoid sclerotic. Antrum small and contracted, containing a few granulations. Dura over tegmen antri exposed, for the only diseased area in the antrum appears to be in the tegmen. Dura normal. Typi- cal radical. Facial ridge is deeply removed to expose the tympanic cavity, for the suspected fistula in the horizontal canal is not found, and the canal appears perfectly normal. Tonogen applied. Inspection of the inner tympanic wall. Promontory normal. But in the recess of the oval window appears a granulation, on which is a portion of the stapes. This is removed and is found to consist of the head and half of one crus of the stapes. Pressure over the round and oval windows produced only indefinite rolling move- ments of the eves. 132 DISEASES OF THE LABYRINTH After tlic operation, 4 P.M.: Rotat. ny. r. and 1., the 1. greater than the r. No vertigo. 9 P.M.: Rotat. ny. r. and 1., that to 1. greater than that to r. Some vertigo on sitting up, when there is only rotat. ny. 1. ; some vertigo when patient looks to 1. Emesis three times. Feels comfortable. May 6: Rotat. ny. 1. greater than r. The ny. is greater in the abducted eye than in the adducted eye, and greater on looking to the extreme right than to the extreme left. Some vertigo on sitting up. May 7 : Rotat. ny. 1. greater than r., but less than yes- terday. No vertigo. May 8: Slight rotat. ny. 1. greater than r. No vertigo. May 10 : Rotat. ny. 1. = r., very slight. Goes about. May 11 : First change of dressing. Wound in good con- dition. Hears (with exclusion apparatus) Con.v. y 2 m. W. r. Middle fork heard a long time by r. ear. d and c 4 r. +. Cal. react, (cold water) very prompt. Spont. ny. r. = 1. rotat. and very slight. Fist, test not made, because of pain. May 13 : Transferred to O.P. Dept. 26. E. M. Age 30. Male. Admitted May 18, 1909. Anamnesis: Discharge from r. ear from youth, occasion- ally ceased; continuous for past three years. Five weeks ago, attacks of vertigo after removal of polyp from r. ear. Vertigo less during past few days. Occipital headache. Nausea past two days. Status praesens: R.e.. Total destruction of drum. Granulations. L.e. : Normal. Functional test: R.e.: Con.v. 1/4 m. ; whisp. 0.; W. r., R. , Sch. lengthened. C, + c 4 +. No spont. ny., no fis- tula sympt. Cal. react, typical; no fever. Operation, May 19 (Ruttin) : Large cholesteatoma, fill- ing entire mastoid. Typical radical operation. Dura of middle and posterior fossae exposed and covered with gran- ulations. Parts of the cholesteatoma invade the capsule of CASE HISTORIES 133 the labyrinth. Curettage. A fistula, 2-3 mm. long, discol- ored, in the horizontal semicircular canal. May 20: Temp. 38.5. Xy. rotat. 1. not strong; slight ver- tigo. May 21 : Temp. 37.4, 38.4. Rotat. ny. 1. decidedly greater, some vertigo, otherwise patient is comfortable. Hears loud voice through dressing. May 22: Rotat. ny. 1. the same. Slight vertigo. Temp. 37.5. May 23 : Rotat. ny. 1. slight. Xo vertigo. Patient walks about. Temp, from now on normal. May 24: Rotat. ny. 1. slight. May 25 : As above. Dressing. May 29: Dressing. Deaf for speech and tuning forks. Xo cal. react. ~\Y. 1., when fork is placed in mastoid process, localized to r. June 1 : Transferred to O.P. Dept. 27. F. K. Age 9. Admitted May 27, 1909. Anamnesis: Discharge following measles at six months. L.e. operated in fourth year. Two years ago, scarlet fever, since which time discharge also from r.e. Status praesens: Conv.v. 10 cm. (with exclusion appa- ratus 1.). Cal. react. -f~- Fistula sympt. -J-, on compres- sion greater ny. r., on aspiration lesser ny. 1. Temp. 38.0. Operation (Bdrdny) : Cholesteatoma in antrum. Pus from sinus region, which is surrounded with pus. Its wall discolored. Emissary vein thrombosed. Sinus does not bleed on removal of the vein. Near the ampulla of the an- terior semicircular canal there is apparently a fistula, from which or from its vicinity there is venous hemorrhage, which is stopped by tonogen. Sinus incised and thrombi removed. Jugular vein not ligated, because of the charac- ter of the fever. Xormal healing. 28. H. R. Admitted Apr., 1909. Advanced pulmonary tuberculosis. 134 Anamnesis: Discharge r. ear since Aug., 1908. No tin- nitus or vertigo. Status praesens: R.e., normal. L.e., chr. middle ear sup- puration. Functional test: L.e. deaf. "W. r. R. . Sch. not short- ened, d and c 4 0. Typical fistula symptom. Both sides irrigated (25), ny. rotat. 1., without vertigo. Cal. react., each side separately tested, gives a good reaction. Galvanic test positive. 29. Th. A. Age 25. Female. Admitted June 3, 1909. Anamnesis: B.e. always healthy. Six years ago, with- out previous pain, deafness in 1. ear. Discharge, though slight, persisted until now. Since Jan., 1909, severe pains and abundant discharge. No vertigo, no emesis, now and then headache. Status praesens: R.e. : membrane normal. L.e.: canal narrowed. Posterior superior wall decidedly swollen, ob- scuring drum. Abundant pus. Functional test: Loudest speech? W. in head. R. . Sch. shortened? d and c 4 O. No spont. ny. Fistula sympt. +. Cal. react. O. No vertigo, no tinnitus. Temp. 37.6. Operation, June 3 (Prof. V rb ants chit sch) : After push- ing periosteum aside, it .was seen that the entire posterior meatal wall was absent. Through this defect, which in- volved also the -surf ace of the mastoid bone, a cholesteatoma was visible. The thin contex removed. Removal of the cholesteatoma, which filled the entire mastoid and extended to the dura of the middle and posterior fossae. Severe hemorrhage from the middle fossa and from the further exposure of the posterior fossa; also from the mastoid emissary vein. The entire inner bony area is movable, and is taken out as a sequestrum, which is interspersed with the cholesteatoma and which shows cholesteatomatus lamel- lae on its dural surface. Jugular bulb is thus exposed. Its bleeding controlled by packing. The resulting defect ex- CASE HISTORIES 135 tends forward to the promontory. The sequestrum con- tains parts of the semicircular canals. June 3: Complete facial paralysis. Increasing uncon- sciousness. Hyperaesthesia of the skin. Rigidity of the neck. Temp. 40.0, 38.2, 39.4. June 4: Lumbar puncture gives cloudy fluid containing many grampositive streptococci. Dura over cerebellum in- cised, results in an emptying of retained subdural pus. In- cision of the cerebellum yields no pus. Temp. 38.8, 39.6, 36.8. June 5: Death, in the midst of deep coma. Temp. 40.0. Postmortem: Acute purulent leptomeningitis on the base and convexity of brain. Pus in the subdural space of the posterior fossa ; canal-like defect in the left cerebellar lobe from probing. Diffuse tuberculosis healing in both upper lobes and at tip of 1. lower lobe. Hemorrhages into the pleural cavity, adhesions of iipper lobes. Parenchymatous degeneration of internal organs. Purulent angina, both sides. 30. J. L. Age 30. Female. Admitted June 12, 1909. Anamnesis: L.e. : normal. R.e.: discharge of three months' duration, without any pain. Since the middle of May, severe vertigo on inserting finger into r. ear. No spont. vertigo. Now 7 and then headache. Tuberculosis of spine and old hip joint disease. Status praesens: L.e.: normal. R.e.: fetid suppuration. Polyps. Functional test: Conv.v. 4 m., whisp. 1/0 m. W. in head. R. . Sch. lengthened; C, shortened; c 4 shortened; no tinnitus, no spont. ny., no vertigo. Fistula sympt, -f, typi- cal, with falling to the diseased side on compression. Symptom elicited even by pressure on the tragus. Irriga- tion with cold water (without pressure) causes slight, but distinct ny. 1., without vertigo, but only after prolonged application. 136 D/>'/-:. I >/>' OF THE LABYRIXTH Kathode divided - - anode to forehead = - rotat. uy. r., 4 M.A. Anode divided - - kathode to forehead = : rotat, ny 1., '2 M.A. Anode right kathode to forehead == rotat. ny. 1., 1 M.A. Anode left - - kathode to forehead = : rotat. ny. r., 4-5 M.A. Kathode right anode to forehead = = rotat. ny. r., 2/10 M.A. Kathode left - - anode to forehead - = rotat. ny. 1., 5-6 M.A. Operation, June 16 (Prof. V rb ants chit sch) : Typical rad- ical. Cholesteatoma in antrum. In the horizontal semi- circular canal, located forward, a large, discolored fistula, pressure upon which causes slow, extensive movement of the eyes to the healthy side. June 16 : Spont. rotat. ny. 1. slight. Some vertigo. June 17: Temp. 37.0. Ny. to healthy side, not strong, but larger than yesterday. Some vertigo. June 18: Temp. 37.2. Ny. to healthy side, slight. No vertigo. About noon, feels well. June 19 : Temp. 37.8. No ny. ; no vertigo. June 20: As above. Temp. 36.2. June 21: In the evening, sudden vertigo. Rotat. ny. 1. of third degree. No headache. Temp. 37.4. Dressing changed. Wound clean. Pressure on the semicircular canal causes no ny. and no vertigo. Hears (without exclu- sion apparatus applied to 1. ear) con.v. 1/4 m. Cal. react, typical, but slight and without vertigo. "W. r., R. heard to 1. ; c 4 , when fork is struck with metal. d 0. June 22 and 23: Rotat. ny. only on looking to 1. No vertigo. June 24 : Rotat. ny. 1. only on looking to 1. Dressed. No vertigo. June 28: Transferred to O.P. Dept. July 14. Patient has vertigo when ear is cleaned. Fis- tula symptom still present. Cal. react, weak, but typical. CASE HISTORIES 137 Aug. 5 : R.e. entirely dry, epidermized. W. r., R. r. . Air conduction for C nearly normal. C t +, c 4 -f. Hearing distance for con.v. = = 2 m. ; whisp. a.c. Fistula symptom present. Caloric test -f. Turning ny. after tr. 1. = hori- zontal r. 16 oscillations in 15". After tr. r. = ny. horiz. 1. 30 oscillations in 25". Div. anode (6 M.A.), no ny. (Xo further galvanic test possible.) 31. M. P. Age 23. Maid. Admitted June 14, 1909. Anamnesis: 1905, after typhoid, suppuration r. ear. Dis- charge continuous, but not treated. Since June 1, frequent attacks of vertigo, recurring often. Xo headache, no ernesis. Status praesens: L.e. : normal. R.e.: canal filled with polyps. Drumhead entirely destroyed. Functional test: Conv.v. 30 cm. W. in head. R. . Sch. lengthened, d and c 4 decidedly shortened. Cal. ny. prompt. Fistula symptom -f. Spont. ny. rotat. and to both sides. Examination June 17 : Fistula symptom typical ; com- pression, ny. r. clearly rotatory, quite strong; on aspira- tion, the reverse. Irrigation of both ears (25), after y 2 '> ny. rotat. r. R.e. only irrigated with cold, giving prompt reaction. No vertigo. Turning reaction: After tr. r., ny. horizontal 1., 21 movements in 20". After tr. 1., ny. horizontal r., 13 movements in 16". Repeated : After tr. r., ny. horizontal 1., 33 movements in 35". After tr. 1., ny. horizontal r., 30 movements in 25". Operation, June 17 (Bondy] : Typical radical. Many granulations in antrum and mastoid. Dura of parietal lobe exposed, for the softening extends to the dura. Fistula in the horizontal semicircular canal running obliquely from the outer posterior portion inward. Pressure here pro- vokes no eve movement. 138 D7>7-:. !>7-:>r OF THE LABYRINTH June 18 : Ny. rotat. r. = : 1. No vertigo. Lies on back. Temp. 37.7. June 19: Ny. rotat. r. = 1. Since yesterday, the rota- tory ny. 1. is stronger. Jsfo vertigo ; temp, normal. June 20: Ny. rotat. 1. No vertigo. June 21: Ny. rotat. 1. (only first degree). June 22 : Ny. rotat. 1. In the evening, vertigo and head- ache. Temp, normal. First dressing. Deaf for spoken voice. Caloric react. -{-, typical. June 23: Ny. rotat. 1. (1st degree). No vertigo. June 24: Ny. rotat. 1. = r. only on looking to r. and 1. Vertigo only on standing suddenly. June 25: As above. June 28 : Transferred to O.P. Dept. 32. E. L. Age 32. Merchant. Admitted June 17, 1909. Anamnesis: One year ago, I removed polyps from r. ear, and after two months of conservative treatment the ear be- came dry. One month ago he returned with a recent an- trum suppuration. When operation was proposed, patient quit treatment. June 11, he had a sudden attack of ver- tigo with emesis, and could not hold himself in the upright position. June 15. I was called into consultation. Status praesens: B.e. : fetid suppuration. Patient is pale and emaciated. Marked spont. rotat. ny. to r. Fistula symptom typical, on compression, rotat. ny. to r. Functional test: Hears shouted words a.c. Also hears the middle fork at the ear. W. r. Ci and c 4 0. June 16: Vomited entire day. Frequent eructations. Hears conv.v. y 2 m. (which is better than on llth hist.). Fistula sympt. as before. Strong spont. ny. rotat. r. Pulse 52. June 17 : Patient feels better ; has vomited less, vertigo less, nausea less. Pulse 72. Spont. rotat. ny. 1. decidedly stronger, being present in whatever direction patient looks. Patient says he feels better, and has less vertigo when he looks to r. R.e. irrigated with cold water, after a long time CASE HISTORIES 139 reacts with some doubt ; no vertigo. Hearing V 2 m. as be- fore. Tuning fork as above. Operation, June 17 (Ruttin) : After pushing aside the meatus, there appears a fistula in the lateral antrum wall out of which flows pus, which pulsates. The entire mastoid is changed into a cavity occupied by a putrid cholesteatoma. Typical radical operation. In the antrum, a sequestrum involves the tegmen. The sinus and the dura of the poste- rior fossa are laid bare, also the dura of the middle fossa. This is markedly thickened and covered with granulations. 1 Fistula in the horizontal semicircular canal, 2 mm. long, not discolored. Typical labyrinth operation. Abundant flow of fluid from labyrinth. Parietal lobe incised. In pene- trating the dura, there is a sensation of entering a vacant space, and only at a depth of 2 cm. is the healthy brain sub- stance felt. No brain prolapse, in spite of a good pulsation and an opening in the dura about l 1 /^ cm. long. June 18 : Eotat. ny. 1. Vomiting and vertigo. Pulse 52. June 19 : Eotat. ny. 1. Pain in the wound. July 8: Slight pain and headache in the region of the vertex r. Less ny. Transferred to O.P. Dept. Never any fever. 33. K. G. Age 15. Comb-maker's apprentice. Admitted July 26, 1909. Anamnesis: Had radical operation 1. at another clinic one yr. ago. Discharge continued. During past two weeks, headache on 1. side and attacks of vertigo, which often recur. Status praesens: B.e. : Scars. Function normal. L. e. : Cavity of radical operation filled with granulations. Retro- auricular wound not closed. Functional test: Conv.v. a.c. With exclusion apparatus to r. e., deaf. W. r. B. . c 4 and C t 0. Fistula symptom now 0, but was present one month ago. Caloric ny. prompt. No fever during two weeks in hospital. Operation, Aug. 9 (Ruttin) : Cavity, filled with scars and granulations, is cleaned out. In the posterior fossa lies the 140 DISEASES OF THE LABYRIXTH dura, and perhaps the sinus. There is so much alteration from scars that details cannot be distinguished. These structures lie so far forward, so close to the facial promi- nence, that there is little room for the labyrinth operation. Typical labyrinth operation. A granulation over the oval window, which admits the probe with almost no resistance. Promontorium, which is very soft, is removed with chisel. The probe, introduced backward, emerges in the tympanic cavity. After the operation, rotat. ny. r. of third degree. Lies on right side. No fever. Feels well, except for vertigo. Aug. 10: Eotat. ny. r., severe emesis and vertigo, espe- cially on attempting to sit up. Temp, normal. Aug. 11: Rotat. ny. r. Emesis like yesterday. Temp. normal. Aug. 12: Eotat. ny. r. and horizontal ny. 1. no longer so great. No emesis since yesterday noon. No vertigo, even on sitting up. Temp, normal. Aug. 13 : Feels well. No vertigo. Eotat. ny. r. and hori- zontal 1. slight. In the night, patient complains of head- ache. Temp, normal. Aug. 14: Temp. 38.4. Headache. Eestless. Ophthal- moscopic exam. (Dr. 0. Ruttin) : Slight neuritis 1. (I was out of Vienna on this day, and saw the patient on Aug. 15.) Operated at once: Dura of posterior fossa exposed over a large area. Nowhere was a wound of the dura found, ex- cluding any possibility of a causal factor in the first opera- tion. In the opened labyrinth, a drop of pus. Since the lumbar puncture made previous to this operation showed cloudy fluid and contained many pus cells and single strep- tococci, I made a wide incision in the dura of the posterior fossa, and, suspecting a cerebellar abscess, I also incised the cerebellum, but with negative results. Aug. 15: Temp. 40. Aug. 16: Death. Postmortem (Prof. Glion) : Diffuse, purulent basal lepto- meningitis, particularly over the cerebellum. In the CASE HISTORIES 141 cerebrospinal fluid and in the exudate of the meningitis, streptococcus pyogenes. 34. K. M. Age 20. Locksmith's helper. Admitted Aug. 11, 1909. Anamnesis: Since childhood, suppuration r. ear. No vertigo. Status praesens: Granulations and bad smelling dis- charge r. Swelling over the mastoid. Temp. 38.3. Functional test: Conv.v. (exclusion apparatus 1.) 2m. Spont. ny., alternating r. and 1. Fistula sympt. -f, typical. Caloric react, weak. Operation (Bar any] : Radical operation. Cholesteatoma in antrum. Fistula in horizontal semicircular canal. Sinus laid bare. Emissary vein thrombosed. Diagnostic punc- ture into sinus. Bleeds freely. Packing. Aug. 12: Temp. 38.0. Ny. rotat. 1. Hears loud voice through bandage. Aug. 14: Temp. 37.3. From Aug. 14 on, normal course. Aug. 19 : Heard con.v. through dressing. 35. G. S. Age 26. Female. Admitted Sept. 11, 1909. Anamnesis: Very deaf and a foreigner. Statements ob- tained through a relative. Supposedly a "tumor" in r. ear, operated five or six years ago. Since then headache. Dur- ing past twenty days pains have been unbearable. Recently disturbances of equilibrium, vertigo, and, since last night, emesis. Status praesens: Both ears chr. suppuration with choles- teatoma. Functional test: R.e. : conv.v. 1 m. ; whisp. % m.; W. r., R. , Sch. lengthened, d and c 4 -f. No spont. ny. Calor. react, typical. Fistula sympt. +. Compression, ny. rotat. r.; aspiration, ny. rotat. 1. (weaker). After tr. r., horizon- tal ny. 1. = 30"; after tr. 1., horizontal ny. r. == 30". Ny. to r. more rapid. 142 DISEASES OF THE LABY1UMU Operation, Sept. 17 (Ruttin) : The first blow of the chisel exposes a cholesteatoma, filling the mastoid and lying upon the sinus, and filling also the antrum. A fistula, 2 mm. long, in the horizontal semicircular canal, permeable for the laby- rinth probe, with dark-colored, sharply defined edges. The ossicles not present. Evening: Vertigo, vomiting. No ny. Sept. 18 : Vertigo, emesis. No ny. Temp. 37.6. Sept. 19 : ^Emesis ; no ny. Sept. 23: Feels comfortable. No spont. ny. Dressing. Conv.v. 1 m., whisp. y 2 m. With exclusion apparatus 1. : Conv.v. y 2 m. Whisp. 0. Wound in good condition. Sept. 28: Transferred to O.P. Dept. Sept. 29: Functional test gives same results as on Sept. 23. 36. H. D. Age 20. Cashier. Female. Admitted Sept. 20, 1909. Anamnesis: L.e. discharged for four yrs. During past eight days, swelling and redness of skin over zygoma. Dur- ing past two days, vertigo on moving rapidly. Fever. Headache. Status praesens: R.e. : Dry perforation. Obstructive deafness. L.e. : Perforation in posterior superior quadrant. Granulations from antrum. Functional test : Conv.v. 7 m. Whisp. % m. W. 1., R. , Sch. lengthened. C t 0, c 4 +. Spont. ny. rotat. r. = = ny. rotat. 1. Fistula sympt. -f ; aspiration ny. vertical up- ward and rotat. r. Compression = ny. vertical, upward and rotat. 1. On aspiration, the ny. is at first stronger, then equal to, the ny. of compression. After several tests, there is greater spont. ny. to both sides. A horizontal component is entirely absent. Cal. react, prompt and very marked. Tr. r. : - after ny. horizontal 1. 24 movements in 25". Tr. 1. : : after ny. horizontal r. 60 movements in 35". Operation, Sept. 22 (Prof. Urbantschitsch) : Granula- tions in antrum. Typical radical. Careful inspection. CASE HISTORIES 143 Horizontal canal smooth, no visible fistula. Normal course, no fever. Sept, 26 : Transferred to O.P. Dept. Second admission, July 14, 1910. After first operation there was no more vertigo. But the discharge continued. Could not take regular treatment. Frequent headaches, but felt well until three days ago. Then had severe pains in r. ear, with free discharge from 1. ear. Severe headache and vertigo. No emesis. Status praesens: L.e. : Ketro-auricular scar. Radical operation. Meatus wide. Upper and middle portions of cavity well covered with epidermis. In inferior anterior part, free pus. Mastoid not sensitive to pressure. R.e. : Membrane retracted and thickened, reddish-yellow. A drop of pus on Shrapnell's membrane. Perforation not visible. Functional test: K.e. : Con.v. 2 m. Whisp. ? Tested with exclusion apparatus: Con.v. 30 cm. L.e.: Con.v. 3 m. AVliisp. y 2 m. With exclusion apparatus : Con.v. 1/2 m. Tin- nitus 1. W. in head. B. , both sides. Sch., both sides lengthened. Middle fork well heard at ear. d and c 4 both easily perceived. Spont. ny. r. on looking to r. Fistula sympt. r. negative, 1. positive, but on compression no ny.; on aspiration, ny. rotat. r. strong, with vertigo. Compres- sion with Valsalva gives no ny. Caloric react, prompt. Tr. r. = after ny. horizontal 1. 