Chapter XX: Preface: iii (19)

The second tunic or coat (membrane) is formed from behind forward by the Choroid, the ciliary body and the Iris. The choroid is the vascular and dark coat covering the posterior five-sixths of the globe. The ciliary body connects the choroid to the circumference of the iris. The iris is the circular muscular septum (division) which hangs vertically behind the cornea, presenting in its center a large rounded opening, the pupil.

The choroid is a thin highly vascular membrane of a dark brown or chocolate color and is pierced behind by the optic nerve and in this situation is firmly adherent to the sclerotic.

The ciliary body comprises three muscles for its make-up and connects the choroid to the circumference of the iris.

The Iris (rainbow) has received its name from its various colors in different individuals. It is a thin, circular shaped, contractile curtain, suspended in the aqueous (watery) humor behind the cornea and in front of the lens, being perforated a little to the nasal (nose) side of its centre by a circular opening, the pupil, for the transmission of light. By its circumference it is continuous with the ciliary body, and its inner or free edge forms the margin of the pupil. The anterior surface of the iris is variously colored in different individuals and marked by lines which converge toward the pupil.

The Retina.--This is a delicate membrane, upon the surface of which the images of external objects are received. Its outer surface is in contact with the choroid; its inner, with the vitreous (glass) body. Behind it is continuous with the optic nerve; it gradually diminishes in thickness from behind forward. The retina is soft, semi-transparent and of a purple tint in the fresh state. Exactly in the centre of the posterior part of the retina corresponding to the axis of the eye, and at a point in which the sense of vision is most perfect, is an oval yellowish spot, called after its discoverer, the yellow spot or Macula lutea of Sommering.

Refracting Media.--The aqueous humor completely fills the anterior and posterior chambers of the eyeball. The anterior chamber is the space bounded in front by the cornea; behind by the front of the iris. The posterior chamber is a narrow chink between the peripheral part of the iris, the "suspensory ligament" of the lens and the "ciliary processes."

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The vitreous body forms about four-fifths of the entire globe, It fills the concavity of the retina and is hollowed in front, forming a deep cavity, for the reception of the lens. It is perfectly transparent and of the consistency of thin jelly. The fluid from the vitreous body resembles nearly pure water. The crystalline lens enclosed in its capsule is situated immediately behind the pupil, in front of the vitreous body. The lens is a transparent, double-convex body. It is more convex on the posterior than on the anterior surface. The rays of light go through this body and converge to a point at the back of the retina.

BLEPHARITIS MARGINALIS.--This means a chronic inflammation of the margin or edge of the eyelids accompanied by congestion, thickening and ulceration of the parts and the formation of scales and crusts.

Causes.--The underlying cause is often an inflammation of the conjunctiva where the proper care is not taken in cleansing the roots of the lashes when the discharge collects.

Other causes are keeping late hours, smoke and dust.

Symptoms.--The red swelling along the roots of the lashes is often the only symptom. This comes and goes at the least excuse, such as eye strain, late hours, dust and wind. Scales and dust form in the severe forms, of the disease. It is most common in children, extends over many years and may finally result in the loss of the lashes, with the edge of the lid, thickened, reddened and turned out.

Treatment.--This is tedious. Fit glasses if there is eye strain, reform the mode of life and attend to any constitutional disease that may tend to make it worse.

Local treatment.--Keep the parts thoroughly clean. The edges of the lids should be washed carefully with soap and warm water or mild solution of borax or soda until the crusts are all cleaned off and then use at night an ointment composed of the following ingredients:

Yellow oxide of Mercury 2-1/2 grains
Petrolatum 2-1/2 drams

Mix and make an ointment and rub on the edge of the lids every night, first cleaning them. The conjunctivitis must be cured.

STYE (HORDEOLUM).--This is a swelling beginning in a gland or glands at the edge of the lid and pus forms finally.

Causes.--Inflammation of the edge of the lid, stomach trouble, run down condition, poorly fitted glasses, when glasses should be worn to relieve the eye strain.

Symptoms.--Itching and burning feeling followed by a red swollen area (lump) at the edge of the lid. Later it comes to a point and discharges.

Cause.--Styes usually run their course in a few days or a week; another frequently follows. When it does not reach the pus stage, it often leaves a hard swelling (blind stye).

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MOTHER'S REMEDY. 1. Stye.--Home Method to Kill.--"To hasten the pointing of a stye apply hot compresses for fifteen minutes every two hours. As ill health may be the cause, a tonic may be needed; glasses properly fitted should be worn and a boric acid eyewash used until long after the stye has disappeared." Applying hot compresses will relieve the congestion and gives much relief. Ill health produces a poor circulation of the blood and a good tonic will be found beneficial. Styes are frequently produced by need of glasses.

