Status: Moderately stout lady of healthy appearance. Depression on right side of frontal bone about one-half inch above supraorbital notch. Low The examination of the ear gives very little information. and high tones are heard on both sides, and a very great difference for voice and watch does not exist. A low fork, she says, is heard much fainter in right ear. "99" whispered, heard at a distance of about fifteen feet in right ear; "81" whispered, heard in left ear at a distance of about eighteen feet. C'=256 fork, when held directly behind auricle on mastoid in the height of upper wall of meatus, heard not so long in right ear as in left ear. Blake's fork 512 VS, heard 6-7" by bone-conduction. Same condition in both ears. Galton: 0.0 right ear; 0.35 left ear. Weber lateralized on right side. Rinne positive on both sides. No nystagmus. Both drum-membranes are somewhat retracted, and no light reflex is visible. Noises: All the time hissing noises, of different tones, in right ear, especially when lying down. When a draught strikes her neck, and when she lies down on anything that shakes, she feels dizzy. Even now, at times, she has the dizzy feeling when she turns to the left. When she turns her eyes up, she feels as if she were going to fall, and she says she can never look up high. Even now, she says, she does not dare turn to left side; if she tries, she feels like getting unconscious. She can turn to the right side only by degrees. Every time when she gets dizzy she has a desire to urinate. Some nights she had to hold herself in order to assure herself that she was in bed. She thinks it is partly imagination. When it is dark, she thinks, it is worse. Never had any headache, although, as mentioned before, head felt big like a "bell," and dull. She imagines that there is a blood clot or a piece of bone somewhere on the brain about one inch above right auricle. The family physician, in Detroit, reports that there does not exist any organic heart lesion at present, and there is no sugar or albumen in urine. In reviewing the case we have prominently before us the following points: 1. Patient says that she never had any symptoms on the part of her ears before she met with an accident fifteen years ago. 2. An injury to the right side of the head; depression on cranium. 3. Disturbances on the part of the ear dating from the time of accident. 4. Noises in the right ear. 5. Somewhat shortened bone-conduction for C1 256, compared with left side. 6. The occasional feeling of faintness when turning to the sides, especially the left. 7. Disturbance of equilibrium when looking up. 8. The feeling of nausea when suddenly raising herself in bed. 9. The feeling as if sinking down in bed at time of accident. 10. Polyuria during attacks. Some light is thrown on lesions of this character, and of other origin, by Dr. Loewenberg in his article, "D'une forme particulière de vertige auriculaire." Extrait du Bulletin Médical des 26 et 30 Août, 1891: "In so far as true diseases of the nervous system are concerned, it is scarcely necessary to remember that a shock which suffices to provoke grave and lasting disorders with some people can leave unhurt individuals with stronger nerves and less great impressiveness. . Among the victims of a railroad disaster, some experience only a more or less great fright, whereas others affected with a constitutionally defective nervous system, especially hysteria, become attacked by traumatic neurosis (railway spine and railway brain), spinal and cerebral troubles caused by the accident." He speaks of the acoustic hyperæsthesia without disturbances of the equilibrium. "It seems," he says, "that with these individuals the cochlear branch of the acoustic nerve is affected, not however the vestibular branch, which governs equilibrium." He further states that if those generalities are not satisfactory he could suppose an excess of tension in the cerebro-spinal fluid or a certain narrowness of the aquæductus cochleæ. Dr. Stenger, in the Berliner klinische Wochenschrift, No. 5, 1903 (February 2, 1903), speaks of the importance of considering the ear in traumas to the head, and I refer you to his article, "The Value of Otitic Symptoms as to the Diagnosis of Injuries to the Head, in Particular Basis Fracture," as justice can only be done to it when extensively quoted. The following may be regarded as affections which may attract our attention prominently while deciding about the nature of the injury and subsequent disturbances in our patient: 1. Affection of the cerebrum, the cerebellum, the medulla, and the dura. 2. Meningitis. 3. Lesion in the origin, course, and distribution of the acoustic nerve. 4. Lesion of the organ of equilibrium. 5. Lesion of the perceptive apparatus proper of the inner ear. 6. Narrowing of the aquæductus cochleæ. 