23 movements in 17". Tr. 1. = after ny. horizontal r. 42 movements in 22." No vertigo from turning in either direction. July 24 : Upon her request, patient is discharged. 37. J. J. Age 24. Coachman. Admitted Oct. 16, 1909. Anamnesis: As long as he can recall, 1. ear has dis- charged and he has had attacks of vertigo. Two to three years ago, had frontal headaches once or twice a day. One month ago, pains in the ear, nausea without vomiting, head- ache more severe. One week ago, headache so severe he was forced to lie down. Since then, vertigo on turning his head and tinnitus. 144 DISEASES OF THE LABYRINTH Status praesens: R.e. : normal. L.e. : membrane totally destroyed. Granulations. Functional test: Con.v. 0. W. in head. E. , Sch. short- ened. G! ; c 4 -J-. Fistula symptom -{- ; compression gives first a deviation of the eyes to r., then a ny. rotat. r. ; with aspiration, the reverse, but stronger. Tr. r. == after ny. horizontal 1. 36 movements in 25". Tr. 1. = = after ny. horizontal r. 19 movements in 24". No fever. Spont. rotat. ny. r. Operation, Oct. 26 (Prof. Urbantschitsch) : Radical op- eration. Granulations in the antrum. Mastoid sclerosed. Horizontal canal apparently intact, but on closer inspection there is on the side toward the labyrinthine nucleus a fis- tula permeable for the labyrinth probe. Oct. 27: Dressing. Ny. rotat. r. still marked. Course without fever. Oct. 28 : Ny. rotat. r. still strong. No vertigo. Oct. 29 : Totally deaf. Cal. react. 0. Spont ny. rotat. r. No vertigo. Nov. 11 : Ny. rotat. r. still present on looking to r. Had no pain or vertigo, he says, after operation. Feels exceed- ingly well. Before the operation he had at times diplopia. Wound granulating well. W. r., R. . (d 0, transmitted to other ear. C 0, c 4 transmitted when hit hard.) Left e. totally deaf. Tr. r. = after ny. horizontal 1. 10 movements in 14", weak, some vertigo. Tr. 1. - = after ny. horizontal r. 31 movements in 24", marked, severe vertigo. Divided kathode, anode to forehead = ny. rotat. r., 6 M.A., very plain and stronger than spont. ny. Divided anode, kathode to forehead = ny. rotat. 1., 10 M.A., very weak, and the existing spont. rotat. ny. r. does not disappear. 38. J. W. Age 36. Laborer's helper. Admitted Nov. 2, 1909. CASE HISTORIES 141 Anamnesis: Discharge I.e. since childhood. During past two weeks, pain and increased discharge. During past two days, vertigo. Fever for one day. Status praesens: Chronic suppuration both ears. E. canal filled with granulations. Mastoid not swelled, but tip sensitive to pressure. In the jugular region, near the angle of the jaw, a cord-like resistance which is not painful. Functional test: R.e. : Con.v. 10 cm. Whisp. 0. With ex- clusion apparatus applied 1., deaf. W. r., R. , Sch. not lengthened, d 0, c 4 -f- when struck hard. Fistula symp- tom -f ; compression == ny. rotat. 1. (to healthy side) ; aspi- ration = = ny. rotat. r. (diseased side); i.e. reversed fistula symptom. Spont. ny. of very slightest degree to both sides. L.e. : Con.v. 4 m. Whisp. U/o m. Staggering gait. Falling to rt. Dizziness. Temp. 40.2. Operation (Bondy) : Ligation of the unaltered blood- containing jugular. Radical operation. Granulations in antrum. Horizontal canal prominent, noticeably white, with a crater-like fistula, with irregular walls and filled with granulations in its posterior portion. Pressure here pro- duces slow movement of eyes to the diseased side. Poste- rior to the antrum, dura of cerebellum and sinus discolored. Sinus laid bare from its upper bend to the bulb, until nor- mal portion is reached. Since normal dura could not be found, the typical labyrinth operation was performed. Twitching of face muscles when granulations are removed. Thrombosed sinus cleaned out. Nov. 3: Facial paralysis. Ny. rotat. to healthy side. Temp. 36.7. Patient comfortable. Nov. 5 : Xy. entirely gone. Nov. 6: Dressing. Nov. 9 : No ny. on looking in different directions. Some ny. behind opaque spectacles. Nov. 22: Transferred to O.P. Dept. Temp, to Nov. 8, 37.8 to 38.1. Since then, normal. 146 DISEASES OF THE LABYRINTH 39. O. D. Age 30. Stationmaster. Admitted Nov. 8, 1909. Anamnesis: Ear trouble r. for 20 yrs. Practically no suppuration. Hammer fixed to promontory. Cholestea- torna in antrum. Functional test: Con.v. y 2 m. W. 1., R. , Sch. short- ened, C x , c 4 . No spont. ny. Cal. react, prompt. Typ- ical fistula sympt. Both sides irrigated 23, 5', ny. rotat. r. very plain, with some vertigo; r. 225 c.c., 1. 200 c.c. (no response r.), irrigator held low. Tr. r. = after ny. horizontal 1. 34 movements in 25". Tr. 1. = after ny. horizontal r. 14 movements in 10". On repeating this test, decidedly less ny. on tr. 1. Standing with closed eyes, well done, but stands better with eyes open. (Falls in no particular direction.) Standing upon r. foot, falls to r. Standing upon 1. foot, falls to 1. Walking with eyes open or shut is well done both for- ward and backward; turning the head has no influence. Kathode divided, anode to forehead = ny. rotat. 1., dis- tinct. 'Anode divided, kathode to forehead = ny. rotat. r. dis- tinct. Nov. 11 : Fistula react, obtained by touching tragus. Cal. react, r. (23) gives at once rotat. 1., as if it were hyper- sensitive; 1. (23) appears slightly later than r., with ny. rotat. r. Temp, normal. Operation, Nov. 11 (Ruttin) : Cortex hard. Large cells behind facial and at tip, filled with discolored pus. Typi- cal radical. A very broad and long (4 mm.?) fistula, in- volving nearly all of the horizontal canal. Bone diseased to the sinus, which is normal. Evening: Rotat. ny. 1. quite marked. Vertigo on looking to 1., otherwise comfortable. Nov. 12 : Morning, ny. rotat. 1. weaker, and with less ver- tigo on looking to 1. No change on sitting up. Hears through dressing 14 m - Temp. 37.3. Xov. 13 : Ny. rotat. 1. on looking to 1. Goes about. Nov. 14: Ny. rotat. 1. on looking to 1. Temp. 37.6. CASE HISTORIES 147 Nov. 15: Ny. rotat. 1. less. Hears through dressing. Temp. 37.2. Nov. 16: Condition same. Xy. rotat. 1. slight. Temp, normal. Nov. 17 : A.M., vomited twice. Ny. rotat. 1. in every po- sition of the eyes. Slight vertigo. Goes about at noon. Dressing. Retro-auricular wound nearly closed, beginning granulations. R.e. totally deaf (?). W. r., B. , Sch. shortened, d 0, c 4 0, a 1 fork heard for a moment. Cal. re- act, weak, with vertigo. Nov. 18 : A.M., emesis once. Generally comfortable. Ny. rotat. 1. quite strong, of 2nd degree. Vertigo on sitting up. Evening, rotat. ny. 1. 3d degree. Vertigo. Temp. 37.8, 38.1. Nov. 19: Better. No emesis. Ny. rotat. 1. only when looking to the left and forward. No vertigo on turning, only weakness. Temp. 37.4. Dressing. Primary closure of wound. Hears (with exclusion apparatus 1.) loud speech a.c., decidedly better than day before yesterday. He him- self observes it. W. r., R. . Sch. slightly shortened. Mid- dle fork heard at ear. a 1 10". d 0, c 4 when struck hard. No reaction with hot saline irrigation. Fistula sympt. -J-, easily provoked, very plain compression ny. rotat. r. ; aspi- ration ny. rotat. 1. weaker, with vertigo. Temp, henceforth normal. Dec. 13: Following findings: No more spont. ny., but present on dressing. Typical fistula symptom and vertigo on touching region of horizontal canal. Vertigo less from day to day. Two weeks ago, had diplopia for three days. Now no vertigo, ny. rotat. r. and 1. Rode home (5 hours) on train. On account of vertigo, stood the ride poorly. Hears (exclusion apparatus) Con.v. a.c.; middle fork, when vibrating very loud, is heard a few seconds by r. ear. d 0, c 4 -f- ; no fistula symptom. Cal. react, typical, but weak. Tr. 1. = after ny. horizontal r. 4 movements in 8". Tr. r. = after ny. horizontal 1. 15 movements in 14". Kathode divided -- anode to forehead, ny. rotat. r., 10 M.A. Slight vertigo. 148 DISEASES OF THE LABTRIXTH Anode divided - - kathode to forehead, ny. rotat. 1., 12 M.A. E. and 1. tested singly give typical galvanic reactions, 4-5 M.A. Feb. 16, 1910: Cal. react, plain. Loud words perceived a.c. No fistula symptom. No vertigo. 40. I. H. Age 17 years. Peddler. Admitted Nov. 18, 1909. Anamnesis: Discharge I.e. one year ago, without known cause. Eight days ago, perforation behind the ear. No headache or vertigo. Slight feeling of tightness in head. Status praesens: K.e. : membrane cloudy, retracted. L.e. : polyps, fetid discharge, retro-auricular fistula. Functional test: Con.v. !*/> m. ; whisp. 25 cm. (exclusion apparatus). B. , Sch. shortened, d 0, c 4 -f-. Spont. ny. only in extreme abduction. Cal. react, weak after removal of polyps, before which it could not be elicited. Fistula sympt. + for a few times only. Operation, Nov. 19 (Bondy) : Large cholesteatoma in smooth-walled cavity of mastoid. Sinus lies free and is thickened. Cholesteatoma lies posterior between dura and bone, so that bone is removed until healthy tissue is en- countered. Dura of posterior fossa also exposed. Hori- zontal canal appears indistinct. At its level, a fine fistula (!). Irrigation with saline at room temp, produces no eye movement. Nov. 20: Temp. 36.5, 37.2. Ny. rotat. of second degree to healthy side. Tested with exclusion apparatus, hears loud con.v. fairly well through dressing. Nov. 21: Temp. 37.3. Nov. 22 : Afebrile and ny. less. Hearing fair. Nov. 25 : First dressing. Con.v. perfectly perceived. Ir- rigation with saline, 48, gives decided lessening of spont. ny. Nov. 26 : Transferred to O.P. Dept. Jan. 17, 1910: Wound cavity fully covered with epi- dermis. Con.v. 8 m. Whisp. 14 m. With exclusion appa- CASE HISTORIES 149 ratus : Con.v. 5 m., W. 1., R. , Sell, shortened, d +. c 4 +, a! +, all when vibrating very little. Fistula sympt. . Cal. react, very prompt, with ether apparatus. Tr. r. = after ny. horizontal 1. 15". Tr. 1. = after ny. horizontal r. 25". Gal. : Kathode divided, anode to forehead == ny. rotat. 1., very plain. Anode divided, kathode to head = ny. rotat. r., very plain. 41. R. B. Age 24. Male. Admitted Nov. 22, 1909. Anamnesis: Occasional suppuration 1. since his twelfth year. Then a dry perforation was found in r. drumhead. The duration of the suppuration 1. averaged 8 months. Then intervals of 1 to iy 2 years. But even during the pe- riods of discharge there were intervals of cessation, at times lasting 3-4 \veeks. Because of extensive discharge, he was operated (radical) in April, 1906. Then two perforations of the 1. membrane were noted. Operation was considered, but local treatment gave improvement for a while. Hear- ing fair. Xo headache or vertigo. Sept. 15, there was pain in 1. parietal region, spreading to face and shoulder. From Sept. 16 to 20, very intense pains, preventing sleep, great sensitiveness to pressure about the ear. Improved by hot applications. Sept. 18, as pain subsides, vertigo and nau- sea. Last suppuration began July, 1909. Sept. 22. Admitted to hospital. Status praesens: R.e. : Healed radical operation. L.e. : Drumhead obscured by swelled posterior superior meatal wall. Canal filled with pus. Mastoid not sensitive. Functional test: Con.v. : r. 6 m., 1. iy 2 m. Whisp.: r. a.c., 1. a.c. (exclusion apparatus used). W. r., E. both sides , Sch. shortened, both sides. C a : weak both sides; c 4 r. -f, 1. 0. Spont. ny. rotat. r. = 1. in abduction. Reversed fis- tula sympt. 1. Cal. tests not made. Temp. 37.4. Operation, Sept. 23 (Ernst Urbantschitsch) : Typical radical. Cholesteatoma in antrum. Horizontal canal in- tact. Below the oval window, a small area discolored and 150 DISEASES OF THE LABYK1XTH covered with small granulations. Probe passes here with- out resistance. Pressure produces movement of eyeballs to extreme 1. (diseased side). Sept. 23: Comfortable. No ny. Facial intact. Sept. 24: Comfortable. Xo ny. No vertigo. Hearing through dressing good (exclusion apparatus used). Temp. 36.5, 37.4. Sept. 25: Feels well. Spont. ny. rotat. r. = 1. is slight. Xo vertigo; temp. 36.7, 37.2. Sept. 26 : No fever or vertigo. Facial intact, but patient complains of excessive flow of tears, 1. Temp, normal. Eve- ning comfortable. Slight weakness of 1. eyelid, but eye can be closed perfectly. L. angle of mouth shows slight rigidity. Sept. 27 : Comfortable. No vertigo or nausea. No head- ache. Facial paresis more distinct, but eye can be closed. Dressing. No pus. Below and in front of the ampulla a second fistula is seen, into which the probe can be passed. Patient being unconscious during dressing, no functional test. 1/4 hour later, hearing remains unchanged (through dressings) ; some words correctly heard. Sept. 28: Dressing. Cal. react, present. Words spoken softly, heard. Middle fork +. Temp, normal. Sept. 29 : Some vertigo, otherwise condition is normal. Sept. 30: Vertigo somewhat greater, otherwise no change. Facial unchanged. Dressing. Fistula no longer plainly visible. Unchanged condition until patient is transferred to O.P. Dept., Oct. 6. 42. St. H. Age 20. Female. Anamnesis: Measles as child. Patient does not recall that she had ear trouble at that time. She only remembers that she had discharge two years ago, and because of pain and tenderness on pressure she had local treatment. Dur- ing past week, vertigo, particularly on moving head. No headache or fever. More vertigo on lying on 1. side. Status praesens: B.C.: Chronic suppuration. CASE HISTORIES 151 Functional test: Hearing: Con.v. 1-2 m. (exclusion ap- paratus used) ; AY. r., R. , C t +> c 4 -f . No spont. ny. (perhaps slight rotat. ny. on looking to !.) Fistula sympt. typical, distinct. Aspiration ny. weaker than compression ny. The specialist who treated patient in the country obtained marked cal. react., due to pressure, no doubt. No marked equilibrium disturbances. On walking with eyes closed, go- ing backward, slight deviation and falling to r. Turns about body axis r. and 1. without vertigo. Operation, Dec. 24, 1909 (Ruttin) : Mastoid very much sclerosed, antrum filled with granulations, undermining the sinus behind. Dura not exposed. In the horizontal canal, a round fistula, the size of a pinhead. Pressure here causes a slow movement of the eyes to r. Typical radical opera- tion. I saw patient one year later. Complete epidermiza- tion. No spont. ny. Hearing distance more than one meter.* 43. K. K. Age 46. Female. Admitted Jan. 5, 1910. Anamnesis: Discharge 1. 30 years. 18 yrs. ago, polyps removed. During past few weeks, vertigo and headache in the 1. ear and vertex. Status praesens: R.e. : normal. L.e. : drumhead present. Polyp from attic. Con.v. 1 m., whisp. a.c. (with exclusion apparatus). W. 1., R. , Sch. lengthened, d 0, c 4 +. No vertigo at present. No spont. ny. ; fistula sympt. +> with vertigo. Cal. react, typical. Operation, Jan. 7 (Ruttin) : Antrum small, like a cleft. Bone sclerotic. Typical radical operation. Horizontal canal deformed ; in its place, three exostoses. Two fistulae. one small one, high up between two exostoses, the second in front of the first exostosis, above the horizontal portion of the facial canal, in the typical position. * I saw patient in Jan., 1912. again. She is completely healed. The opera- tive wound is covered with epidermis. No fistula symptom. Hears 2 m. +. No symptoms whatever. ir.2 DISEASES OF THE LABYRINTH Jan. 8: Xy. rotat. r. slight. Xo vertigo. Emesis. Jan. 9: As above. Jan. 10: Xo ny. or vertigo. Xo emesis, some headache. Jan. 14: Dressing. Cal. react, positive, but slow. Deaf (tested with exclusion apparatus). X'o spont. ny. Jan. 17 : Cal. react, plain. Deaf. Xo fistula reaction. Jan. 20: Until now, afebrile. To-day, 38.1. Jan. 21: Afebrile. Jan. 22, 39.1, 38.5; Jan. 23, 39.8, 38.4; Jan. 24, 37.6, 37.7; Jan. 25, 37.3, 38.6; Jan. 26, 38.0, 39.6; Jan. 27, 37.5, 39:3; Jan. 28, 38.5, 40.0, 38.1. Internal examination (Dr. 8. Bondy} : "Catarrh" in both upper lobes. Mitral insufficiency, arteriosclerosis. Fever cannot be accounted for by internist. Second operation (Ritttin) : Exposure of sinus and the dura of the middle and posterior fossae, both normal. Patient was removed from the hospital by relatives. Died the next day. Cause of death unexplained. 44. M. S. Age 33. Male. Admitted Jan. 12, 1910. Anamnesis: Pains for past six months. Discharge for two months. Emesis once. Pains continuous; frequent vertigo. Status praesens: R.e.: normal. L.e. : polyps in canal, fetid pus. Functional test: With exclusion apparatus to r.e. : deaf. W. r., R. , Ci 0, c 4 0. Spont. ny. rotat. r. = ny. rotat. 1. With head inclined to 1., ny. rotat. 1., and with head inclined to r., ny. rotat. r. Cal. react. == 0. Fistula sympt. +, and very active, provoked by slightest pressure on the tragus. Tr. 1. = after ny. horizontal r. 15". Tr. r. -- -- 0. No fever. Advanced phthisis. Operation, Jan. 14 (Prof. Urbantschitsch) : The opened mastoid shows extensive destruction. A sequestrum as large as a bean, made up of cells from about the antrum. The hori- zontal semicircular canal perforated like a sieve. Dura of the middle and posterior fossae lies exposed and is cov- CASE HISTORIES 153 ered with spongy granulations. Facial nerve lies exposed. Twitching of face when tympanic cavity is scraped. Jan. 15. Temp. 37.7. Facial paresis. Jan. 20: Dressing. Wound granulating. Deaf 1. (tested with exclusion apparatus). Spont. rotat. ny. r. Xo cal. re- act, Fistula sympt. cannot be elicited. Jan. 21, temp. 37.3; Jan. 22, 37.7. Jan. 24: Totally deaf 1. Irrigation produces slight ca- loric reaction ; i.e. the suspended reaction has been restored. Tr. r. = no trace of ny. Tr. 1. = = after ny. r. 21 movements in 24* -". Jan. 26: Total deafness 1. Cal. react, plain, but slight, with hot and cold irrigation. Jan. 30, temp. 37.4 ; Feb. 2, 38.1. Feb. 3 : Transferred to O.P. Dept. Patient later treated for tuberculosis. 45. K. B. Male. Admitted Jan. 17, 1910. Anamnesis: L.e. diseased for 20 yrs. Does not know that ear is discharging, but is conscious of pain. 8 days ago polyps were removed. No headache, no vertigo, no emesis. Temp, normal. Status praesens: B.e. : normal. L.e.: membrane totally destroyed. Polyps. Con.v. 2y 2 m. "Whisp.v. 10 cm. W. in head. R. . Sch. shortened, d 0, c 4 shortened; spont. ny. rotat. r. = ny. rotat. 1. No fistula symptom. Typical cal. ny. Operation, Jan. 19 (Dr. Ranch) : Typical radical. Choles- teatoma in antrum. Fistula in horizontal canal, about 2 mm. long, discolored. Temp. 37.7. Jan. 20: Comfortable. Temp. 36.8, 37.7; Jan. 21, 37.4; Jan. 22, 36.9; Jan. 23, 37.3; Jan. 24, 37.1; first change of dressing; Jan. 25, 38.7; Jan. 26, normal. Jan. 23: A.M., patient complains of vertigo; on sitting up, has severe ny. rotat, at times r., again 1. There are severe attacks of ny. When head is bent backward, ny. is upward. 1.-.4 DISEASES OF THE LABYRINTH Jan. 24 : Xy. rotat. r:, large, rolling, of third degree, with severe vertigo and emesis. Hears through dressing. With dressing removed, he hears conv.v. well (exclusion appa- ratus). "W. in diseased ear. Middle fork scarcely heard at ear, even when vibrating after heavy blow. A 1 only heard for short time. Cal. react, (hot saline) causes cessation of the spont. ny. with the appearance of ny. to diseased side. Fistula sympt. not to be elicited by pressure on the horizon- tal semicircular canal. Jan. 25: Large, rolling ny. rotat. r. ; but only of second degree. Vertigo less, particularly on sitting up. Dressing. Totally deaf 1. Cal. test (hot saline) produces a distinct ny. to the diseased side. The ny. to healthy side ceases. Xo headache. Temp. 38.7. Jan. 26 : Temp, normal. Xo headache. Hears (with ex- clusion apparatus r.) con.v. 1., but does not make out the words. With conversation tube, hears single words when spoken fairly loud ; when spoken near the tube, he does not hear. A 1 heard for a moment. Cal. react. ; cold gives ny. rotat. r. of second degree, while spont. ny. rotat. r. is m- creased on looking to r. Jan. 27 : Less spont. ny. r. Xo vertigo, except on sitting up. Xo headache or fever. L.e. totally deaf. Cal. react, distinct. Jan. 28 : Less spont. ny. rotat. r. Jan. 30: Cal. react, distinct. Feb. 3: Dressing. Total deafness 1., perhaps a trace of hearing with the intermediate tuning fork. Cal. react, prompt. Feb. 9. L.e. totally deaf. Slight spont. ny. rotat. 1. Tr. r. = ny. horizontal 1. 4 movements. Tr. 1. ; - ny. horizontal r. 15". 46. A. H. A^e 28. Male. Admitted Feb. 3, 1910. Anamnesis: Patient first consulted me privately three years ago for deafness. Does not recall that ear ever dis- charged. R.e. totally deaf ; I.e. perceived loud voice a.c. At HISTORIES l.V. that time I stretclied tlie adhesions of the hammer handle by means of the hook, and the hearing was decidedly better for a while. This procedure was repeated several times with good results during the year, and he could attend to his duties. Then I lost sight of him for two years. Early in 1910 he returned, complaining of attacks of severe head- ache and vertigo. No spont. ny. No fistula sympt. Hear- ing as before. Neurological exam, showed possibility of tabes (had lues). In the region of the antrum, small scales. I prescribed hot compresses, and asked him to return. Examination after two weeks: A drop of pus aspi- rated from the region of the antrum. Fistula symp- tom very plain, and on compression slight ny. to the diseased side; on aspiration, to the healthy side. Aspi- ration is more effective than compression. Jan. 26 : Vertigo and headache less. No spont. ny. Fis- tula sympt. not demonstrable. Cal. react, (cold air) prompt. No vertigo, headache or emesis. Status praesens: Feb. 3, R.e. : con.v. deaf, also for tun- ing forks. L.e. : con.v. 5-6 m. ; whisp. a.c. ; ~W. in head, E. , Sch. shortened; Cj and c 4 +. No spont. ny. Fistula sympt. 0, but was present two weeks ago. Temp. 37.0 to 37.4. Tr. 1. == after ny. horizontal r. 22". Tr. r. = after ny. horizontal 1. 20". Cal. react. +. Operation, Feb. 7 (Ruttin) : Mastoid sclerotic. Radical operation with preservation of the ossicles, according to Bondy's method. The ossicles are distinctly seen in the antrum after removal of the bridge. A fistula cannot be found in the horizontal canal, though this cannot be all in- spected. A few granulations in the antrum. Dura of the posterior fossa laid bare to the extent of a one heller piece. Feb. 9 : Comfortable, some ny. rotat. r., no vertigo. Feb. 10 : Comfortable, some ny. rotat. r. Less than yes- terday. No vertigo. Feb. 12: Dressing. Wound clean. Hears con.v. 7 m.; says he hears better than before the operation. Dismissed 156 DISEASES OF THE LABYRINTH for ambulatory treatment. Temp, regularly between 37.0 and 37.5.* 47. L. F. Age 23. Male. Admitted Feb. 11, 1910. Anamnesis: Since Dec. 31, 1909, when he received a blow on the 1. ear while bathing, pain and discharge. Was then at the clinic in Lemberg. Vertigo during the past few days, with increased pain. Status praesens: E.e. : normal. L.e. : upper, posterior and anterior walls of external canal swelled, so that canal is greatly narrowed. At the bottom of the canal, pulsating secretion. Membrane not visible. Mastoid somewhat sensi- tive to tapping. Temp, normal. Functional test : R.e. : normal. L.e. : con.v. 1 m. Whisp. a.c. (with exclusion apparatus). W. 1., B. , Sch. length- ened; Ci +, c 4 +. Tinnitus only on 1. side. Vertigo pres- ent. Spont. ny. rotat. r. = ny. rotat. 1. Tr. 1. == after ny. horiz. r. 15". Tr. r. = after ny. horiz. 1. 32". Cal. react. 0. Fistula sympt. +, on compression, ny. horiz. and rotat. r. ; on aspiration, most severe ny. rotat. 1. and much stronger than on compression. Temp., Feb. 14, 37.4. Operation, Feb. 14 (Ernst Urbantschitsch) : Incision through the infiltrated soft parts. Mastoid pneumatic, con- taining thick, pulsating non-smelling pus. Many granula- tions. Posterior meatal wall softened. Radical operation. In the horizontal canal, a fistula larger than a millet seed. Sinus lies exposed. Plastic, etc. Feb. 15: Comfortable. Temp, normal. Feb. 17: As above. Feb. 18 : Slight spont. ny. rotat. r. Comfortable ; gets up. Feb. 19: Dressing. Temp. 37.6. Mch. 21 : Dismissed to the O.P. Dept. After examination, May 3: No spont. ny. L.e. deaf for * Note during reading of proof: The patient came for examination in Jan., 1912. The operative area entirely covered and dry. Hearing for con. v. 7 m. No fistula sympt. No symptoms. CASE HISTORIES ir>7 speech and tuning forks. "W. r. Tr. r. == after ny. horiz. ]. 20". Tr. ]. = after ny. r. 20". Cal. react, not' present (perhaps a trace). Fistula sympt. negative. 48. J. M. Locksmith. Admitted Mch. 30, 1910. Anamnesis: Two yrs. ago, sudden pain in 1. ear, fol- lowed at once by discharge, lasting one week. No symp- toms for one year. Last year a repetition of the same proc- ess occurred, lasting two weeks. Five weeks ago, sudden tinnitus, headache and discharge. During past two weeks, attacks of vertigo. To-day, emesis. Status praesens: K.e. : Membrane cloudy, retracted. L.e. : Membrane entirely destroyed. Granulations. Ex- ternal canal narrowed ; pulsating pus. Functional test: Con.v. % m., whisp. a.c. Tinnitus now and then. W. 1., R. , Sch. lateralized to the healthy side (?). d 0, c 4 -f. Vertigo present. Spont. ny. rotat. r. and 1. Cal. react. 0. Tr. r. = no after ny. Tr. 1. = horiz. ny. r. 15". Fistula sympt. +; on compression, ny. r. ; on aspiration, stronger ny. 1. No fever. Operation (Ernst Urbantscliitsch) : Mastoid pneumatic, filled with pus and granulations. Radical operation. In horizontal canal, a fistula, 3 mm. by 1 mm. Bone diseased up to the sinus. Large cells filled with pus toward the bulb of the jugular. ' Mch. 31 : Comfortable, no vertigo, no nausea, no vomit- ing. Spont. ny. not changed. No fever. Apr. 1 : The same. Apr. 2 : No vertigo, no nausea ; some retching. Spont. ny. rotat. r. on looking to r. and forward. A ]n*. 3: A.M., had some vertigo and feeling of weakness. Some tinnitus. A little headache. Apr. 5: No vertigo; slight rotat. ny. r. Dressing. Wound healing. Apr. 7: Dressing. Condition excellent ; slight ny. rotat. r. on look- ing to r. Transferred to O.P. Dept. 4!. K. M. Age 37. Ironworker. Admitted May 19, 1909. Anamnesis: Both ears have discharged for 18 years. 158 Dlsi-:.\si-:s OF THE LABYRINTH Pain in r.e. for past 14 days. Paracentesis. Pains con- tinue. No vertigo or emesis. Status praesens: R.e. : Marked swelling and redness of drumhead. Much discharge. Perforation with pulsating pus in posterior-superior quadrant. L.e. : Perforation, polyps, slight discharge. Functional test: Con.v. r. 1 m., 1. 7 m. Whisp. r. a.c., 1. 3 m. W. indefinite. K. r. , 1. +. Bone conduction, both sides shortened. Ci both sides +, c 4 both sides + No ver- tigo or spont. ny. No fistula symptom. Cal. react, both sides prompt. May 29: Patient treated about eight days by means of attic irrigations. Condition remains unchanged, pus flow- ing from above and backward. Immediately after to-day's irrigation patient complained of vertigo. May 30: Vertigo almost continuous since yesterday, especially on bending, coughing and moving head to 1. Head movements to r. cause no vertigo. Fistula symp- tom -f-, compression causing large, slow, rotatory motion to the diseased side, followed by a small rotat. ny. to the healthy side. Aspiration causes a quick rotat. ny. to the diseased side. The same occurs on compression and re- lease of the tragus, with severe vertigo. Spont. ny. rotat. 1., loud con.v. a.c. W. 1., R. . Sch. lengthened, d 0. c 4 + Cal. react. +, typical. Operation, June 1 (Bondy) : Sclerosed mastoid. Choles- teatoma in antrum. No fistula in horizontal canal. Pres- sure in region of oval window causes slow eye movement to the diseased side. After the operation: Spont. rotat. ny. 1. June 1, A.M., some vertigo, but on quickly moving the head and on sitting up, no vertigo, though he moves without hesitation. June 2: Evening, feels comfortable. Spont. ny. rotat. r. = L June 4: No vertigo or ny. June 5 : Slight rotat. ny. 1. on looking to 1. Vertigo. CASE HISTORIES 159 June 6: Headache. Dressing. Hears voice, but can- not make out words. Cal. react, distinct, June 7 : Tr. r. == after ny. horiz. 1., 30 movements in 20". Tr. 1. == 0, possibly some ny. downward. 50. G. F. Age 35. Woodchopper. Admitted May 21, 1910. Anamnesis: Twelve weeks ago patient noticed discharge 1. without previous pain. Xo previous ear trouble. Slight vertigo. No emesis. Status praesens: R.e.: Normal. L.e. : Central perfora- tion. Abundant discharge. Posterior superior wall of canal bulging. Functional test: Con.v. 2 m. Whisp. 5 cm., tinnitus. W. in head. E. . Sch. shortened. Ci 0, c 4 -f . Vertigo now' and then. Spont. rotat. ny. r. == 1. Fistula sympt. +. On compression, slow movement of both eyes to r., and imme- diately thereafter, ny. 1. Aspiration, only slow movement to 1. Cal. react, weak. No fever (ten days). Operation, May 31 (Prof. Urbantschitsch) : Mastoid sclerotic. Ant rum filled with granulations. Xo fistula. Pressure on horizontal canal or on the inner wall does not produce eye movements. Extra-dural abscess of posterior fossa. P.M., slight rotat. ny. to healthy side. Slight vertigo. June 1: Ny. decidedly increased and of third degree. Tested with exclusion apparatus : Con.v. with mistakes. Temp. 37.2. June 2 : Ny. and vertigo increased. Emesis. Dressing changed. Loud voice heard with mistakes. Hot irriga- tion (48) gives distinct ny. Temp. 37.1. June 3: Condition the same. Dressing. Emesis less. Xy. on looking to the diseased side not visible. Temp. 36.2, 37.5. June 6: No vertigo. Xy. rotat. r. only on looking to r. Tested with exclusion apparatus: Con.v. with mistakes. Cal. react., a trace. Temp, normal. June 7: Temp, normal. 160 DISEASES OF THE LABYRINTH June 8 : Cal. react. 0. L.e. entirely deaf. No fever. Tr. r. = = after-ny. lioriz. 1. 10" (12 movements). Tr. 1. = ny. boriz. r. 19" (48 movements), but without vertigo. June 18 : Cal. react, prompt ; no spont. ny. Tested with exclusion apparatus: Loud words heard a.c. Fistula sympt. . Tr. r. = after-ny. horiz. 1. 8 movements in 11". Tr. 1. = after-ny. horiz. r. 45 movements in 20". 51. O. M. Age 22. Milliner. Admitted Sept. 15, 1907. Anamnesis: As child, patient had severe headache on r. side. Three years ago, erysipelas, beginning in r. eye, and rheumatism in the hands and feet. At age 2 had suppura- tion r. ear. Drafts have always caused pain in r. ear and r. parietal region. Hearing always poor on r. side, and has always had attacks of vertigo, which were never as severe as of late. Has always had pains in r. mastoid and parietal region. L.e. always healthy. Three weeks ago, the dis- charge became very marked; she had vertigo and more se- vere pains in her head and mastoid, the latter sensitive to pressure. This condition improved in one day. Two weeks ago she suddenly collapsed and became unconscious. On coming to, one-quarter hour later, she had severe vertigo, with movement of objects about her ; emesis. Had also very severe headache (r.), particularly in the region of the fore- head. Mastoid very sensitive to pressure. Unable to stand up since this, attack, and cannot raise her head. On setting her up, she complains of the vertigo, and the ny. becomes more severe. Frequent emesis. Status praesens: L.e.: Filled with bad-smelling pus, and inflamed tissue (granulations). R.e. : Very fetid pus in the canal. Inner wall of tympanic cavity covered with granu- lations. Pus comes especially from the region of the an- trum. Mastoid very sensitive to pressure (this may be due to hysteria). Functional test: The labyrinth does not react to the cal. test. W. to 1. E. . Tuning forks not heard through the air. Severe rotat. ny. to healthy side. CASE HISTORIES 161 Labyrinth operation, Oct. 23, 4 P. M. (Bdrdny) : Typical radical operation under local anaesthesia. Bone very hard, sclerosed. In the antrum, a very fetid cholesteatoma, the size of a hazelnut, reaching into the mastoid. Exposure of the sinus', which is well forward, a distance of 1 cm. Dura of the middle fossa laid bare the size of a five Kronen piece. Procedure with the typical labyrinth operation, by remov- ing larger fragments of bone. The upper angle of the pyramid is removed. The vestibule is opened from behind, when the upper portion of the facial bend of the facial canal is broken, so that the facial nerve lies free in the tympanic cavity, but is not injured. Cochlea opened from the promontory, when a large amount of fluid escapes. Plastic after Pause. Vestibule drained from behind, cochlea from in front, Until Oct. 28, temp, is about 37.8. Oct. 28 : Change of dressing. Normal temp, from now on. Oct. 30: Dressing. Nov. 7: Regular dressing every other day. The dura lies rather low. Facial paresis. Comfortable. Nov. 8: Dressing. Dura of the posterior and middle fossae adherent. Nov. 12: Dressing. Pulse 118. Headache. Ny. to 1. on looking to 1. in slight degree. Nov. 12-19 : Dressing every other day. Nov. 19 : Patient discharged well. Rotat. ny. to each side marked. Wound cavity size of hazelnut. The prolapsed dura adherent to the facial spur. Slight secretion. Or- dered to come for daily dressing. 52. J. F. Age 28. Female. Admitted Nov. 6, 1907. Anamnesis: Patient has had discharge from 1. ear two years. Stopped for a while. Following a confinement ten months ago, it returned. Two days ago she was brought to the surgical clinic witli a high fever. Transferred to this clinic. Status praesens: Internal examination negative. B.e.: A calcification in anterior portion of drum ; above, a perfo- 162 DISEASES OF THE LABYR1XTH ration opposite the autruin and covered with a granulation. From behind this, thin pus flows out ; mastoid is sensitive to pressure. L.e. : A dry perforation, the size of a pinhead. Patellar reflex present, slightly increased. Dermography present. Kernig not present. Babinski negative. Neck rigid. Frontal headache. Slight anisocoria. Pulse 72. No emesis. Temp. 39.0. Functional test: L.e.: Normal. R.e. : Deaf for voice and tuning forks. W. 1., R. , Ci and c 4 heard when struck with metal. Fistula symptom . Cal. react. . Large spont. rotat. ny. 1. Temp., Nov. 7, 39.1. Operation, Nov. 7 (Prof. Urb ants chit sell) : Radical operation. Dura and sinus laid bare. They are unchanged. After the sinus has been widely exposed, the tympanic cav- ity is cleared of granulations, likewise the antrum. Ham- mer and anvil are not to be found. The horizontal semicir- cular canal is now opened, and also, after crowding the sinus and the dura back, the posterior vertical semicircular canal is opened from behind. The promontory was then opened. No cerebrospinal fluid. As the promontory was being chiseled, a fragment of the facial ridge became de- tached. Through this ran the facial nerve. This piece was cut down to a minimum by the bone-cutting forceps. No facial twitching. Plastic; at the close of the operation a lumbar puncture was made, giving diffuse, cloudy cerebro- spinal fluid. (Bacteria: Gramnegative cocci.) Saline in- fusion. Nov. 8 : Night tolerably comfortable. Some headache on moving and on jarring the bed. Severe pains in the head. Facial paresis. Ny. rotat. 1. Temp. 37.5. Nov. 9 : General condition not bad. Photophobia. Some headache. Temp. 37.8. Nov. 10: Temp. 37.6. Nov. 11: 37.6. From Nov. 12: normal. Nov. 13: Patient improves remarkably, with no temp. Headaches less. Sits up. Appetite good. N'ov. 14: First change of dressing. Wound bleeds. The CASE HISTORIES 163 sequestrum on the facial nerve is still loose and is left. Slight discharge. Nov. 16 : Patient feels well. Dressing. The sequestrum is already attached by granulations, only slightly movable. Xov. 18: Dressing. The sequestrum is surrounded by granulations and is not to be seen. Nov. 28: Wound normal. Transferred to 0. P. Dei >t. 53. J. S. Agent. Admitted Feb: 2, 1908. P. M. Anamnesis: Chr. suppuration 1. with occasional exacer- bations. Four days ago, very severe headache, slight stupor. Temp. 38.6. Hearing, r., normal; 1., noticeably diminished. Status praesens: L. perforation, superior posterior quadrant. Fetid secretion. Mastoid and head not sensi- tive. No stiffness of neck or sensitiveness of spinal column. Pupils different in size; they react slowly. Convergence weak. Slight ptosis 1., facial paresis, 1. Motor strength on both sides good. Perhaps some hyperaesthesia. Patellar reflex almost absent. Babinski positive. Speech slow. Slow cerebration. Complains of most severe pains in en- tire head. On standing up, an attack of ny. to 1. rotat., very large (after 5 hours, a trace of rotat. ny. r.). Hear- ing greatly diminished on both sides. No fistula symptom. Cal. react, two days ago positive. Slight ataxia. Moist rales over the lungs. Pulse soft, 90. P.M., 2y 2 hours later : Unconscious. Rt. eye deviates outward. Large ny. to 1. rotat. Does not arouse, picking at the bedclothes. Kernig probably present. Ophthalmoscopic exam, impossible. Radical operation, Feb. 2 (Bdrdny) : Mastoid filled with pus. Much pus in the antrum. Sinus is exposed, when the emissary vein (iy 2 cm. long) bleeds. Stops on packing. Sinus very thin, at certain points covered with fibrinous exudate. Sinus very near labyrinth, which appears nor- mal. Difficult to expose the posterior fossa in front of the sinus, because the sinus lies forward. Bleeding from the slightest injury. Sinus exposed to the bend. Packing be- tween bone and the bend. Sinus exposed nearly to its hori- 164 DISEASES OF TEE LABYRINTH zontal portion. Pus and brain substance under heavy pres- sure are pressed out as the bone between the labyrinth and sinus is removed. Labyrinth removed, vestibule and cochlea opened. Dura of posterior fossa is incised. Exploration of brain negative. Brain prolapsed under severe pressure. Middle fossa explored; negative. Lumbar puncture yields a purulent fluid. After the operation, strong ny. to the healthy side. Does not become entirely conscious. Feb. 2: Deep coma. Slow, deep breathing. 6.30 P.M., death. Postmortem (Prof. Stoerk) : Purulent meningitis, espe- cially of base (fibre-purulent). Lobar pneumonia, with in- dividual foci in each lobe. Acute swelling of the spleen. Cloudy swelling of the parenchyma. Coronary sclerosis. 54. Sch. S. Male. Admitted Mch. 29, 1908. Anamnesis: Acute otitis 1. for three weeks, but he has suffered for three months from a headache following a fall. Headache more severe since the otitis. Paracentesis in our out-patient department one week ago, with relief. Last night, complained of severe headache; later, became un- conscious and did not awaken. Status praesens: Unconscious. Dyspnoea. Temp. 40. Cannot be aroused. No restlessness. Skin pale, face slightly cyanosed. Pupils equal, react promptly. Rigidity of neck not noticeable. Pronounced dermography. Re- flexes not definite. Kernig test seems to be painful. Ex- tremities, especially the lower ones, rigid. Sphincters re- laxed. L.e. : Profuse non-fetid, yellow, purulent discharuv. Mombrana tympani red and swelled. Perforation not visi- ble. Cal. react, negative 1., on r. side, prompt. Cold irri- gation causes the eyes to remain in r. canthus, with rotat. ny. 1. Operation, Mch. 29 (Ruttin) : Cerebrospinal fluid milky. The very pneumatic mastoid is opened. Its cells filled with pus and granulations. Antrum opened. Sinus exposed, and is normal, slightly filled and very small. Middle fossa CASE HISTORIES 165 opened. Dura is stretched, but looks normal. Radical op- eration ; tympanic cavity filled with granulations. The cu- rette enters a cavity, which proves to be the labyrinth, filled with granulations. Labyrinth opened from behind, without laying bare the dura, and leaving the upper pyramid angle. The labyrinth is filled with granulations. Xo labyrinthine fluid comes away. Facial twitching twice during the chisel- ing. Promontory opened. Xo fluid. Dura of the middle fossa is incised. Xo fluid. Xo prolapse, though the incision is long. Xo plastic. Packing. Camphor saline infusion. Death during the night. Postmortem, Mcli. 20 (Dr. Erdheim) : Acute, purulent, chiefly basal meningitis. Cloudy arachnoid and pia. Ex- tensive adhesion of the dura to the cranial vault, with multi- ple osteomata. In sigmoid sinus, liquid blood. Purulent bronchitis, etc. 55. W. J. Age 62. Admitted Apr. 18, 1908. Anamnesis: Attempted suicide one week ago. Bullet from revolver penetrated in front of r. ear. Xot uncon- scious. After two days, he noticed a yellow secretion from r. ear. At once tinnitus. Very little vertigo, increased by moving in bed. Hearing was immediately gone. Prolonged pain in ear. Xo headache. Pains on masticating. Status praesens: In front of r. ear, bullet wound, form- ing scar, with skin blackened. Anterior meatal wall granu- lating. Movement of jaw causes granulations to move. From the meatus comes much purulent secretion. Xo de- tails visible. The probe comes in contact with a hard body lying above and posteriorly. Mastoid slightly tender. Temp. 37.6. Functional test: R. : Con.v. % m. ; whisp. a.c. Deaf when tested with the exclusion apparatus. "W. 1., R. negative, Sch. shortened. Xo vertigo. Spont. rotat. ny. to healthy side. Xo fistula symptom. Cal. react, negative (1. posi- tive). Tr. 1. == after-ny. horiz. r. 12". Tr. r. == after-ny. horiz. 1. 16". 