7. Lesion of the middle ear. 8. Ménière's disease. 9. Traumatic neurosis. 10. Affections of other organs (heart, stomach). II. A combination of some of the before mentioned affections. SUPPLEMENT: July 24, 1903.-The patient reports that she has not had the feeling of faintness when turning sideways since December. Also the disturbance of the equilibrium when looking up did not appear since last winter. While she could not lie on an elastic sofa when she came to Detroit, she is able to do it now, and she does not become nauseated when she raises herself suddenly. The patient thinks that the summer always agrees with her better. REPORT OF THE MEETING OF THE GERMAN OTOLOGICAL SOCIETY IN WIESBADEN, MAY 29 AND 30, 1903. BY DR. HARTMANN. The President, Professor KOERNER, opened the meeting and brought to the memory of the Society the names of Drs. Schwendt and Kieselbach, who had died during the past year. He further stated that otology was slowly making its way to a similar position with the other special branches. A new ear clinic has been opened in Heidelberg, and the second full professorship in otology in Germany has been established. The number of members is now 279. The library has received numerous additions. Berlin was chosen for next year's meeting; Professor LUCAE to be presiding officer. Professor SIEBENMANN will read a report on the anatomy of deafmutism. Dr. HARTMANN's proposal that a composite work on the anatomy of deafmutism be issued by the Society was accepted. 1. DENKER reported on stapes-anchylosis. After a short historical survey of the cases of bony stapes-anchylosis which had appeared up to the year 1885, the speaker said that in that year our knowledge of stapes-fixation had been considerably furthered by the publications of Bezold, as this author was able to examine anatomically a case which had been studied clinically, and showed that fixation of the sound-conducting apparatus caused a negative Rinne. With aid of a large number of illustrations, the histological changes in the stapes, in the annular ligament, and in the labyrinth capsule were demonstrated and the results of these examinations explained. In all cases of bony stapes-fixation, the normal bony structure of the stapes and of the bone surrounding the niche of the oval window were converted into osteoid, then rarefied, tissue. In some cases the annular ligament was completely converted into new-formed bone, while in other cases the stapes was connected to the window-margin by osseous bridges. As regards the starting-point of the bone disease, there are two possibilities. The beginning of the bony process may be secondary to a previous inflammatory condition of the middle-ear mucous membrane, or the disease may begin primarily in the bone or periosteum. According to the author, it seems quite probable that a middle-ear affection can lead to an ossifying periostitis and cause the transformation into bone, and he thinks that this is quite probable on account of the frequent association of the two morbid processes. This, however, leaves unexplained the origin of the rarefying process in those cases where no change is found in the tympanic mucous membrane which can be regarded as the residue of preceding inflammations. In these cases a primary disease of the periosteum or of the bone seems to be reasonable. A number of cases where isolated foci were found in the cochlea, which were not in connection with the other areas and did not extend to the tympanic mucous membrane, make it probable that rarefaction may take place without affecting the periosteum. In general the new-formed bony tissue has extended to the periosteum of the tympanic cavity or to the vestibule. The question of the etiology of this rarefying process in the labyrinth capsule is partly answered by statistics, which show that bony stapes-anchylosis usually occurs in women, where the disease appears to originate with pregnancy or the puerperium. As is well known, ear disease in general affects the male in three-fifths of the cases and the female in only two-fifths. This, however, only explains some of the cases, and the author agrees with Katz and Schwartze, who assume that a constitutional anomaly must be present. This latter view is favored by the fact that the disease usually develops simultaneously on both sides, and that the degree of deafness in many cases is the same on both sides. The diagnosis of the uncomplicated stapes-anchylosis is not difficult, given the history, the objective and functional examinations. If the Eustachian tube is patent and the picture of the drum-membrane is normal, the diagnosis of stapes-fixation is probable when the functional examination, in the presence of decided diminution of hearing for speech, shows the symptom |