166 DISEASES OF THE LABYRINTH Operation (Bardny) : Typical radical operation. The bullet lies on the oval window. Hammer and anvil are broken. Promontory is intact. Sinus exposed for an area the size of a pea, lies well backward. Tegmen tynipani broken by the bullet. A broken-down extradural haema- toma reaches to the superior petrosal sinus, and far for- ward, so that the tegmen tympani must be removed. The dura is not wounded. Labyrinth is opened posteriorly. The vestibule is discolored black (old hemorrhage). Promon- tory is opened. No labyrinthine liquor flows away. Probe introduced into the vestibule appears in the oval window. Dura of the posterior fossa not exposed. Anterior meatal wall is destroyed and granulating. Broken-down cartilage in the track of the bullet excised. Mandibular joint not opened. Plastic; dressing. Apr. 19 : Ny. 1. has diminished. Some headache. Apr. 25 : Ny. behind opaque spectacle O. Some headache and pain in ear. Sleeps poorly. Abundant purulent dis- charge from the wound. May 3 : Feels comfortable. Some pain in the wound. May 12 : Daily dressings. Wound granulating up to the facial. Entire course without fever. 56. L. B. Age 23. Female. Admitted May 6, 1908. Anamnesis: L.e. : Always well. Four yrs. ago, furuncle in r. ear. Past four months pain in r. ear. Polyps were removed, then followed bad-smelling discharge. Pains in back of head. No vertigo, no fever. Hearing very bad on r. side. Status praesens: E.e. : Drum cloudy, thickened. Above posteriorly, a granulation, apparently coming from the an- trum. At the juncture of the external ear with the head, a depression in the bone the size of a bean, covered with a scar, but of normal colored skin. Mastoid process normal. Temp. 36.2. Functional test: Con.v. 8 m. (?). W. r., E. . d -f, c 4 +. No vertigo. No spont. ny. Cal. react. +. CASE HISTORIES 1G7 Radical operation, May 8: Temp. 37. Because the sinus was well forward and the dura low, the operation was diffi- cult. Both structures were exposed. On smoothing the fa- cial ridge, twitching of r. facial muscles. At the close of the operation the r. corneal reflex was gone. Plastic after Panse. May 9 : Elevation of temp, to 37.6. Large ny. r. Com- plete facial paralysis r. May 9-12: First change of dressing. Wound bleeds. Details not visible. Deaf on right side. No cal. react, with cold saline irrigation, at which time the spont. ny. did not change its character. May 13: Temp. 38.3. May 14 : Dressing. No caloric react, with cold. Wound covered with purulent exudate. Spont. ny. 1. much less. Temp. 38.6. Lumbar puncture. The cerebrospinal fluid in all three test tubes very cloudy. Coverglass specimen stained with methylene blue shows many polynuclear leu- cocytes. Morphine 0.01, 10 A.M. Operation (Prof. U rb ants chit sch) : Skin incision back- ward. The sinus, lying far forward, is now exposed for l l / 2 cm., and the dura in front of the sinus is exposed. Hori- zontal semicircular canal is opened. The vestibule is opened from behind and the cochlea from in front by re- moval of the promontory. No fluid flows away on opening the labyrinth. May 15 : Spont. ny. to 1. decidedly stronger. May 18: Temp, to 38.2. Postmortem (Decent Bartels) : Acute purulent lepto- meningitis after otitis media suppurativa chr. dextr., and radical operation, etc. 57. F. S. Age 19. Waiter. Admitted July 15, 1908. Anamnesis: Discharge r. ear since childhood. No treat- ment. No subjective symptoms. Hears fairly well. An old apex catarrh, otherwise well, until five days ago. Then he 168 DISEASES OF THE LABYR1MII noticed that he could not hear with 1. ear; felt a hammer- ing in this ear and had severe headache from the forehead to the occiput, "as if the skin were being pulled off." July 14, 1908, in the evening, a sudden a'ttack of vertigo, with' vomiting. All objects seemed to move about him from left to right. Patient had to hold on to things to keep from fall- ing. In bed, the vertigo and vomiting were better, but re- turned on sitting up or standing. High fever, with sweat- ing. Whistling, ringing and hammering in the I.e., con- tinuing for hours, with short pauses. These noises less since yesterday. Status praesens: Patient appears very sick. Old tuber- culosis r. lung. Sensoriurn free. Patient replies promptly and positively. Suggestion of rigidity of neck. On ac- count of pain, patient cannot bring knee to abdomen. Passive movement of the neck is free. Reflexes and sensi- tiveness unaltered. On showing his teeth, the 1. angle of the mouth does not move. Retina very hyperaeniic, other- wise normal (Dr. 0. Ritttin). Motion of eyes free. Vision normal, except vertigo prevents reading. He lies partially on the r. side, with the head entirely upon the right side. Lying on the left side provokes severe vertigo, when ob- jects swing from the left to the right. After a short time on the left side, emesis. Likewise, vertigo and vomiting on sitting up, slight improvement when eyes are closed. Spont. horiz. ny. r., even with eyes to extreme 1., in which position there is some rotat. ny. The ny. is very quick and of large size, so that even with the eyelids closed we can plainly see the quick movement. The 1. labyrinth does not respond to the calor. test. Prolonged irrigation with warm water at 48 does not affect the ny. Functional test: Con.v. heard r. ear promptly. L. (tested with exclusion apparatus) when words are shouted; he hears some numerals. "\Vhisp. O. With conversation tube, con.v. and shouting are not perceived. Lower limits : a, 5". Bezold's a,: 8" (normal 80"-90"). C '>", c: 8", c 4 and c 5 much shortened. ~\V. to r. from every part CASE HISTORIES 169 of head. Bone conduction (a 1 16") heard from 1. mastoid. Operation, July 15 (Ernst U rb ants chit sch) : Typical radical operation. Anvil carious (long process gone). Hammer gone. Granulations in antrum and tube, also cholesteatomatous masses. Promontory noticeably pale, with a blue tinge below. Posterior fossa is laid bare after completion of the radical operation. Sinus lies relatively well back. Hemorrhage from sinus embarrasses the work. Abundant flow of cerebrospinal fluid. The probe is passed from behind under the facial into the tympanic cavity. In chiseling, slight facial twitching. Promontory opened with one blow of the chisel. Cochlea destroyed. Dressing. July 16: Subjectively decidedly better, no emesis. Ap- pears better, eyes brighter. Slight facial paresis of the upper branch (the eye can, by effort, be entirely closed). A somewhat more marked paresis of the lower branch, which, however, was present in a slight degree before the operation. Appetite poor. July 17 : Subjective condition like yesterday. Facial pa- resis the same (upper division better). Spont. ny. practi- cally entirely gone, visible only on looking to r. Great thirst. Slight emesis. July 18-20: Feels comfortable. Normal progress. July 21 : First change of dressing. Practically no pus. Wound looks very well. July 22 to 31 : Normal course. Transferred to O.P. Dept. 58. L. Sch. Age 54. Waiter. Admitted April 22, 1909. Anamnesis: Two years ago, some tinnitus, but no dis- charge. Eight days ago, severe pain in 1. ear, followed three days later by discharge. Since then, extreme head- ache, prolonged vertigo, emesis and fever. Status praesens: K.e. : Drum and function normal. L.e. : Membrane red and swollen. Perforation not visible; mod- erate, non-fetid discharge. Deaf for speech and tuning forks. Cal. react, cannot be elicited. Large, most marked spont. ny. rotat. r. Anisocoria (left pupil smaller) lids 170 DIX/-:A*I-:S OF THE LABYRIXTH painful. Spinal column at level of neck sensitive to pres- >ure and painful on movement of bead. Reflexes greatly exaggerated. Ankle-clonus. Ataxia of upper extremities. General hyperaesthesia ; calf muscles especially sensitive. Kernig. Dermograpby. Temp. 38.8. Pulse 130. Operation, Apr. 22 (Ruttin) : All the cells of tbe pneu- matic mastoid filled with pus. Radical mastoid operation. Dura of the middle and posterior fossae laid bare. Dura is normal. No perforation of the labyrinth wall to be discov- ered by the application of tonogen. Typical labyrinth op- eration. No flow of labyrinthine fluid. Apr. 23: Meningitis symptoms more marked. Ny. rotat. r. Temp. 39.7. Apr. 24: Unconscious. Temp. 39.8. Apr. 25: Death. Postmortem (Decent Bartel) : Purulent leptomeningitis (abundant exudate over the anterior part of frontal lobe, on the upper convolution, less at the base), etc. 59. J. K. Age 39. Weaver's helper. Admitted May 4, 1909. Anamnesis: Chronic suppuration during past eight years. Eight days ago, vertigo. During past day, continu- ous vertigo, emesis and headache. Status praesens: L. : Membrane and function normal. R. : Pus and granulations fill meatus. Totally deaf. Ny. rotat. 1. with eyes in all positions. Cal. test not demonstra- ble. No fistula symptom. Temp. 37.8. Operation, May 4 (Bardny] : Typical radical. Cholestea- toma in antrnm. Fistula in horizontal semicircular canal. Facial nerve lies exposed above the oval window. Dura of the middle and posterior fossae and the sinus all laid bare ; all normal. Typical labyrinth operation, without extensive exposure of the posterior fossa. A small piece of the facial ridge is broken off, so that the facial nerve lies exposed. No visible pus in the labyrinth. Facial paresis. Temp. 37.6. Normal course. CASE HISTORIES 171 May 5 : Ny. somewhat less. Facial paresis. Temp. 37.6. Normal course. May 14: Discharged. 60. M. H. Age 26. Female. Admitted May 13, 1909. Anamnesis: Apr. 8, following a cold in the head, pains in I.e. Apr. 12, spontaneous perforation. Pains stopped 3-4 days later. Abundant discharge, but no further symp- toms of note, so that the patient could do her work. May 8, A.M., severe vomiting of bile-tinged food masses, re- peated in the afternoon. At this time the vertigo was slight, so that she could work. May 9, the vomiting became less, but the vertigo caused her to stay in bed. Vertigo and emesis continued the following days. Vomiting stopped after the morning of May 13, but the vertigo continued, though less severe. With the first onset of the vertigo there was an apparent movement of objects to the right. Patient says there was a swelling behind the ear in the beginning of the illness. Status praesens: E.e. : Normal. L.e. : Profuse; creamy, purulent discharge. In the posterior meatal wall there is a circumscribed swelling the size of a pea, granulating on its surface. Pressure here causes pus to exude. Ap- parently a perforation in the inferior anterior quadrant. Skin over the mastoid normal. Functional test: For speech (tested with exclusion ap- paratus) and tuning forks, deaf. Cal. ny. not to be elicited on 1. side. Turning ny. 1. . Large rolling spont. ny. r. with eyes in any direction. Fistula symptom . Severe vertigo. Patient stayed under observation until May 24, during which time the vertigo and the rotat. ny. r. dimin- ished, but are still present. Repeated tests of hearing and reactions give the same results. Operation, May 24 (Prof. Urbantschitsch) : Mastoid pneumatic. Its cells filled with non-fetid pus. Typical rad- ical. Labyrinth wall inspected after application of tonogen. Oval window, over which lies a granulation, is empty. The 172 DISEASES OF THE LABYRINTH probe enters without resistance, but produces a twitching of the face muscles, indicating that the horizontal portion of the nerve is exposed. Dura of the posterior fossa is laid bare. Typical labyrinth operation. In the afternoon, after the operation, ny. rotat. r. moderate, but little vertigo and emesis. Patient lies quietly upon her back. Slight facial paresis. May 27 : Patient able to sit up without vertigo. Rotat. ny. r. on looking to r. and forward. Pulse 104, strong and regular. No fever. May 29: First change of dressing. Wound looks well. Patient discharged. June 9 : Wound healing. No vertigo. At no time fever. 61. L. K. Age 4y 2 . Admitted June 4, 1909. Anamnesis: R.e. affected during past five weeks. Dis- charge supposedly three weeks. Fever 39-40 during past two days, and child highly, irritable. Frequent emesis dur- ing past ten days. Status praesens: Temp. 39.1. Pulse 124. Kernig. Slight rigidity of neck. No Babinski. Right hyperaes- thesia, reflexes slightly exaggerated. Cerebrospinal fluid cloudy. L. drum normal. R. drum red. In the posterior segment a teat-like swelling, from which exudes tenacious pus through a paracentesis wound made the day before by the attending physician. Functional test: Hearing test impossible. Large rotat. ny. 1. Cal. react. 0. Fistula sympt. 0. Operation (Ruttin) : Mastoid pneumatic. Cells filled with pus. Dura of middle and posterior fossae laid bare ; normal. Labyrinth operation. Wound inspected after ap- plication of tonogen. Fistula visible. Condition unchanged after operation. July 6 : Death. Postmortem (Dr. Wiesner) : Purulent meningitis. Strep- tococcus pyogenes in the pus. Cerebrospinal fluid shows grampositive cocci in short chains and many leucocyte-. Culture: Streptococcus pyogenes. CASE HISTORIES 173 62. M. Sch. Age 14. Admitted Sept. 10, 1909. Anamnesis: Since early childhood, discharge r. Three weeks ago, discharge became more abundant and a painful -welling appeared behind the ear. Slight fever. The mother says patient had vertigo and stumbled in the morn- ing on arising. Status praesens: L.e. : Drum retracted. E.e. : Back of the external ear, a large fluctuating mass, the size of an apple, covered with reddened skin, extending forward to the zygoma and backward to within two finger-breadths of the median line. Skin infiltrated about the swelling. Meatus filled with a hard polyp. Functional test: Con.v. \'. 2 m. ; with exclusion apparatus applied to 1. ear, deaf. W. r. ; R. and Sch. could not be tested. No vertigo ; no fistula sympt. Spont ny. rotat. 1. ; behind the opaque glasses, spont. rotat. ny. 1. on looking forward. Cal. react. . Tr. r. = after-ny. horiz. 1. 20". Tr. 1. == after-ny. horiz. r. 10". Temp. 37.8. Operation (Bar any) : Abscess opened. Decomposed pus. Eadical operation. Black fistula, size of pinhead, in hori- zontal canal, from which pus pours forth on slight pressure. Typical labyrinth operation. Facial nerve exposed in the region of the facial spur. Twitching. Sinus laid bare 2 cm. Its wall thickened, covered with exudate. Dura of poste- rior fossa laid bare, but not that of the middle fossa. Dress- ing. 4 P.M.: Temp. 37.3. Pulse 84. Normal course. Temp. normal. Sept. 17: First change of dressing. Comfortable. Fa- cial intact. Wound looks healthy. Ny. rotat. 1. very slight, but distinct behind opaque glasses. Sept. 24: Discharged. V/X I 1 180 DISEASES OF THE LABYKIXTII Operation, July 4 (Dr. Froeschels) : Bone hard, no cells. Antrum very small, filled with granulations. Radical op- eration. Sinus laid bare over small area ; normal. Plastic after Panse. July 6 : Dressing wet. Changed. Eczema of external ear and the adjacent skin. Drain removed; also the metal sutures. July 7: Patient complains of vertigo. l>;ul-smelling dis- charge comes through the dressing. Facial as it was be- fore the operation. Hearing (tested with exclusion appa- ratus) : Perceives loud shouting and vowels. Wound nor- mal. Eczema unchanged. Alcohol coin])) esses. July 9 : Eczema improved. Discharge still of bad odor and free. Zinc salve. July 11: Temp. 37.5. Feels well, except for temp. Xo headache or vertigo. Hearing tested with exclusion appa- ratus and with dressing off: Loud shouting faintly per- ceived. July 15: Patient complains since yesterday of nausea and slight headache. Temp. >ince July 13 over 38. This A.M., 36.8. Stronger spont. ny. to both sides; on looking to 1., horiz. ny is stronger than rotat. ny. on looking to r. Hearing doubtful. No cal. react. After tr. ]., ny. horiz. r. 30". After tr. r., ny. = 0. Xo fistula symptom. Wound secretes abundant bad-smelling pus. Eczema better. July 19: Dressing changed. Sudden chill, slight head- ache; otherwise condition is unchanged. Slight pleurisy r. Thickening. Fundi normal. 6 P.M., Operation (Dr. Ruttin) : The granulations cov- ering the inside of the wound curetted away. Sinus lies free for 1 cm. Covered with grayish-red granulations. Dura of posterior fossa laid bare. This is apparently nor- mal. Inner wall of tympanic cavity inspected. Horizontal canal smooth, no stapes, but in its place, granulations. The probe passes without the slightest resistance into the oval window. Promontory soft. Labyrinth opened from behind. The chisel goes through without resistance. Probe CASE HISTORIES 181 passed behind the facial. Dura of middle fossa laid bare ; normal. Sinus laid bare for more than 2 l / 2 cm. Its wall is not entirely normal, but only slightly changed by slight grayish-red exudate. Wound cleaned. White gauze packing. July 21 : Comfortable. No headache. Pulse 84. N\ . rotat. r. = 1. as before, slower to the 1. and more rotatory. Pupils equal, and react promptly to light and accommoda- tion. No headache or vertigo. Lies on back. Facial pare- sis of eye and mouth inervation as before. Abdominal, patellar and ankle reflexes well defined. No ataxia. No sensory disturbances. Mentality normal. Feels well ex- cept for lack of appetite. July 22: Ny. as before. No vertigo, headache or emesis. July 23: Dressing. Wound purulent and bad smelling. HoCK used. Feels well. Ny. rotat. r. 1., the latter slower. No headache, vertigo or emesis. July 25 : Condition of lungs as before. Internally, no cause for fever. (Dr. Biach.) July 26: Because the temperature persists and is pyaemic in character, and the neurological and internal findings are negative, we operated again in the evening (Ruttin). Jugular ligated above the common facial vein. Jugular normal, filled so that it is the size of one's thumb. Sinus laid bare below to the jugular bulb, above to beyond its bend, until healthy tissue is found. Sinus opened and emptied of abundant quantities of grayish-red, fetid, but not discolored, thrombi, which extend from the bulb to above the bend. No bleeding from below, but free hemor- rhage from above. Packing and dressing. July 27 : Fever continues, otherwise patient is comforta- ble. Internal findings negative (Dr. Biach). Stool liquid, fetid. July 28: Dressing. Sinus covered with yellowish-green exudate, very fetid. Bleeding from upper end of sinus. July 29 : Slight pain in r. eyeball and slight oedema of the conjunctiva. Does not complain of pain. Restless at 182 DISEASES OF THE LABYRLMII night. Drowsy by day. No vertigo, no headache. Pulse 88. Ny. as before. July 29, Report from Institute of Pathology: Thrombus from sinus: Masses of bacteria. In the culture, pseudo- diphtheria and proteus (Dr. Wiesner). July 30: Dressing. Sinus covered with thick exudate, very fetid. H 2 2 . Still bleeds from upper end. Jugular wound clean. Complains of pain in throat. Slight redness in throat. Otherwise as before. Ny. as before. July 31 : Eestless at night, drowsy by day. No headache or vertigo. Ny. as before. Pulse 84. Neurological exam, negative. Dressing. Sinus covered with greenish-yellow exudate, fetid ; H.O,. Bleeding from upper end. Slight pro- trusion of r. eyeball. (Diagnosis: Rapidly developed cav- ernous thrombosis.) Aug. 1 : Dressing. Sinus as it was yesterday. H 2 2 . Protrusion greater. Oedema of both lids r. FIG. 25 Aug. 2: Dressing. Sinus as before. Manganese perox- ide and H 2 2 . Condition like that of yesterday, but the protrusion is greater, likewise the oedema of the lids. Evening: Electrargol isoton. 5 c.c. given subcutaneously. CASE HISTORIES 183 Aug. 3: Death. (See temp, chart.) Postmortem (Prof. GJion) : Purulent basal leptomenin- gitis and pachymeningitis interna, especially in the region of the posterior fossa. A recent abscess, the size of a small cherry, on the under surface of the 1. cerebellum. Throm- bophlebitis of the sigmoid sinus, and the bulb of the 1. side of the 1. inferior petrosal sinus and both cavernous sinuses. Eadical operation on the 1. side on account of chronic otitis, with opening of the labyrinth. Thrombi in the peripheral section of the veins (sinuses) named. Acute oedema of the lungs, etc., etc. Bacteriological report: In the exudate of the meningitis, a few long Gram-negative threads. 69. H. W. Male. Admitted July 15, 1910. Anamnesis: Since childhood, a discharge from r. ear, to which patient attached no importance. Three weeks ago, sudden pains in the diseased ear, with intense continuous headache and complete loss of appetite. Three weeks ago, had such severe vertigo that he could not leave his bed and recognized nobody. Also severe ernesis. Now some ver- tigo, but not so much. Temp. 39.2. Pulse 104. Status praesens: Patient sits moaning, with head bent forward. Every movement is painful. On attempting to put the head upright by passive movement, he feels severe pains in the neck, where there is a pronounced rigidity. Passive movements of the head laterally are also impossi- ble. Pupils alike, and react to light and accommodation. Abducens paralysis 1. Facial intact. Abdominal reflexes strong and nearly equal. Patellar reflexes, especially 1., ex- aggerated. Suggestion of ankle clonus. Kernig and Babinski positive. L.e. : Normal. E.e. : Meatus narrow, drum destroyed. A polyp protrudes from the antrum, which is discharging pus which shows pulsation. Functional test: E.e.: Deaf for speech and tuning forks. Tinnitus. W. indefinite. E. oo , Sch. shortened. No spont. ny. No fistula sympt. Cal. react, cannot be demon- strated. 184 DISEASES OF THE LABYRIXTH Operation (Bondy) : Very hard, sclerosed bone. In the antrum, whose walls are smooth like ivory, foul-smelling, thin, brownish pus. Posterior fossa opened. Sinus and dura of the cerebellum discolored over a wide area, thick- ened and covered with granulations. Typical labyrinth op- eration. Some liquid flows from the labyrinth at the close of the operation. Exploration of the cerebellum in differ- ent directions is negative. Dura of the middle fossa widely incised. No plastic. Sinus not opened, in spite of altered wall. Dressing. Lumbar puncture. Cerebrospinal fluid equally cloudy in all three portions. July 16: A.M., temp. 37.8. Sensorium like yesterday, somewhat dull. Reacts when addressed with loud voice. No ny. July 18 : 7 P.M., death. Postmortem (Prof. Ghon) : Eecent fetid leptomeningitis and internal pachymeningitis of the posterior portion of base of brain, in addition to an older leptomeningitis in the 1. Sylvian fissure and on the 1. convexity of the cerebrum; acute internal hydrocephalus, fresh subdural hemorrhage in the region of the convexity and of the base, after inci- sion of a vein in the dura over the right petrosal bone. In- cision of the lateral pole of the posterior occipital lobe, and a small incised wound of the right parietal lobe. Radical operation, with labyrinth operation of r.e. A fetid abscess, the size of a small bean, in the posterior part of the infe- rior lobe. Diffuse bronchitis, confluent, lobular pneumonia foci. Atalectases in the posterior parts of both lungs. 70. J. D. Age 18. Admitted Feb. 23, 1910. Anamnesis: Discharge from I.e. since childhood, follow- ing measles. Conservative treatment since middle of Jan- uary, without results, for which reason the radical opera- tion was performed, Feb. 11, in the sanatorium (Bondy). Sinus exposed over a small area, dura of the middle fossa widely exposed. Both normal. Panse-plastn . Feb. 12: Temperature rises to 38.3. Slight vertigo on CASE HISTORIES 185 turning. Ny. to the healthy side, disappears on looking to diseased side. Evening: Change of dressing. Hears spoken voice, but does not understand. Middle fork heard 1. Irrigation with hot water has no effect. Dressed with xeroform gauze. Feb. 13: Ny. somewhat less. Otherwise condition is the same. Cal. test gives no response. Temp. 37.6, 38.3. Feb. 14: Ny. only on looking to the healthy side. Irri- gation with cold water greatly intensifies the ny. Temp. 37.5, 38.0. Feb. 15 and 16 : Condition the same. Temp. 37.3, 37.6. Feb. 17 : Normal temp. Ny. on looking to healthy side is* noticeable. To Feb. 21 : Normal temp. Daily dressing. Discharged from the sanatorium. Feb. 22 : Temp, elevation to 37.4. Severe headache. Can- not sleep. Feb. 23 : Condition the same. Transferred to the clinic. Ophthalmoscopic findings normal (0. Ruttin). Pupils equal, react promptly. No Kernig, no increased reflexes. No hyperaesthesia. Dressing changed. Labyrinth not af- fected by hot or cold irrigation. L.e. : Total deafness. Temp. 37.8. Feb. 23, Labyrinth operation: Typical. Oval window appears to be empty, for the probe enters easily. Dura of the cerebellum laid bare from the exposed sinus. The bone covering the superior petrosal sinus was left untouched. Vestibule widely opened. Facial twitching once during the operation. In the angle between the dura of the cerebellum and the facial nerve, below the vestibule, there is a granula- tion extending into the vestibule (perilabyrinthine cell). The dura of the cerebellum distinctly discolored a brownish- red. Incision here with puncture of the cerebellum with the brain knife gives a negative result. Horizontal incision sewed. Dressing. Feb. 24: Moderate pains in the wound. Head free; vomited once. Ny. unchanged. Temp. 36.0-37.2. 186 DISEASES OF THE LABYh'lMII Feb. 25 : Xy. chiefly horiz. to healthy side, more strongly rotat. to diseased side ; vertical ny. on looking upward. De- cided headache. No stool for three days. Enema with good results. Dressing. Wound shows nothing unusual. Eczema of pinna. Alcohol dressing. Pulse 68. Temp. 37.4, 36.0. Feb. 26: Unable to sleep because of headache. Ny. un- changed. Objects held to 1. of patient he is unable to fix for any length of time (fixation paresis 1. ?). No diplopia. Dressing. Frequent emesis. Pulse 64. Temp. 37.7, 37.2. Feb. 27 : Again unable to sleep on account of headache. Pulse 60. Diplopia on looking to the 1. Dressing. Incision of the cerebellum opens an abscess, from which a table- spoonful of thick, creamy pus flows. Drainage with iodo- form gauze soaked in H 2 0o. After the incision, almost im- mediate disappearance of the headache. Pulse 66. Temp. 36.2 to 37.6. P. M. : Temp. 37.6. Pulse 90. No more emesis, no headache. Feb. 28: Report from the Pathological-Anatomical In- stitute on pus from the cerebellum : Streptococcus pyogenes (Dr. Bartel). Slight headache during the night. Dressing. A rubber drain introduced into the abscess cavity. Pulse 72. Evening: Dressed again, on account of severe head- ache. Ophthalmoscopic exam. (Dr. 0. Ruttin) : Fundus normal. Temp. 36.6 to 37.0. Mch. 1: Slept until 2 A.M., then awoke, but without pain. Pulse 84. Dressing. Abscess cavity irrigated with H K 2 . Drainage, pains for one-half hour. Then no pain. Appetite good. Evening: Feels well. Temp. 36.3 to 37.4. Mch. 2: Severe headache during the night; vomited three times. Dressing. Little pus, but upon entering the cav- ity with the dressing forceps, a large amount of pus comes from the cavity. Headache is at once less. Irrigation with H 2 2 . A strip of iodoform wick is introduced. Diplopia is less. Slight headache in the evening. Dressing. Temp. 36.3 to 36.9. CASE HISTORIES 187 Mch. 3: Slept well, appetite good; no more cliplopia. Pulse 100. Dressing. Temp. 36.0-37.1. Mch. 4: Feels entirely well. Dressing twice a day. Ex- cellent appetite ; sleeps well. Temp, normal. Mch. 5 : Condition the same. Xy. appreciably less, but still pronounced, and lioriz. ny. to both sides, vertical ny. on looking up or down. Mch. 9 : Some headache in the morning. On changing dressing, some retention of pus evident. Drained with iodo- forni gauze (heretofore iodoform wick had been used). Evening, free from headache. Ny. as before, but decidedly less. Wishes hot food. Mch. 12: Up to this morning, felt entirely well. On changing dressing, immediately after irrigation of the cav- ity with IL0 2 (which heretofore has always been well tol- erated), there is very severe headache. No retention of pus evident. Ate well at noon, but soon vomited it all. P.M. : Increasing headache. On changing dressing, nothing un- usual, and no pus. Puncture of the cerebellum in various directions is without result. Emesis after the dressing. Pulse 57. Arythmic. Left abducens paralysis. Mch. 13 : 5.30 P.M., death. Postmortem (Prof. Glion] : A hemorrhagic abscess, about the size of a small nut, in the 1. cerebellar lobe, embracing nearly all of the central portion, about to perforate at the posterior pole. Puncture of the abscess and drainage with gauze (Feb. 27); radical operation 1. (Feb. 10); labyrinth operation (Feb. 23) ; recent puncture of the 1. cerebellar hemisphere (Mch. 12). Circumscribed lepto- and pachy- meniugitis interim on the posterior portion of the petrosal bone, with adhesion of the left cerebellar hemisphere in this region. Internal hydrocephalus and a few hemorrhagic points in the ependyma of the lateral ventricle. General hyperaemia of the internal organs. Hyperplasia of the lymphatic tissue of the mouth and pharynx, of the splenic follicles and, in a limited way, of the follicles of the small intestines. Colloid struma. Open foramen ovale. 188 DISEASES OF THE LABYRINTH Bacteriological report: 1. Haemorrhagic exudate of the cerebellar abscess. Abundant and exclusively grampositive cocci of the streptococcus pypgenes type. 2. The contents of the lateral ventricle, sterile. 71. J. R. Age 14. Apprentice. Admitted Oct. 3, 1907. Anamnesis: Discharge from r.e. at age of 10, following scarlet fever and diphtheria. This lasted a couple of years. One month ago, a free discharge began. Two weeks ago, patient had vertigo, when objects seemed to move; his gait was somewhat unsteady; there was emesis, headache and lancinating pains behind the ear. Hearing was not noticea- bly diminished. The same manifestations again appeared three days ago. Hears well on 1. side. Says he has always been well. Status praesens: Mastoid process not swelled or sensi- tive to pressure. Infra-auricular gland somewhat painful on pressure. Large perforation in drumhead, with whitish polyp, posteriorly located. Functional test: R.e.: Con.v. 2 m., whisp. 0, c 4 , C t +, when struck hard. Spont. ny. to 1. on looking forward and to the 1. Fistula sympt. negative. Test with conversation tube, con.v. without error. Whisp. not heard. After tr. 1. ny. horiz. r. 5" ; after tr. r. horiz. ny. 1. 30". After tr. 1., with head bent forward, ny. rotat. r. 8" ; after tr. r., head inclined forward, ny. rotat. 1. 22". After irrigation, r. ear, with 2 bags of cold water, only slight ny. 1., no stronger than the existing spont. ny. Temp. 37.8. Radical operation: After opening the mastoid, granula- tions appear in the tympanic cavity and antrum ; also dis- eased cells in the posterior superior angle of the mastoid. No cholesteatoma. No fistula to be seen. The region be- tween the three semicircular canals is very carefully cleaned out and inspected. After making smooth the surface of the wound, plastic closure (Neumann} is made. Oct. 4: About midnight, temp. 39.0. This morning. Patient is noisy, tosses about in bed, face drawn with pain. CASE HISTORIES 189 Complains of headache, frequent vomiting. Pulse 80. Ir- ritable. Kernig +. Operation: Wound opened. Sinus lies well forward. Cochlea opened. Facial is intact. Dura of the middle and posterior fossa opened. Drainage. Wound cleaned and dressed. On opening the softened promontory and the vestibule, no labyrinthine fluid escaped. Oct. 5: Patient feels better. Less emesis and normal temp. Headache is better. No vertigo. Pulse 72. At 1 P.M., he has fever (38.4) and pains in the head and sacrum. Oct. 6: Patient has some fever, less headache. Com- plains of pain in sacrum and in both feet, which are not swelled or sensitive to pressure. No vertigo. Ny. r., which was not present yesterday. Dressed 1 P.M. No discharge. On pressing on the dura of the middle fossa, there is bleed- ing from the petrosal sinus. Temp. 38.3. Oct. 7, A.M.: Kernig + Some restlessness. Pulse 82. Xy. to the healthy side, none to the diseased side. Temp. .'17.0. Pain in the legs on movement. Slight headache. No disturbances of co-ordination. Ophthalmoscopic exam, shows the papilla swelled, with outlines somewhat indis- tinct; veins somewhat widened and tortuous. This condi- tion is more pronounced in the r. eye than in the 1. Oct. 8, A.M. : Slept little during the night ; was very rest- less. Pulse 72. Ny. to both sides. Evening: Ny. r. Fa- cial paralysis r. in all divisions. E. angle of mouth twitches. Unconscious, delirious. Dressing. Wound clean. Explora- tory incision of the parietal lobe and the cerebellum through the previous wounds; the parietal lobe cut in three direc- tions. Death the same day. Postmortem, Oct 9 : Basal meningitis, with severe oedema of the brain. Left petrosal trephined. Sinus empty. Lobar pneumonia. Haemorrhagic foci in both lungs. Fatty degeneration of parenchyma of internal organs. Dilatation of ventricle?. Diplococcus pneumoniae in the exndate. 190 DISEASES OF THE LABYRINTH 72. M. R. Age 6. Admitted Jan. 13, 1908. Anamnesis: For several years, a fetid discharge from 1. ear. Face distorted for two weeks. Status praesens: R.e. : Normal. L.e. : Slight postauricu- lar swelling without fluctuation. Pus and cholesteato- matous masses in the canal, which is filled in its lower part with granulations. Functional test: Deaf for speech and tuning forks. Cal. react, not demonstrable. Tr. r. == 0. Tr. 1. == prompt ny. r. No fistula symptom. Spont. ny. rotat. r., hut slight. W. r. Operation, Jan. 14 (Rnttin) : Typical incision through the skin and infiltrated tissues. The knife enters a depres- sion in the upper end of the wound. After pushing aside the periosteum there appears a cavity the size of a walnut, filled with movable sequestra, abundant granulations, cholesteatomatous layers and fragments and some very fetid pus. The rough, unrecognizable sequestra, covered with poorly defined granulations, are removed. Three of them measure from one to four cm. in their greatest diame- ter. The resulting cavity is the size of a hen's egg. The dura of the middle fossa lies exposed from the carotid canal to the sinus and from the upper angle of the pyramidal bone to the squamous; further, a strip of the dura of the poste- rior sinus, li/o to 2 cm. long, lies exposed in front of the sinus. The dura of both fossae is everywhere thickened, grayish-red. In the region of the sinus, many fungus-like granulations are removed. The sinus is laid bare until healthy tissue is reached. There remains of the pyramid only its posterior and lower walls and a portion of bone, which may contain the facial nerve. At the site of the laby- rinth there is a smooth-walled cavity the size of a hazelnut. Plastic after Panse. Dressing. Jan. 20: First dressing. Granulating. No discharge. Facial paresis the same. Feb. 4: Dressing every other day. Wound granulating CASE HISTORIES 191 nicely. Abundant discharge, not fetid. Bronchitis. Facial paresis the same. Dressing every other day. Feb. 17 : Wound granulating well. Its lower angle still open. Borated alcohol. Allowed to go home. 73. K. F. Age 22. Male. Admitted Apr. 8, 1908. Anamnesis: No children's diseases recalled. The r.e. has run since childhood, but patient knows no cause. Xo treatment until six to eight weeks ago. Never had earache; no vertigo, emesis or headache. The discharge has been constant and always very bad smelling. Six weeks ago, in- fluenza, following a cold. Then he noticed no unusual ear symptoms; the discharge was the same as before. Head- ache, especially at the vertex, but also radiating forward and backward. Emesis once, three weeks ago. For two weeks, vertigo, especially on walking, with a sensation of falling backward. Chills and fever during past 2-3 weeks. Status praesens: Patient complains continuously of pain. Sensitive to percussion in the region of the vertex. Mas- toid, especially at the tip, very sensitive to pressure. Head can be moved actively and passively with slight pain. Cer- vical spine sensitive to pressure. Pupils equal and of me- dium size; react promptly. Eye muscles move freely. K. papilla distinctly hyperaemic, with slight oedema. Facial: Right upper lid lags somewhat, but only noticeable when he is told to close his eyes slowly with head bent backward as far as possible. Tongue is promptly protruded. Grip strong and practically equal. Patellar reflex present, pos- sibly exaggerated. Xo foot clonus, no Babinski. Deep re- flexes of the upper and lower extremities present. Cremas- teric reflex alike on both sides. Walks well with eyes open, a slight tendency to fall with eyes closed. A suggestion of Romberg. Stands poorly on one foot with eyes open, im- possible with eyes closed. Xo disturbances of sensory nerves. Trousseau very plainly -f. Kernig O. Pulse 92. Temp. 38.3. Heart: Second aortic sound accentuated. R.c. : Superior posterior meatal wall bulged. Canal filled with 192 DISEASES OF THE LABYRINTH a polyp with broad base. L.e. : Membrane looks normal, but lias small perforation in Shrapnell's membrane. No dis- charge, but a few lamellae of epidermis; probe can be in- troduced into the attic. Functional test: R.e. : Con.v. i/o m., whisp. a.c. ; tested with exclusion apparatus, deaf. B. , Sch. shortened. W. 1., Ci 0, c 4 +> when struck hard. Spont. ny. rotat. r. Cal. react. . Middle fork heard only 13" after being struck hard. Operation (Ruttin) : Mastoid sclerosed. Antrum opened simultaneously with removal of the bridge. Antrum filled with sticky, yellowish-green, very fetid cholesteatornatous fragments, which are removed. The anterior bony wall of the external canal is thickened with hyperostoses, making the tympanic cavity narrow. The inferior wall is likewise thickened. Typical radical operation. Transverse incision backward. Sinus laid bare 2 cm. Its wall is normal. In the horizontal semicircular canal, a fistula, the size of a pin- head, with edges discolored black. Also a fistulous passage in the labyrinth nucleus between the canal and the facial prominence, leading in the direction of the posterior semi- circular canal. In following this passage, we actually come upon the posterior semicircular canal, which has a fistula. The entire bone up to the dura is soft and diseased. Typi- cal labyrinth operation. Vestibule is opened from behind. The probe enters the fossa. In following np the fistulous passage above mentioned, there is twitching of the facial muscles, but this is unavoidable, as the diseased bone in the region must be removed. The dura of the posterior fossa at several points presents single grayish-red granulations. The cochlea is opened from the promontory. Plastic after Panse. Dressing. Apr. 9: Decided improvement. Patient complains of only slight headache. Appetite good. No emesis, no ver- tigo. Ny. rotat. r. == 1. Apr. 10: Improvement continues. Patient complains only slightly of headache; is quite lively. No vertigo, no CASE HISTORIES 193 symptoms of any kind. Ny. rotat. r. = 1., less than yester- day. Neurological report (Primaerarzt Infeld) negative. No fever. Pulse 84. Apr. 18: During the following days, feels well. Ny. to the affected side is still present, but diminishing. A varia- bility in the intensity was not noticed. Vertigo and dis- turbances of equlibrium not present, though patient com- plains of headache, particularly in the .evening. Nothing unusual at time of dressing. Some discharge in the tym- panic cavity, which, with the retrolabyrinthine wound, shows beginning granulation. Apr. 23: Dressing. Very little discharge. No headache; ny. rotat. r. = 1., and very slight. Apr. 25 : Discharged. 74. H. J. Age 58. Musician. Admitted Apr. 30, 1908. Anamnesis; Chr. suppuration 1. Facial paralysis for three weeks. Deafness 1. No vertigo. Some headache, no emesis, no fever. Status praesens: Polyps in the canal, marked discharge. Mustoid not sensitive. Total facial paralysis 1. Temp. 37.8. E.e. : Normal. Functional test: L.e. : Tested with exclusion apparatus, perceives only loud shouting and the tones of the harmonica without differentiating them. W. in head, E. , Sch. short- ened. Spont. ny. (behind glasses) to r. No ny. on mov- ing head. No fistula sympt. Cal. react, not present. Tr. r. = ny. horiz. 1. 8"; tr. 1. = ny. horiz. r. 16". Operation, May 1 : A large sequestrum is felt in the tympanic cavity, which is removed after widening the passage. This sequestrum is embedded in granulations. It contains the inferior wall of the external auditory canal, the inner half of the fossa of the mandibular joint, as well as the facial canal, with the central portion of the nerve lying free. The sinus and the posterior fossa are laid bare. The horizontal semicircular canal and the labyrinth are opened up to the internal auditory ineatus. Through a tear 194 DISEASES OF THE LABYRINTH in the dura of the posterior fossa, a small amount of fluid escapes. Pus comes from the labyrinth. An iodoform wick is placed in the tear in the dura, another in the cavity left hy the sequestrum. Plastic, packing:, dressing. May 1: Temp. 37.3. May 2: Feels well. Temp. 38.6. May 3 : Some headache. Large flow of liquid from the wound. Temp. 39.0. Dressing. May 4: Somnolent. Coma. Death. Postmortem (Decent Bartel) : Purulent meningitis of the base and convexity of the brain. Pachymeningitis puuu- lenta interna of the 1. posterior fossa. Healed apex tuber- culosis. Fatty degeneration of internal organs. 75. J. A. Age 4. Admitted May 1, 1908. Anamnesis: Otitis after scarlet fever. Status praesens: R.e. : Normal. L.e. : Fistula in the mas- toid, marked purulent discharge from the meatus, which is filled with polyps. Temp. 37.1. Functional test: Deaf for speech and tuning forks. Xo spont. ny., no fistula sympt. Cal. react, negative. Turning reaction, after tr. r., weak ( !) ; after tr. 1., strong. Operation, May 2 (Bdrdny) : Radical. Large sequestrum embracing a part of the tegmen and the mastoid. Dura of the middle and posterior fossae lie exposed; likewise the sinus, which is covered with granulations. Posterior meatal wall destroyed. In the labyrinth (in the region of the am- pulla of the anterior vertical semicircular canal), a large, round fistula, out of which appear polyps. The horizontal canal is entirely destroyed, appearing as a groove. Laby- rinth operation, without exposure of the posterior fossa. Vestibule opened from behind. Promontory opened. Fis- tulae of the ampulla and vestibule enlarged, a small bony support left on the other side. Plastic. Facial intact after the operation. May 3: Ny. rotat. 1. Temp. 38.2. May 4: No ny. Feels well ; 38.5. CASE HISTORIES 195 May 5 : Normal tempt, from this date. May 7 : First change of dressing. Wound looks well. May 20: Dressing until now every other day. Wound filled with healthy granulations. Discharged, cured. 76. H. U. Age 22. Female. Admitted May 25, 1908. Anamnesis: R.e. : Diseased for years. Recently no dis- charge. Up to eight days ago, patient complained of tran- sient headaches. During the past eight days the pains have increased; fever, vomiting vertigo. Fourteen days ago, some discharge, bad-smelling pus, after which she felt some better. During past two days, stiffness of neck. Her consciousness undisturbed. The pains are localized in the r. parietal and occipital regions. Hearing on r. side has always been poor. Two normal confinements; now two months pregnant. Husband says he knows of no other sick- ness and himself denies lues. Status praesens: Patient admitted in very bad condition at 11 A.M. Temp. 37.7. Pulse 78 (high tension, rythmic). Of medium size; poorly nourished; anaemic. Lies bent on her left side. Raising her causes great distress, and can be done only passively. Then she holds her head turned to the 1. and backward. If held rigidly, turning head to the median position is very painful. Patient responds when addressed, but lies with eyes closed. No stupor or delirium. Complains of pains in the occipital region and neck. R.e.: Deaf for speech and tuning forks. Fistula sympt. negative. On sitting up and lying down again, very marked, large vertical ny. was produced. Unable to produce it again. Variable, small horiz. ny. when eyes are in extreme abduc- tion. Abducens paralysis. Facial intact. Further exami- nation postponed until consultation with internist and ophthalmologist, for patient asks for a rest. Operation ar- ranged for afternoon. 1.45 P.M. : Patient shows excite- ment, with violence. Then becomes quiet and dies. Postmortem report, May 26, 8 P. M. (Prof. Ghnn) : Dif- fuse, purulent, fetid, meningitis, most marked in the large 196 DISEASES OF THE LABYRIXTH lymph space at the base of the brain. A fetid abscess, the size of a nut, with perforation in the inferior cornu, pyocephalus with pseudomelanosis of the ependyma ; cir- cumscribed internal and external pachymeningitis over the r. antrum; chr. otitis media r. with cholesteatoma in the antrum. In the exudate of the meningitis, abundant bac- teria, chiefly Gram-positive, of various forms. 77. N. R. Age 3. Admitted June 24, 1908. Anamnesis: Scarlet fever eighteen months ago, after which, discharge r. As the condition did not improve, pa- tient was operated one year ago, but the discharge has con- tinued. For past six months, I.e. has also discharged. The father says the child is entirely deaf. No vertigo, headache or emesis. Status praesens: B.e. : A cavity, the size of a cherry, in the mastoid, with margins of bluish-red necrotic skin; and in the deeper parts of the cavity, fragments of necrosed bone. Abundant yellowish-green, thick, creamy pus. Up- per and posterior walls of canal greatly depressed. Granu- lations and cholesteatomatous masses deep in the canal. L.e. : Small fistula behind the ear, discharging fetid yellow pus. Functional test: Child is too young for a reliable test, but it certainly cannot hear with r. ear. Perceives a fork held near I.e. Spont. ny. at most is very slight. Turning ny. : I.e. = ; r.e. = trace. Cal. react, r. == 0, 1. -f . Operation r.e., June 29 (Ruttin) : Incision near retro- auricular fistula. Periosteum pushed aside, exposing a cav- ity filled with necrotic bone fragments and sequestra, dis- colored black. The sequestra, which reach to the dura of the middle and posterior fossae, are removed. Dura of the middle and posterior fossae and the sinus are laid bare over a large area. They are discolored a yellowish-red and cov- ered with granulations. Typical radical operation. A fis- tula is now seen in the horizontal canal. Typical labyrinth operation, under difficulties presented by the smallness of CASE HISTORIES 197 the field and by bleeding from a branch of the styloid artery. Labyrinth opened from behind. Facial nerve lies exposed in the tympanic cavity. Panse's plastic. Dressing. July 4: Dressing. Wound normal. Operation on left side: Typical radical operation. Dura not exposed. Panse's plastic. Aug. 7 : No spont. ny. No ny. after turning. Sept. 9 : Transferred to O.P. Dept. 78. L. M. Age 44. Male. Admitted July 18, 1908. Anamnesis: Seven weeks ago, noticed that his face .was distorted, felt pains in the I.e. ; at the same time, became dizzy and had a fever, so that he took to his bed. A physi- cian gave him electricity every other day. There was then no discharge. Three weeks ago the discharge began, and he was sent to the clinic. Status praesens: External canal wide; a large polyp growing from the antrum covers a part of the drum- head. The rest of the drumhead is reddened and covered with pus. Perforation is not visible. Cholesteatoma. R.e. : Normal. Functional test: L.e. (tested with exclusion apparatus): Con.v. 40 cm. ; whisp. 10 cm. ; Sch. shortened ; c 4 poorly heard. Cal. react, negative. Had vertigo before. No spont. ny. Operation (Ernst Urbantschitsch) : On opening the an- trum, there appear masses of cholesteatoma, which reach to the dura of the middle fossa, which lies exposed over a considerable area. The facial ridge has been entirely de- stroyed by cholesteatoma. In the anterior end of the hori- zontal canal there is a wide fistula, in which it is possible to pass an ordinary probe. Ossicles gone. Dura of the posterior fossa and the sinus not exposed. Panse's plastic. July 21 : Some pain in the wound, no fever, no ny. July 22-25, A.M.: Feels well, no temp. P.M.: Temp. 40. Therefore, dressings are changed. Wound looks very well. No free pus. Light packing. Compresses. 1S DISEASES OF THE LABYRIXTII July 26 : Dressing. Wound normal. No free pus. Some headache. Speech not entirely coherent. Slight stupor. July 28, 7 A.M. : Temp. 37.4. Stupor. Delusions. July 29: Unconscious. 11 A.M.: Death. Postmortem: Decomposed, fatty deposit on the inner surface of the dura in the vicinity of the operative field, and diffuse, dirty, greenish-brown discoloration of the surround- ing parts of the dura. Decomposed abscess in the left pa- rietal lobe, as well as of the parts reaching toward the ver- tex, etc., etc. 79. E. K. Female. Age 3i/o years. Admitted Aug. 26, 1908. Anamnesis: Had scarlet fever thirteen weeks ago. Measles three weeks later. In the fourth week, a severe sore throat and discharge from both ears. Status praesens: R.e. : Canal narrowed, filled with granu- lations. Suppuration. Skin over the mastoid oedematous. Deaf. Cal. react. . L.e. : Drumhead bulging, perforation in the anterior inferior quadrant. Suppuration. Operation (Ruttin) : Large fistula in mastoid, filled with granulations and sequestra, and including a part of the posterior wall of the external auditory canal. Mastoid opened and three sequestra, the size of a bean, removed. Radical operation. Antrum cleaned of granulations. An- trum is enlarged ; its walls all softened. Now is seen a dis- colored fistula, several mm. in diameter, in the horizontal canal. Besides this, a fistulous tract leads into .the laby- rinthine nucleus. This is curetted. The softening extends to the tegmen, which is in part removed, so that the dura, covered with granulations, lies exposed for an area equal in size to a bean. In curetting the tympanic cavity, we see that the posterior meatal wall is largely destroyed. Plastic after Neumann. lodoform wick. Dressing. On the day after the operation, very slight rotat. ny. to the op- posite side, without any vertigo. No preference for any particular posture in bed. During the next two days the CASE HISTORIES 199 slight ny. entirely disappears. First change of dressing shows moderate discharge. Eetro-auricular transverse in- cision. Stitch abscess. Feels well. Sept. 7 : Dressing. Some pus from behind. Removal of a packing which was overlooked. Sept. 9 : Transferred to O.P. Dept. 80. E. B. Female. Age 23. Admitted Sept. 25, 1908. Anamnesis: Discharge from both ears for nineteen years, following measles. Then was deaf on both sides, according to her statement. L.e. improved, while the hearing with the r.e. has always remained very poor. The discharge con- tinued with transient remissions until now. Occasional pains in the r. parietal region. No vertigo, no emesis. Status praesens: R.e.: Drumhead totally destroyed. De- posit of pus on mucous membrane of tympanic cavity. L.e. : Drumhead nearly destroyed. Round window visible. Tym- panic cavity granulating. Functional test: R.e.: Tested with exclusion apparatus, deaf for speech and tuning forks. R. , Sch. shortened, no fistula sympt. Cal. react, negative. L.e. : Con.v. 4!/o m., whisp. 1 m. "W. 1., R. , Sch. shortened; Ci and c 4 short- ened; no fistula sympt. Cal. react. +. After tr. r., ny. horiz. 1. 25" (repeated, 15"). After tr. 1., ny. horiz. r. = 12" (repeated, 16"). Xo tinnitus or vertigo. Spont. ny. slight to both sides. Operation, Oct. 5 (Ern#t Urbautschitsch) : Carious an- trum opened. Dura of the middle fossa laid bare over an area the size of a small lentil. At the lower angle of the facial ridge is a carious area covered with granulations. This is removed. In the carious tympanic cavity only cari- ous anvil is found. The labyrinth probe does not enter the labyrinth, nor does the labyrinth capsule present patho- logical changes. The horizontal semicircular canal is opened, and the. promontory wall removed. Nothing un- usual in the labyrinth. Pause's plastic without sutures. 200 DISEASES OF THE LABYRIXTII lodoform wick packing. During the operation, slight twitching of the face muscles. Oct. 6 : No ny., no headache. 7.30 A.M. : Slight spont. ny. r. 9 A.M. : Slight spont. ny. 1. Oct. 7 : No vertigo, headache or ny. Oct. 8 and 9 : Feels well. Oct. 10: Dressing changed. Healing excellent. No pus. No ny. on pressing on the horizontal canal, or on irrigating with cold saline. Light iodoform packing. Oct. 11-15 : No ny. Normal progress. Oct. 16 : Dressing. Discharged. 81. H. F. Age 9. Admitted Sept, 25, 1908. Anamnesis: Chr. suppuration both ears, healed on 1. side, present on r. Fell upon head six weeks ago. Brought to the clinic because of emesis, fever and headache. Status praesens: L.e. : Dry perforation. Membrane to- tally destroyed. Promontory covered with epithelium. E.e. : Perforation below the hammer. Slight discharge. ]\Iastoid not sensitive. Slight stiffness of neck. Variable headache, especially over the forehead. Nasal cavity nega- tive. Hypertrophied tonsils. Reflexes normal. No ataxia. Pulse small. Somewhat irregular respiration. Splenic en- largement. Functional test: Tested with exclusion apparatus, deaf for speech and tuning forks. No fistula sympt. Cal. react, and turning react, not demonstrable. Spont. ny. r. (mod- erate). No vertigo. L.e.: Hearing and caloric react, nor- mal. Repeated emesis. Beautiful example of domed skull (Turmschddel). Operation: The first blow of the chisel exposes the sinus pulsating in the wound. A small amount of pus and granu- lation tissue in the antrum. Radical operation. Facial ridge smoothed without facial twitching. Prominence of the horizontal semicircular canal intact. Oval window filled with granulations. Stapes cannot be found. Labyrinth opened from the promontory and the ampulla of the hori- CASE HISTORIES 201 zontal and anterior vertical canals. In cleaning the hypo- tympanic cavity, some bleeding. In exposing the floor of the tympanic cavity, the pulsating jugular bulb appears. Plastic after Panse. Dressing. Xo flow of lymph. Lum- bar puncture. Low pressure. Turbid cerebrospinal fluid. After the operation, the patient does not complain of pains. No ny. At 2 A.M., sudden death. Postmortem (Dr. Wiesner) : Purulent meningitis of the base of the cerebrum and cerebellum; abundant exudate, acute oedema of the brain. Multiple old hemorrhages over the convex surface of the cerebrum ( ; ' plaque jaune") after trauma of the skull. Eadical and labyrinth operation of r. ear for chronic otitis and labyrinth suppuration, etc., etc. Bacteriological findings : Streptococci. 82. M. M. Age 60. Male. Admitted Jan. 14, 1909. Anamnesis: Since Dec., 1908, has had trouble with r.e., following an influenza. Four days later, discharge, which has continued. Eight side of patient is painful, especially at night. No vertigo at present, no tinnitus. Status praesens: L.e. : Normal. E.e. : Total destruction, polyps. Functional test: Con.v. iy 2 m. Whisp. % m. With ex- clusion apparatus to 1. ear, total deafness. W. r., E. , Sch. shortened; C 0, d 0; c 4 0. Some spont. ny. rotat. 1. A trace of rotat. ny. 1. behind opaque glasses. No fistula sympt. Cal. react, not demonstrable (3 irrigations with cold water). Operation, Jan. 16 (Bondy] : Bone sclerotic. Antrum large, and filled with pus and cholesteatomatous material. Typical radical operation. Foramen ovale empty. Hori- zontal canal has a large fistula, and probe presses out gran- ulations and pus. The bridge between the fistula and the foramen ovale is about 1 mm. in thickness. Typical laby- rinth operation, with exposure of the dura of both fossae. On cleaning out the cochlea, a large polyp comes out of the 202 DISEASES OF THE LABYRINTH fistula in the horizontal canal. Total facial paralysis after the operation. Jan. 17: Slight ny. on looking toward the healthy side. No vertigo. Evening: Temp. 38.0. Dressing changed. Feb. 24: Partially covered with epidermis. Discharged. 83. J. K. Age 29. Admitted Jan. 26, 1909. Anamnesis: Discharge from I.e. since childhood; from r. ear for four or five years. In Nov., 1909, severe attacks of .vertigo. Severe pain in the I.e., so that the patient lay in bed four weeks. Gradually the vertigo decreased, but re- curs on bending or running. Still has headache, more on 1. side. Temp. 37.2. Status praesens: R.e. : Drumhead largely destroyed, two granulations from above. On the promontory, dried se- cretion and particles of epidermis. L.e. : Large polyp, fill- ing meatus. Dried secretion. Drumhead not visible. Polyp comes apparently from attic. Functional test: R.e.: Con.v. 5-6 m. Whisp. 1 m. W. r. T R. , Sch. lengthened. Ci +, c 4 +. Spont. ny. r. No fis- tula sympt. Caloric react, prompt. L.e. : Tested with ex- clusion apparatus, deaf for speech and tuning forks. No fistula sympt. Cal. react. 0. After tr. 1., ny. horiz. r. 21". After tr. r., ny. horiz. 1. 12". No spont. ny. Operation, Jan. 29 (Bdrdny] : Radical operation. A large fistula in the horizontal semicircular canal, through which granulations can be removed from the labyrinth. Labyrinth operation. Posterior fossa laid bare. The hori- zontal canal is removed, exposing the facial nerve. Base of the petrosal bone removed. Promontory opened. Laby- rinth filled with granulations. No flow of cerebrospinal fluid. Temp. 37.3; Jan. 30, 37.6; Jan. 31, 37.2; Feb. 1, 37.1 to 38.0. Feb. 2: 37.4 to 38.0. Feb. 13 : Occasional fever. Discharge less. Feb. 14: Dismissed to O.P. Dept. CAXE JIJSTOKIKS -Ji>:{ 84. E. P. Female. Admitted Feb. 3, 1909. Anamnesis: Disease of r.e. for thirty-two years, during which time there has been discharge, except at short in- tervals. Occasional treatment. Has frequent headaches. For one week, very severe headache on r. side, extending into occipital region; evening, vomiting; at first, food; later, mucus. The next day she noticed a swelling over the zygoma and the upper half of the nose. At the same time she had severe pains in this region. The swelling subsided, but the pain remained. Status pmenens: L.e. : Normal. R.e.: Large perforation in the anterior superior quadrant ; within the perforation, abundant masses of epithelium (cholesteatoniaf). Small perforation in the posterior superior quadrant behind the hammer. Slight fetid discharge. Temp, normal. Functional test: R.e.: Deaf for speech and tuning forks (tested with exclusion apparatus). \V. in head, R. oo , Sch. shortened; slight spont. ny. rotat. to 1. Cal. react, not demonstrable. Fistula sympt. 0. After tr. r., ny. horiz. 1. 15"; after tr. 1., ny. horiz. r. 10". Operation, Feb. 5 (Ernxt Urbantschitsch} : Radical op- eration. Bone sclerotic, antrum small. Facial ridge very prominent, horizontal semicircular canal intact. Granula- tions in the hypotympanic cavity. Dura of the middle and posterior fossae, and also the sinus, laid bare. Vestibule opened. The labyrinth probe enters the middle ear in front of the posterior surface of the pyramidal bone. Cerebro- spinal fluid flows away. Dura of the posterior surface of the pyramid adherent to the bone. After the operation, the facial is intact. Some pain in the wound, frequent emesis during the night. Feb. ."): Kvening. Facial intact, no ny., temp. 37.4. Feb. 6: Some pain in wound, and headache; facial in- tact, no ny., temp. 37.8. Feb. 7: Relatively well and looks well. Has a good ap- petite, no fever, temp. 37.2. Feb. 8: Headache during the night. Very pale and ex- 204 DISEASES OF THE LABYRINTH tremely weak, unable to take liquids without help. A.M. : Vomited once. Very irritable ; easily frightened. Hysteri- cal. Suspicious. Feb. 9: Temp. 37.8. Feb. 10: Feels better. Headache less. Appetite better. Sleeps poorly. Temp. 37.8. Feb. 11 : Subjectively better. Has dressing while sitting up. Wound doing well. Posterior to the facial prominence and horizontal semicircular canal, it is entirely dry. In the labyrinth a single drop of pus. Light packing. Dressing. Temp. 36.8 to 37.4. Feb. 15 : Feels well. Out of bed once. Temp, to Feb. 15, between 37.2 and 38.0. Feb. 16: Some headache, otherwise well. Dressing. Wound healing well. Slight deposits on the dura. Little discharge. Temp. 37.4. Feb. 17 : Feels well. Dressing. Temp, normal from now on. Feb. 19 : Dressing. Transferred to O.P. Dept. 85. T. K. Age 3. Admitted June 14, 1909. Anamnesis: Nine weeks ago, measles. Until then, well, though child has complained of pain in 1. e. when washed during past six months. Discharge was not noticed. L.e. began to discharge while in the hospital with measles. Scarlet fever followed measles, when r. ear began to dis- charge. Nephritis. Discharged from Franz-Joseph Hospi- tal fourteen days ago. Status praesens: Large perforation. Fetid secretion. L.e. : Large perforation in anterior inferior quadrant. Fis- tula behind the ear. Functional test: Hearing test impossible. Cal. ny. r. +, 1. 0. No spont. ny., no fistula sympt., no fever. Eczematous conjunctivitis. Operation, June 15 (Bondy] : Sequestrum of part of mas- toid surface the size of a heller piece. Radical operation. A round fistula in the horizontal canal, through which the CASE HlST01Ut:s 205 probe is easily passed. Dura of posterior fossa laid bare and the semicircular canal opened from behind. Vestibule not opened. Granulations in the horizontal canal. Cochlea cleaned out. P.M.: Patient has not vomited and is veiy bright. Temp, normal. Slight ny. rotat. r. No fever. July 11 : Transferred to O.P. Dept. 86. Th. S. Female. Age 13. Admitted Aug. 28, 1909. Anamnesis: In May, patient noticed an abscess back of the ear which had discharged since Jan. Abscess opened spontaneously. Had headache ; no emesis. Status praesens: L.e. : Normal. K.e. : Drumhead red, covered with fetid, greasy pus. % Retro-auricular swelling with elevated fistulous opening. Facial paralysis for five weeks. Functional test: With exclusion apparatus, deaf for speech and tuning forks. W. 1., K. , Sch. shortened; no spont. ny., no fistula symptom. Cal. react, not demonstra- ble (possibly the slightest trace). After tr. 1., horiz. ny. r. 5 movements in 10" ; after tr. r., ny. horiz. 1., 36 movements in 26". Operation (Ruttin) : Sclerotic mastoid opened. Sinus lies well forward ; normal. Typical radical operation. Pin- head fistula in horizontal canal. Inner wall of tympanic cavity covered with diffuse granulations which fill the cochlea. Probe enters the oval window freely. Vestibulum opened from behind. Probe passed back of the facial into tympanic cavity. The probe encounters a loose fragment of bone in the depths of the labyrinth, which, on being re- moved, proves to be a part of the lower turn of the cochlea. Dura of posterior fossa laid bare and the vestibulum opened from behind. Curettage. Dressing. Temp. 37.9. Sept. 5, 36.9 to 38.4; Sept, 6, 36.5 to 37.8; Sept. 7, 36.7 to 37.7. To Sept. 8: Ny. rotat, 1., not very large. No vertigo. Temp, from now on normal. Sept. 10: First change of dressing. Wound healthy; slight discharge. Packing removed. Sept. 16: Transferred to O.P. Dept. 206 DISEASES OF THE LABY1UMII 87. M. R. Female. Age 21. Admitted May 14, 1909. Anamnesis: In Feb., 1908, had pains in I.e., followed by discharge, lasting until summer. After conservative treat- ment the discharge ceased, returning in the winter. Re- newed discharge since Feb., continuing until now. In the beginning of this attack, vertigo for two days, and tinnitus until now. No emesis, much headache. Status praesens: L.e. : Mucous membrane of tympanic cavity granulating. Fetid discharge. Deaf .for speech and tuning forks. Fistula sympt. . Cal. react. 0. Temp. 37.6. R.e. : Drumhead retracted. Calcifications. Operation (Ruttiii) : Cholesteatoma in antrum, which has destroyed its lateral wall apid has invaded the meatus. Typ- ical radical operation. Region of the oval window is cov- ered with a granulation. Probe enters without resistance through the oval window. Typical labyrinth operation, with exposure of the dura of the posterior fossa. Probe passed behind the facial appears in the posterior fossa. No flow of the cerebrospinal fluid. Promontory removed. Fa- cial intact. May 18: Severe ny. rotat. r. Vertigo, emesis; lies on r. side. Temp. 37.8. Pulse 80. May 19: Ny., vertigo, vomiting like yesterday, nausea, headache, pain in wound. Temp. 37.2, pulse 80. May 20: Headache less, ny. rotat. r. somewhat less. Nausea and vertigo. Pain in wound. Lies mostly on r. side, but sometimes upon back. Temp. 37.6. Pulse !)L'. May 21 : Condition decidedly better. Ny rotat. r. much less. No nausea, slight vertigo. Pain in head and in the wound. Lies upon back. Evening: Sudden nausea and vomiting. I examined patient about half an hour after the onset of this attack during the nausea and vomiting, but could make out no essential change in the existing ny. Temp. 36.6. Pulse 72. May 22: Feels well. Ny. rotat. r. very slight. Some headache and pain in the ear. P.M.: Complains of sudden nausea and severe vertigo; severe attack of ny. rotat. r. CASE HISTORIES 207 This ny. unchanged by sitting up. Feels well again after one-half hour. Temp. 37.6. Pulse 72. May 23 : Feels well, except for headache and pain in ear. Ny. rotat. r. slight. Appetite good. First change of dress- ing. Abundant discharge, not fetid. Dura looks well. Xo cerebrospinal fluid. Temp. 37.4. Pulse 84. May 24: Noticeably well. No headache, no pain in the ear. Lies upon back, for the first time, without cold com- press to forehead. Vertigo on sitting up, but less. Temp, normal. No more vertigo. Ny. rotat. r., slight and small in movement. Wound shows normal course. Occasional tinnitus in operated ear. June 30 : Transferred to O.P. Dept, with wound nearly healed. 88. H. St. Age 4. Admitted Sept. 20, 1909. Anamnesis: At age of one year, discharge from 1. ear. Since then, occasional discharge. Increased discharge dur- ing past fourteen days. Since yesterday, mother noticed a swelling behind the ear. Status praesens: Fluctuating swelling behind 1. ear. Fetid pus and cholesteatoma in the canal. Granulations deep in canal. Functional test: Hearing test impossible. Cal. test. 1. 0. Turning ny. r., prompt; 1., practically 0. No fistula reac- tion. No spont. ny. Slight facial paresis recognized by slow closing of eyelid when head is bent backward. Operation, Sept. 21 (Ruttin) : Fistula, the size of a pea, in the cortex. Extensive destruction of the mastoid, which is filled with pus and granulations. The diseased bone ex- tends to the dura of the middle and posterior fossae and to the sinus, all of which lie in part exposed and are covered with granulations. Before healthy tissue is reached, the jugular bulb is exposed and laid bare according to the method of Voss. The bulb appears to be normal. Healthy dura over the cerebellum is first encountered, below, near the cranial base; posteriorly, behind the sinus; above, over 208 DISEASES OF THE LABYRINTH the bend of the sinus, and forward, cannot be found before proceeding with the labyrinth operation. Typical labyrinth operation. Dura of the middle fossa is laid bare over an area the size of a gulden before healthy tissue is reached. Angle of the pyramid is removed as far as the labyrinth nucleus. Plastic. Sept. 22 : The child is noticeably quiet. No ny., no ver- tigo. Lies upon r. side. No emesis. Complains only of headache. Restless sleep. Temp. 37.2. Sept. 23: No ny., no vertigo. Slept quietly. Pulse 92. Temp. 37.4. Normal course. Discharged, with granulating wound, Oct. 21. 89. B. M. Female. Age 50. Admitted Sept. 28, 1909. Anamnesis: Chr. discharge. For ten days, severe pains in ear, with vertigo and vomiting. No fever. At the same time patient noticed that her face was "crooked." Stum- bled on walking. Her physician referred her to the clinic. Status praesens: L.e. : Noticeable facial paresis. Ex- tensive otitis externa, preventing otoscopic examination. R.e. : Drumhead thickened anteriorly, very atrophic and re- tracted posteriorly. Functional test: R.e.: Nearly normal. L.e.: Tested with exclusion apparatus, deaf for speech and tuning forks. W. 1., R. , Sch. lengthened. Spont. ny. rotat. r. Cal. re- act. : It cannot be determined whether or not the spont. rotat. ny. r. is increased by the irrigation. Fistula symp- tom : Excessive movement of the eyes prevents a satisfac- tory test. Oct. 2: No caloric react, (cold water). Fistula test can- not be made. Spont. ny. perhaps a little less. Otitis ex- terna less. No fever. Oct. 4 : Spont. ny. rotat. r. as marked as before. Fistula test cannot be satisfactorily made. Cal. test : One irrigator full of cold water causes no change in the spont. ny. De- CASE HISTORIES iM!) creased otitis externa permits one to see a total destruc- tion of the drum; cholesteatoma; the probe touches bare bone. Upper wall of meatus slightly swollen. Serous, haemorrhagic discharge. Deaf (tested with exclusion ap- paratus). Turning test cannot be satisfactorily made on account of the severe spont. ny. rotat. r. Operation, Oct. 5 (Prof. Urb ants chit sell) : Mastoid ex- tensively destroyed beneath the surface. Granulations and masses of cholesteatoma in the antrum. Dura of the poste- rior fossa, which is covered with granulations, is laid bare. Sinus, laid bare, is only slightly altered. An abnormal con- nection between the lateral sinus and the petrosal sinus. The angle is removed. Typical radical. In the horizontal semicircular canal is an elongated, discolored fistula, 2 mm. long. Typical labyrinth operation. The horizontal portion of the facial nerve lies free in the tympanic cavity. Oct. 10: First change of dressing. Sutures left in place. Dressing every other day. Suppuration slight. Small se- questra are thrown off. Oct. 22: Transferred to O.P. Dept. Temperature has been alwavs normal. * 90. K. P. Age 22. Admitted Feb. 4, 1910. Anamnesis: R.e. : Was always normal. Discharge from I.e. for fourteen years, occasionally stopping for a short time. Since Jan. 20 there have been severe, tearing pains, particularly at night. Xo headache or emesis. Measles at age 9. One year before, glands behind I.e. swelled, and after fourteen days broke and discharged, but healed over after two or three weeks. This recurred every two or three months, lasting for one or two weeks, until his fourteenth year. Thereafter no more retro-auricular suppuration. The suppuration of the I.e. began with the glandular suppura- tion, and continued, except for short intervals, until now. No pains until Jan. 20, 1910; never any vertigo or nausea, and, he says, no fever. Always well (labored as farmer until admitted). External ear never affected. Mother died 210 DISEASES OF THE LABYRIXTH of "catarrh of lungs" at 38. Father well. One brother and one sister always well. Moderate drinker. Denies lues. Status praesens: R.e. : Hammer prominent and fore- shortened. In front of the hammer, an elongated calcifica- tion. Function normal. L.e. : A little pus in the canal. The posterior meatal wall is so swelled that it touches the ante- rior wall. Functional test: L.e.: Tested with exclusion apparatus, deaf for speech and tuning forks. W. 1., R. , Sch. shor- tened. No spont. ny. No fistula sympt. Cal. react, not demonstrable. After tr. 1., ny. horiz. r. = 21". After tr. r., ny. horiz. 1. == l"-2". Temp. 39.2. Operation, Feb. 5 (Ernst Urbantschitsch) : On retract- ing the periosteum, the outer, wall of the mastoid appears to be inflated and approximates the anterior meatal wall. On opening this cyst-like bone, whose wall is only about 2 mm. thick, a decomposed pulsating cholesteatoma pours forth. On sponging, there is repeated facial twitching. After removing the posterior meatal wall, we see the tym- panic cavity invaded by the cholesteatoma, which extends even into the tube. The ossicles, including the stapes, are gone. Granulations in the oval window. The probe passes easily into the labyrinth. In the horizontal canal, a large fistula, with granulations, into which an ordinary ear probe cannot be passed. No reaction upon pressure on the fistula opening, nor after hot and cold irrigation. Typical laby- rinth operation. Escape of cerebrospinal fluid. Dura of the middle fossa very prominent. Wall of sinus (already exposed) somewhat thickened and covered with granula- tions. Considering this fact, and also the elevation of tem- perature, the sinus is opened, and found to be entirely free from blood and thrombi and having a lumen the size of a quill. Feb. 6: Comfortable. No spont. ny. or vertigo. Head- ache much better; no nausea. Flow of cerebrospinal fluid. Facial paresis, but the 1. eye can be half closed. Temp. 37.4. CASK HISTORIES 211 Feb. 7 and 8 : Comfortable. Sleep and nourishment sat- isfactory. Normal temp. Feb. 10 : First change of dressing. No free pus. Wound healing well. Feb. 11-16: Healing progressing favorably; no free pus in the tympanic cavity. Facial nerve paralyzed in its lower division, while there is only paresis of the upper division (1. eye can be more than half closed). Feb. 18-22: Normal course. Feels exceedingly well. Feb. 23-28 : Condition as above. Mch. 4: Transferred to O.P. Dept. Report on pus (Prof. Ghon) : Microscopically, an abun- dant conglomeration of bacteria : 1. Gram-positive cocci in pairs in short chains, round and elongated. 2. Gram-posi- tive bacilli of the fusiform type. 3. Gram-positive bacilli in capsules. 4. Gram-positive bacilli, of variable breadth and thickness. 5. Gram-positive bacilli with club-shaped ends. 6. No acid fixing bacteria. M. E. M. Age 8. Admitted Feb. 15, 1910. Anamnesis: Discharge from I.e. during past year. Then an abscess formed behind the ear, with vertigo and head- ache, which at once improved when the abscess broke. No fever, emesis or vertigo. Status praesens: L.e. : Normal. R.e. : Behind the pinna, a radiating tear, in part adherent to the bone. Upon the scar lies a brownish crust. Drumhead swelled, reddened, with a perforation* in the anterior inferior quadrant. Gran- ulations. FuHctioiuil test: With exclusion apparatus r., I.e.: Deaf. \Y. 1., R. , Sch. shortened. 0, +, c 4 +. No vertigo. Spont. ny. r. not always clearly rotatory, to the 1. slight, more horiz. No fistula sympt. Cal. react.: The spont. rotat. ny. r. is increased (?). No vertigo. Operation, Feb. 17 (Prof. V rb ants chit sch) : Typical radi- 212 DISEASES OF THE LABYRINTH cal. No fistula of the labyrinth to be seen. Test under the anaesthetic. Typical labyrinth operation. Feb. 18, temp. 37.5; Feb. 19, 37.0; Feb. 20, 36.9-37.8; Feb. 21, 36.2, 37.7; from Feb. 22, normal. Feb. 23 : First change of dressing. Moderate suppura- tion, with slight tendency to granulate. Feb. 28: Transferred for after-treatment in the O.P. Dept. 92. E. L Age 32. Admitted Mch. 5, 1910. Anamnesis: Two years ago patient noticed a bloody dis- charge from I.e., with vertigo and headache. In Warsaw, where he went eight days ago, a small operation is supposed to have been performed. Patient complains of vertigo, headache and nausea. Status praesens: R.e. : Drumhead retracted, scars in front of and behind the hammer. Function normal. L.e. : Drumhead swollen and red in its upper portion. Attic fis- tula ; central perforation, with small granulations. Functional test: L.e.: Deaf for speech and tuning forks. W. in head, R. , Sch. greatly shortened. Xo spont. ny., no fistula sympt. Calor. react, not demonstrable. After tr. r., ny. horiz. 1. == 2"-4". After tr. 1., ny. horiz. r. = 15". Operation, Mch. 9 (Ruttin) : Mastoid sclerotic. Antrurn deep and containing many granulations. Typical radical operation. Horizontal semicircular canal flattened, with exostosis, with an irregular groove in the middle. Typical labyrinth operation. The horizontal canal carefully exam- ined, but no lumen found. It is plainly filled by bony hyper- plasia. Vestibule opened from behind without exposure of the dura. The probe passes through the oval window and emerges under the facial. No twitching during the opera- tion. Promontory removed. No cerebrospinal fluid. Plas- tic. During the operation the caloric test was made with cold water, without the slightest reaction. Wick in front of and behind the facial. Mch. 20: After the operation, absolutely no ny. or laby- CASE HISTORIES 213 rinth symptoms. No vertigo. Only the first few clays, head- ache. Tinnitus. Apr. 28: After a normal course, transferred for treat- ment to the O.P. Dept. Temperature always normal. 93. Sch. K. Female. Age 27. Admitted Apr. 19, 1910. Anamnesis: For one year, discharge from ear, with in- termissions. One month ago, an attack of vertigo. Since then, often slight vertigo. Ten days ago, patient noticed facial paralysis. Tinnitus. Status praesens: R.e. : Total destruction of drumhead. Granulations in the tympanic cavity. L.e. : Almost com- plete destruction of the drumhead. No ossicles. Granula- tions. Functional test: L.e.: Nearly normal. R.e.: Tested with exclusion apparatus, deaf for speech and tuning forks. W. 1., R. , Sch. shortened. Spont. ny. rotat. and horiz. r. -= ny. rotat. 1. No fistula sympt. Cal. test gives no re- sponse. After tr. 1.. ny. horiz. == 10". After tr. r., ny. horiz. 1. == 40". Operation, Apr. 22 (Dr. Bondy] : Radical operation. No ossicles. Abundant granulations in the antrum and in the tympanic cavity. Large fistula in the horizontal canal, filled with granulations. It surrounds the eminence of the canal like a horseshoe. The probe does not enter deeply into the vestibulum. Posterior fossa laid bare. The overhanging edges of the fistula removed with the chisel. Vestibulum widely opened from behind. As the entire facial ridge ap- pears to be necrotic and the probe can be introduced deeply beneath it, a restoration of the function of the facial nerve seems unlikely; accordingly, the entire facial prominence is removed to the level of the base of the fistula to expedite healing. Promontory opened. Plastic after Stacke, lower flap sutured. Dressing. Apr. 23: Feels well. Ny. like before the operation. No vertigo. No fever. Apr. 28: First change of dressing. Wound unirritated. 214 DISEASES OF THE LAKYlil.\TH May 24: Wound (javity granulating. Moderate secretion. Discharged. Tinnitus persists. Temp, always normal. 94. K. C. Female. Age 19. Admitted Apr. 29, 1910. AinuiiHcxix: Was blind until her sixth year. No chil- dren's diseases. R.e. has discharged continuously for eight years. Eight days ago, a polyp was removed; since then, patient noticed that her face is asymmetrical and she can not entirely close the right eye. There was also fever. Status praesens: L.e. : Calcification and scars. R.e.: Posterior superior wall of canal swollen. In the tympanic cavity, many soft granulations, which bleed easily. In the canal, thick, bad-smelling pus. Fluctuating mass behind ear. Temp. 37.1. Pulse 9(i. Functional test: With exclusion apparatus L, r. ear is deaf. W. 1., Ci 0, c 4 0. Spont. ny. r. == 1. No fistula s\ nip torn. Cal. react. 0. Nervous system normal, except for facial paresis of all divisions. Slight ataxia of the upper r. extremity. Operation, May 4 (Prof. Urbantxcliitxch) : Typical radi- cal. In the horizontal canal, a discolored fistula, 2 mm. long. The sinus and the dura of the posterior fossa laid bare. These are normal. Typical labyrinth operation after Neu- mann. May 10: First change of dressing. Some pus behind the labyrinth. Normal course. Temp, practically normal after May 9. 95. L. S. Male. Smallpox in fifth year. Discharge was lir>t noticed on entering military service; lasted until Jan. of this year, being continuous and moderate in quantity. Since Jan., in- creased suppuration. No headache or vertigo. During the past seventeen days, severe pain, so that patient could not sleep. L.e. always well. Never any tinnitus or vertigo. Status praesens: L.e. normal. Very offensive discharge. Posterior meatal wall very low and granulating, prevent- CASE HISTORIES -Jir, ing further examination. Mastoid tip quite tender upon pressure. Functional test: Deaf for speech and timing forks (tested with exclusion apparatus). AY. in head. R. co , Sch. not shortened. Slight spout, ny. to both sides. No fistula sympt. Xo cal. react. Tr. react.: After tr. 1. == 0; after tr. r., typical. Pupils equal, react promptly to light and accommodation. Reflexes active, no disturbances of sensibility, no ataxia. Intelligence unaffected. Pulse 100. Operation, July iM (Ruttin): Mastoid very sclerotic. Cholesteatoma in antrum. In the horizontal canal, a grayish-red fistula, the size of a pinhead. Oval window empty, the probe entering without resistance. Labyrinth opened from behind without exposure of the dura of the posterior fossa. The anaesthetist reported repeatedly dur- ing the entire operation that there was no facial twitching. Promontory removed. Xo cerebrospinal fluid. Sinus and dura of the middle and posterior fossae not exposed. Plas- tic. Dressing. After the operation, slight facial paresis. .July L } (): Paresis somewhat increased. July '27 : Paresis, still greater. July ;!1 : Xormal course. Wound in good condition, little discharge. Aug. 2: Paresis the same. Aim. (i: Transfererd to O.P. Dept. Temp, at all times normal. W5. F. K. Male. Age 37. Anamnesis: Discharge from both ears since childhood. llcariim reduced on both sides, especially r. Two weeks ago, sudden high fever, and was in bed eight days. On get- ting up, he had severe vertigo, so that he could not stand. Had headache during the fever. No emesis. Temp., July I'D: :',<;.(>, 36.4. xt nl us praesens: L.c. : Ketid discharge. Polyp, size of a pea, in canal. R.e. : Complete destruction of drumhead. 216 DISEASES OF THE LABYRINTH Fetid suppuration. Fistula into antrum. Hammer imbed- ded in a polyp.-like swelling. Functional test : L.e. : Con.v. 2 in., whisp. a.c., W. 1., R. , Sch. greatly shortened. C, 0, c 4 shortened. No fistula >\ mptom. Cal. react, typical. R.e. : Tested with exclusion apparatus: Deaf for speech and tuning forks. No spont. ny. Cal react, could not be elicited. After tr. r., ny. horiz. 1. == 20". After tr. 1., ny. horiz. r. == 0. Operation, July 29 (Ruttin) : Mastoid very sclerotic. Typical radical. Cholesteatoma in antrum. Labyrinth opened from behind without exposing the dura. Labyrinth wall inspected after action of tonogen. In the horiz. semi- circular canal, no fistula. Oval window empty. Granula- tions visible upon opening the promontory. No flow of laby- rinthine fluid. No exposure of dura or sinus. Plastic. Fa- cial, after the operation, intact. Aug. 2: First change of dressing. Wound clean, little discharge. Granulations forming. No suggestion of ny., no vertigo, no headache. Ang. 12 : Wound normal. Patient feels well. Dismissed, to be dressed in O.P. Dept. 97. S. G. Male. Age 19. Admitted Oct. 14, 1907. Anamnesis: Patient has had an ear suppuration from childhood, which supposedly began after a vaccination, stopped at intervals, only to begin again. Headache for about six months, which at first was on the left side, later more diffuse. Four attacks of vertigo within the past three months. With such an attack conies the feeling as if his legs were like lead. Then he collapses, and is dazed, when he is dizzy. The last attack, early in October. Hearing 1. very poor since childhood. Status praesens: L.e.: Drumhead totally destroyed, a small defect in the lateral attic wall. The head and poste- rior leg of the stapes is visible. Tympanic cavity covered with granulations. Purulent discharge in the meatus. The CASE HISTORIES 217 infra-auricular gland somewhat sensitive to pressure. R.e. : Calcifications. Functional test: R.e.: "\Vhisp. 6 m. W. r., R. , Sch. lengthened, d +, c 4 +. L.e. : Con.v. 3 m. Whisp. 5 cm. R. , Sch. not shortened, spont. ny. 1. Cal. react, -f. After tr. r., ny. lioriz. 1. = 25". After tr. 1., ny. lioriz. r. == 25"; also equal with head forward. For I.e., c 4 , when lightly struck with the finger, is negative. When struck somewhat harder it is positive. With the conversation tube, the pa- tient repeats accurately easy words when whispered; diffi- cult words are lost. Operation (Prof. Urbantschitsch) : Radical operation. Nothing of note. Oct. 22 : First dressing. Wound normal. After leaving hospital, felt well for five days. Oct. 27, severe unilateral headache occurred, lasting the entire day. Oct. 29 : A.M., severe vomiting, combined with vertigo, so that he could not raise himself up in bed. Dr. Bondy was called, and ordered him taken to the hospital. Status praesens: Operation wound granulating nicely. Canal no longer visible. Spont. rotat. ny. to the healthy side. Cal. react, not to be elicited. L.e.: Con.v. 0, even with the conversation tube. Xov. 5 : Xo ny. on looking toward the well side ; on look- ing to the 1., rotat. ny. 1. Warm irrigation produces in- crease of the ny. on looking to the diseased side. Cold irri- gation gives a reversal of the ny. Xov. 6 : Whisp. 0. Moderate con.v. is heard through con- versation tube. Tuning fork not perceived. Vertigo some- what better. Patient leaves the hospital to be treated as out- patient. Nov. 11 : Had vertigo and vomiting yesterday. 98. W. B. Age 21. Admitted Xov. 1, 1908. Anamnesis: Discharge from I.e. seven years ago, which ceased. Two years ago, again a discharge, which also 218 DISEASES OF THE LABYRIXTH ceased. Seven days ago, severe pain, followed by discharge and relief. Stat H* i>r whisp. a.c., W. r., R. , Sch. lengthened, C l 0, c 4 0. Spont. ny. rotat. 1. No ny. on moving head. No fistula symptom, no vertigo. Cal. react, typical. After tr. 1., ny. horiz. r. = 30" ; after tr. r., ny. horiz. 1. 30". No fever. Apr. 13: Small spont. ny. rotat. r. appears; attacks of vertigo have ceased. No fever. Apr. 17: Spont. ny. to 1. continues. Spont. ny. to r. diminished. Headache still present. Dismissed upon his own request. Apr. 14 : R.e. : Irrigated with very cold water, ny. rotat. 1., the spont. ny. persisting, larger and also present on look- ing forward, which was not the case before irrigation. Ex- clusion apparatus 1., hearing distance V> 2 m. for con.v., W. r., R. exquisitely , Sch. lengthened, Ci -f, when lightly struck. c 4 +, the same. After tr. r., ny. horiz. 1. == 19 oscillations in 16". After tr. 1., ny. horiz. r. = 26 oscillations in 15". Divided kathode anode to forehead \ = ny. rotat, r. 8-10 M.A. Divided anode -- kathode to forehead = ny. rotat. 1. 12 M.A. Carefully tested and controlled by reversing elec- trodes. Anode r. - kathode to forehead : ny. rotat. 1. 10 M.A. Kathode r. - - anode to forehead : ny. rotat. r. 4 M.A. Kathode 1. - - anode to forehead = ny. rotat. 1. 6-8 M.A. Anode 1. - kathode to forehead : ny. rotat. r. 6 M.A. 104. F. W. Female. Age 20. Admitted Apr. 14, 1910. A)t(.n)iuc*i*: At age 6, measles; otherwise well, except for a chr. rhinitis. Three months ago, suppuration, no pains, 224 DISEASES OF THE LABYPIXTH tinnitus or vertigo; occasional discharge of blood, occa- sional attacks of fainting; never fever. Status praesens: E.e. : Large perforation in anterior in- ferior quadrant, a small one in the anterior superior quad- rant. Small granulations and much pus in the meatus. Functional test: W. r., B. , d +, c 4 +. No vertigo or spont. ny. No fistula sympt. Cal. react, prompt. Operation (Prof. Urbantschitsch) : Mastoid diploetic, antrum of moderate size. Cholesteatoma in attic and an- trum. Head of hammer gone, anvil not found. Typical radical operation. Panse plastic. Apr. 15: Patient complains of severe vertigo, vomits much; lies upon the healthy side. No spont. ny., but rotat. ny. to both sides on moving the head. Difficult micturition. Apr. 16 : A.M. : Severe vertigo, especially upon moving. Rotat. ny. r. Nausea. Must be catheterized. Apr. 17 : Vertigo. Ny. Retention ; catheter twice a day. Apr. 18: Vertigo, retentio urinae. Ny. rotat. r. and 1., stronger to r. No headache. Lies on 1. side. First change of dressing. Wound normal. With exclusion apparatus, patient hears con.v. 2 m., W. r. Middle fork heard next to the ear. d and c 4 , when struck gently, +. Cal. react. +. Apr. 19: No spont. vertigo; vertigo only on sitting up (before Apr. 16, 17 and 18 it was present with eyes open). Retentio urinae. No vertigo. Evening: Spontaneous micturition. Apr. 20: Feels relatively well. Head heavy. Retentio urinae. Apr. 21 like Apr. 20. Apr. 22: Second change of dressing. Wound normal. Cal. react. + Patient hears (with exclusion apparatus) the middle tones clearly, but the high and deep tones are not perceived. Retentio urinae. No vertigo. Evening: Spontaneous micturition. Apr. 23: Nausea, vomiting, severe vertigo. Rotat. ny. r., later 1. Apr. 24: Feels well again. CASE HISTORIES 2i>5 Apr. 25-28: Everything in good condition. No vertigo or emesis, occasional ny. rotat. r. and 1. Out of bed. Apr. 29: Transferred to O.P. Dept. Temp, throughout normal. June 16: R.e.: Whisp. 1 m. (exclusion apparatus 1.). \V. in head. Middle fork heard at ear. Spont. ny. 1. not great. C t +, c- 1 +. After tr. 1., ny. horiz. r. = = 12". After tr. r., ny. horiz. 1. = 14". 105. S. K. Age 30. Admitted Mch. 6, 1908. Anamnesis: Discharge r.e. for about five years. Now and then vertigo. No headache. Status praesens: L.e. : Normal. R.e.: Meatus narrowed. Posterior superior wall bulges. Destruction of drumhead. Attic suppuration. Functional test: Con.v. 6 m., whisp. 2 m., W. r., R. -f, Sch. shortened, d -f , c 4 +, shortened. Spont. ny. 1. on look- ing to 1., but r. on looking to r. No fistula sympt. Cal. react, prompt. Operation, Mch. 16: Large cholesteatoma in mastoid, but it has at no point exposed the dura. Radical operation. In smoothing the facial prominence, the horizontal semicircu- lar canal is opened. Facial twitching twice. Plastic. Mch. 17: Patient has attacks of vertigo and vomiting upon moving. A regular, slow, rolling and horizontal move- ment of both eyes on looking fonvard. On moving, attacks of ny. rotat. 1. At times, no ny. Mch. 18: No more regular rolling. Ny. rotat. 1. marked. Mch. 22: Ny. rotat. 1. moderate, only on looking to 1. Patient is up; goes about with confidence; does not com- plain of vertigo. Mch. 23: First change of dressing. Wound looks well. Tested with exclusion apparatus, he hears sounds, but no speech. Mch. 26: Wound granulating well. The wounded part 226 DISEASES OF THE LABYRINTH of horizontal canal still visible. Vertigo very slight. Xo ny. Temperature has always been normal. 106. R. L. Male. Age 15. Anamnesis: For several years, discharge r. Increased discharge during past few weeks. Status praesens: L.e. : Drumhead retracted. R.e. -.Large perforation, with drumhead adherent to promontory. Lit- tle discharge. Functional test: Con.v. 3V> m., whisp. i* m., AY. r.. R. , Sch. lengthened, C, -4-, c 4 + No vertigo or spont. ny. No fistula sympt. Cal. react, prompt. Operation, Feb. 9, 1908: Radical operation. Dura of the middle fossa laid bare. Plastic, packing. Feb. 9: Temp. 38.1. Ny. rotat. 1. with eyes in any posi- tion. Retching and vomiting. Lies upon the diseased side. A r omiting upon sitting up. Dressing changed. Dura looks well, no exudate. But the inner wall of tympanic cavity is discolored. Functional test: No change of the ny. rotat. 1. after applying gauze strip soaked in hot saline, nor after dropping hot saline into the cavity. AY., with medium fork, in the head. AY., with a 1 , 1. Middle fork, heavily struck, held at ear, 0. A 1 fork, when heavily struck, 7"; c 4 , when heavily struck, +. AYith the conversation tube, whisp. O; con.v. is well heard, but the other ear cannot be excluded. Temp, on operating table, 37.25. After the dressing, pa- tient took soup without vomiting. One-half hour later, emesis once. Temp, does not reach 38.0. A labyrinth op- eration was considered, but since the temp, did not reach 38.0, it was not performed. Feb. 10: Ny. rotat. L, less on looking to the r. than yes- terday. No emesis. 'Feels well. Diplopia, with images above each other. Temp. 37.4. Feb. 11 : Ny. rotat. 1. still very large. Less than yester- day, but still present with every position of the eyes. No emesis. Still diplopia. Feb. 12: No diplopia. Ny. rotat. 1. gone when looking to r. Feels well. Temp. 37.4. CASE HISTORIES 227 Feb. 13: Xy. rotat. 1. no longer present on looking to r., but still present on looking to 1. With head bent backward and eyes slowly closed, the right eyelid is noticeably weaker. Temp, from now on normal. Feb. 14: Ny. rotat. 1. on looking forward only a trace; on looking to the r., none. Only a little vertigo, no diplopia. Dressing. Wound granulating nicely. But little dis- charge. Feb. 15 : Ny. rotat. 1. now only on looking to 1. Patient says he again has vertigo and diplopia in the forenoon, after he gets up, but no change in the ny. P.M. : No ver- tigo or diplopia. Feels comfortable. Gets up. Feb. 16: Ny. rotat. 1. only on looking to 1. Feels well. Is up. Feb. 18 : Ny. rotat. 1. only on looking to 1., but with some vertigo. To Feb. 23 : Feels well and goes about with steady gait. Patient says that on going to the eye clinic, where he was sent yesterday, he had the sensation of falling forward. At the eye clinic there was found some diplopia, in that, on looking to the extreme right, he saw the finger used for fixation "lengthened." There was also a tendency to see double images one above the other. 107. E. H. Age 18. Bookbinder's apprentice. Admitted Feb. 22, 1910. Anamnesis: Patient has had a diseased r.e. since child- hood, with otorrhoea up to one year ago. Two months ago the I.e. began to discharge, continuing until now. No head- ache, no emesis, no vertigo. Status praesens: R.e.: Has already had a radical mas- toid. Cholesteatomatous material in the antrum. Opera- tive scar over mastoid. L.e. : Drumhead destroyed. Ham- mer remains. Mucous membrane of tympanic cavity red and swelled. Functional test: "R.e. : Con.v. 3i/L> m., whisp. y 2 m., E- > Sch. shortened; d O, c 4 +. No fistula sympt. Cal. react. 228 DISEASES OF THE LABYRINTH prompt. L.e. : Con.v. 5 m., whisp. 1% in., W.I., Sch. normal. Xo fistula sympt. Cal. react, prompt. No spoilt, ny. Operation, Feb. 28: Typical radical operation. The cav- ity is covered with bluish-white epithelial masses, both at the tegmen and backward over the mastoid process into the cells and to the middle of the mastoid process. After re- moval with the curette, there is visible, lying in the course of the horizontal semicircular canal, a furrow, about y 2 cm. in size. Pressure here causes no ny. In the posterior part of the antrum and from there backward the exposed dura appears of a whitish color. Plastic. Immediately after the operation, severe vertigo, falling movements to the left and violent vomiting. He cannot possibly sit up. In the eve- ning there is severe horizontal ny. to the r. (toward the un- operated ear). Mcli. 1: Ny. somewhat less; retching less. With the ex- clusion apparatus in r. ear, loud voice is perceived by I.e. Mch. 2: Ny. much less; no emesis since morning; no headache. Words spoken moderately loud are perceived by I.e. at 1/2 m - with exclusion apparatus in r.e. Mch. 5 : Only a trace of ny. Mch. 7 : First change of dressing. Wound appears nor- mal. Mch. 21 : Transferred to O.P. Dept. Ny. and vertigo en- tirely gone. Temp, has been normal throughout. 108. R. S. Age 12. Schoolboy. Admitted Aug. 12, 1910. Anamnesis: Measles in sixth year. Since then, otor- rhoea. Now and then headache and vertigo. No nausea or vomiting. Temp. 36.8. Status praesens: L.e.: Normal. R.e.: Drumhead totally destroyed. Tympanic cavity filled with granulations. Pus from antrum, from which project granulations. Ossicles not visible. Functional test: Con.v. (tested with exclusion appa- ratus) 1 m., whisp. 2 cm.; W. in head, R. , Sch. short- ened, Ci 0, c 4 -f. No spont. ny. No fistula sympt. Cal. react, prompt. H1STORJI-:* 229 Operation, Aug. 14 (Dr. Froescliels) : Typical incision. Sinus lies very far forward and is laid bare over an area the size of a hempseed. Ant mm is deep and small, mastoid sclerosed. Over the horizontal canal, which appears no- ticeably small and rough, -is a black, punctate depression. Pressure here causes no eye movements. Granulations over the facial toward the oval window. While sponging, the facial muscles twitched three times. Plastic after Pause. Wick. A caseous abscess on the chin opened. Immediately upon awakening, the corneal reflex on both sides is alike. At 7 o'clock P. M. : Marked rotat. ny. 1. of third degree. Pa- tient complains of vertigo. Lies upon 1. side. Typical laby- rinthine emesis. Temp, normal. Hearing of operated ear, tested with exclusion apparatus, is 1 m. for con.v. through bandage. 10 P.M. : Condition the same, but hearing acuity has fallen to y 2 m - Aug. 15 : Xy. perhaps somewhat weaker, but still of the third degree. Patient slept well. Less vertigo and emesis. Lies upon the left side. Con.v. only \k m. 7 P. M. : Ny. decidedly less. Hearing the same. Feels relatively well. Temp. 37.2. Aug. 16: Xy. diminishing, but still of the third degree. Hearing the same. Xo emesis. Patient lies at times on his back. Evening: Ny. rotat. toward the unoperated side, only of the second degree. Lies on his back. Temp, normal. Aug. 17: Xy. is small. Hearing perhaps better. Feels well. Xo vertigo. Free from temp. Complains of pain in throat. Aug. 18: Xy. is small and only during abduction. The number of oscillations is limited. Vertigo still present. Aug. 19: Xy. still further diminished. Hearing positive at 15 cm. Patient reads the papers and is free from vertigo. Aug. 20: Change of dressing shows everything to be in good order. Hearing is positive. Cal. react, prompt. Temp. 37.0. Aug. 21 : Xo vertigo. Xo ny. on lying upon his hack, but on sitting up. ny. rotat. 1., with some vertigo. Temp. 37.6. 230 DISEASES OF THE LABYR1XT1I Aug. 22 : Temp. 36.2 to 37.3. Aug. 23: Because he no longer has ny. or vertigo and feels entirely well, patient is allowed to go about. Imme- diately he has severe emesis and is forced to go to bed again. Examination shows: Severe ny. rotat. r. (to the affected side). The ny. is very large and rotatory. Pa- tient takes the 1. lateral position in bed. Dressing removed. He is totally deaf in the 1. ear. Tnl. react, cannot be ob- tained. Headache and slight rigidity of the neck. Pulse 105. Temp, normal. After two hours the condition is the same. Severe vomiting. lie complains of headache and weakness. Severe vertigo, ny. to affected side, slight stiff- ness of neck and sensitiveness to pressure over cervical vertebrae. No other symptoms of meningitis. Operation, Aug. 23 (Ruttin] : Wound opened and granu- lations removed. The inner wall of the tympanum curetted under most careful inspection. Stapes not present in the oval window. The probe enters the empty window easily. Labyrinth opened from behind, after exposure of the dura of the posterior fossa. This is normal. The sinus lies ex- posed for an area the size of a lentil and is normal. The dura of the middle fossa is exposed and is normal. Eve- ning: Ny. rotat. 1. Vomiting. Headache. Pulse 104. Ver- tigo less. Aug. 24 : Ny. rotat. 1. of third degree. Lies upon 1. side. Vertigo not very severe. No headache. Occasional pains in the wound. Notwithstanding repeated and careful in- spections during the day, there is no change in the ny. Cer- tainly there is no ny. rotat. r. Temp. 38.2. Aug. 25: Temp. 37.4. Aug. 26: 37.5. Aug. 28: Feels well. No ny. No headache. Dressing changed. Wound in very good condition. Little discharge. Swelling of the posterior cervical glands r., with pain. Temp. 37.3. Aug. 29: No ny; no headache. Temp. 38.4. Aug. 30: Wound runs a normal course. No ny., no ver- tigo. Feels well. Spends the entire day out of doors. Temp, from now on normal. LIST OF AUTHORS ABEL, 8 ALEXANDER, 72, 85, 88, 89 ALT, 86 ASPISSOFF, 23 BARANY, 2, 3, 4, 8, 15, 17, 18, 20, 23, 45, 49, 51, 55, 61, 92 BECK, 6, 21 BEZOLD, 2, 38, 78, 79 BLOCK, 23 BONDY, 45, 58, 90 BBIEGER, 76 BRUEXIXGS, 6, 8, 24 BUYS, 6 EWALD, 8, 10, 18 FECHXER, 24 FLOUREXS, 5 FOEX, 23 FREITAG, 84 FREY, 68 FRIEDRICH, 29, 38, 56, 84 HAMMERSCHLAG, 68 HEGEXER, 32, 38 HERTZFELD, 88 HERZOG, 40, 45, 87 HIXSBERG. 71, 78, 84 HOFER, 20 JAXSEX, 67, 84 KALLMAXX. 22 KIPROFF, 6 KVMMEL, 78, 79 LANCE, 29. 38 LEIDLER, 17 i MARX, 79, 87 MEYER, 29, 86, 87 XAGER, 38, 87 XKI MANX, 2, 3, 39, 41, 68, 72, 79, 83, 92 POLITZER, 23, 32, 50, 75, 86, 87 RIXXE, 2 RUTTIX, 32, 38, 80, 85 SCHEIBE, 33, 75 SCHSIIEGELOW, 44 SCHWABACH, 2 SHRAPXELL, 73 SIEBEXMAXX, 38, 87 STEIX, 27 STRANSKY, 55 TRAVTMANN, 68 UFFEXRODE, 87 UUBAXTSCHITSCH, E. 31, 38, 41, 74, 90 V. 54, 72 VALSALVA, 23 Voss, 2, 86 WAGENER, 91 WAXXER. 3, 75 WEBER, 2 WHITEHEAD, 84 WHITTMAAK, 38 WOJATSCHEK, 6, 88 Abscess, cerebellar, 57, 65, 91 of temporal lobe, 91 otogenous, 93 Acuteness of hearing, 44 After-nystagmus, 13 Antrotomy, 78 ASPISSOFF'S device, 23 INDEX BARAXY'S fixation appa- ratus, 17 procedure, 3 rubber bell. 23, 61 BEZOLD'S method, 2 BLOCK'S device, 23 Caloric irritation, 18 reaction, 22, 45, 86, 89 test, 21, 92 231 Cartesian suspension of eyeball, 5 Case histories, 98 Cholesteatoma, 32, 53, 54, 73, 87 Cochlea, opening of, 70 Compensation, 37 Conversation tube, 2 232 INDEX Diminution of hearing, 28 EDELMANN'S continuous tone series, 2 Emesis, 34, 41, 42, 77, 89, 94 Endolymph, movement of, 37 effective, 37 less effective, 37 Enforced decubitus, 42 Equilibrium, disturb- ances of, 25, 28, 34, 41, 42, 77, 89 EWALD'S law, 18 Examination, cochlear, 1 functional, 1 vestibular, 1, 3 Exclusion apparatus, 2 Exposure o f TRAUT- MANN'S triangle, 68 Facial ridge, undermin- ing of, 69 FECHNEB'S law, 24 Fever, 55 Fistula test, 8, 23, 25, 50, 92 FOEX air apparatus, 23 Headache, 94 HINSBEBG method, 71 Horizontal circular ca- nal, undermining of, 69 Labyrinth, injuries of, 77 migratory diseases of, 88 necrosis of, 38 oedema of, 85 operation, technic of, 67 typical radical, 68 ossification of, 50 probe, pliable, 70 purulent inflamma- tion of, 86 sequestration of, 38, 50 suppuration of, 87 Labyrinthitis and brain abscess, 91 anamnesis, 40 circumscribed, 28, 35, 60, 73 diffuse purulent, 28, 35 latent, 35, 66, 74 manifest, 35, 42, 64, 74 serous secondary, 28, 35, 63, 74 etiology, 31 pathology, 28 post-operative, 85, 89 purulent, 41 serofibrinous, 86 serous induced, 85 spontaneous, 45 symptoms, 34 present, 41 termination, 73 therapy, 59 Laermapparat, 2, 27 LTJCAE-DENNERT test, 2 Mastoiditis, 87 Measles, 33 Mechanical irritation, 23 Meningitis, 43, 63, 76, 92 post-operative, 57 Metastasis, suppurating, 57 NEUMANN'S method, 3 Nystagmography, 6 Nystagmus, 3, 28, 34, 41, 43, 89, 92, 94 associated of STBAN- SKY, 55 caloric, 54 degree of, 6 direction of, 5 exaggerated, 95 extraordinary, 95 fistula, 54 of the third degree, 7, 42 production of, by physiological stimu- li, 8 reversed aspiration, 51 compression, 51, 54 turning, 48, 77 typical, 51 aspiration, 51 compression, 51 Otitis, acute, 85 chronic, 85 Panotitis, 87 PANSE plastic, 70 I'aralabyrinthitis, 34 Paralysis, facial, 38 Paresis, facial, 38 Politzer bag, 23, 50 Polyp. 54 Position of preference, 42 Pyaemia, 65 Reaction, caloric, 35 rotation, 35 RIXNE test, 2 ROENTGEN rays, 73 Rotation stimulus, 8 Scarlet fever. 33 SCHWABACH test, 2 Stapes luxation, 80 Statistics, 81 Stimuli, adequate, 24 caloric, 24 inadequate, 24 mechanical, 25 relative value of, 24 rotation, 25 turning, 25 Strabismus, 18 Tinnitus, 28, 34, 41 Tuberculosis, 32, 45, 57, 93 Tumor, 93 Tuning fork. 2 Turning reaction, 46, 86 stimulus, 8 test, 92 Unhealed radical opera- tion, 85 VALSALVA method, 23 Vertigo, 28, 34, 40, 77, 89 Ycstibularausschaltungs- symptom, 35 Vomiting, 28 WANNEB'S method, 3 WEBER test, 2 Wick drain, 70 7. \vangslage, 42 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. MAY 1 1 1355 1 3 tf 60 JUN MAY 2 5 198? WAY 24 ROT OCT 2 1 1968; OCT16RECQ APR 1 JIL* SEP 16 RECD Form L9-42m-8,'49(B5573)444 THE LIBRARY UNIVERSITY OF CALIFORNIA LOS ANGELES 3 1158 A 000414490 3