Treatment.--Treat the stomach and system if necessary. Ice or cold cloths against the stye may abort it. If it goes on, hot fomentations will hasten it. It should then be opened up and scraped out. It will soon heal then and will not leave a lump.

ACUTE CATARRHAL CONJUNCTIVITIS (Pink Eye).--Definition.--This is an acute inflammation of the mucous membranes under the eyelids, and there is congestion (too much blood), swelling and a discharge of mucus and pus.

Causes.--Exposure to wind, dust, smoke, or irritating foreign substance, cinder, sand, etc. It may occur in epidemic form and then is contagious and is called "pink eye."

Symptoms.--The lids appear stiff to the patient, the light causes discomfort and the patient fears it. Burning feeling as if there was some dirt, etc., under the lid, not much pain, but discomfort especially in the evening. The lids look swollen and red. The conjunctiva on the cornea is reddened and that on the lid is thickened, reddened and rough. The discharge collects at the roots of the lashes or lies on the conjunctiva. The lids are stuck together in the morning. The sight is slightly affected by the discharge on the cornea, which is otherwise clear. Sometimes little (minute) ulcerations are seen.

Course.--It may run into a chronic conjunctivitis. One eye is usually attacked a few days before the other. The first stage lasts a few hours or a day and then the discharge follows which may last a few days or a week or more.

Treatment.--First: Use gauze or cotton and dip in ice or cold water and apply to the eyelids. A wash of hot water can be used to cleanse the eye or ten to sixty grains (one teaspoonful) of boric acid to an ounce of water can be used as a wash also.

The following remedies are good in combination as follows:

Alum 3 grains
Sulphate of Zinc 2 grains
Distilled Water 1 ounce

Mix and drop one drop into the eye two or three times daily. A weak solution of tea can be used also as a wash. Anoint the lids at night with white (tube) vaselin.

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INFLAMMATION OF THE EYE OF NEWLY BORN (OPHTHALMIA NEONATORUM).--This is a severe inflammation of the conjunctiva in the new born infant, usually due to a discharge from the mother and it is characterized by a discharge of pus.

Causes.--Mild cases may come from a less violent form of infection from the mother's discharge from the vagina, or from outside causes. The majority of the severe cases is due to a poison (the gonococcus infection).

Symptoms.--The first symptoms are swelling and redness, usually of both eyes, usually occurring a few days after birth. Soon the discharge appears and shortly becomes creamy pus, which runs from the eyes when the swollen lids are partly opened. As the disease continues to advance, the membrane of the lid is thickened, red and velvety looking and the conjunctiva (membrane) in the eye is swollen, puffy and watery.

The disease may last from two to six weeks or longer.

If the pus is not cleaned from the eye, the cornea may look dim and ulcers may appear. If the ulcer eats through the cornea the iris is apt to be caught in the opening and in the scar resulting from the ulcer. The cornea may later bulge and protrude or the disease may involve the whole eye in an inflammation which may destroy it.

The result generally depends upon how soon treatment is begun. If attended to early the great majority of cases recover. It is serious to neglect early treatment for this disease. It causes a great many cases of blindness and generally the cases are neglected too long. Treatment must begin before the disease begins. Immediately at the birth of the child, when if there is any poison in the eye due to a discharge in the mother's vagina, it can be immediately cleansed.

TREATMENT PREVENTIVE. What to do first.--As soon as the child is born and before its eyes are opened the discharges should be carefully wiped away from the lids with small squares of cotton or gauze, pieces wrung out of a weak solution, three per cent (three parts to one hundred of warm, boiled, water) of boric acid. The eyes should not be exposed to the light. At the first both the eyes should be bathed and the same piece of linen should not be used for both eyes.

As soon as any redness appears the eye should be frequently bathed with this warm, weak solution of boric acid and sometimes cold compresses should be used by taking squares of folded gauze or masses of absorbent cotton. Take them cold from a block of ice and lay them over the eyes, and keep constantly changing to keep them cold. This relieves the congestion and prevents a great amount of blood from flowing and settling (congestion) there. When pus appears in the eye it should be cleansed every half hour at least. You can do this by letting the solution run over it from a medicine dropper. After being allowed to trickle from the outer to the inner angle (corner) of the eye, it will then run down beside the nose and can be caught in a piece of absorbent cotton or sponge. If there is a great amount of pus in the eye, the eye may have to be washed out in this manner, every fifteen minutes, day and night, so that the cornea will be kept clean. If this must be done a small fountain syringe with a glass tube (eye-dropper) attached will cause a steady flow of the solution. The boric acid can be increased to five or ten grains to the ounce of water. If only one eye is diseased the other eye may be covered.

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All cloths, etc., should be burned at once and the basin which has held them, filled with carbolic acid solution of the strength of one part acid to twenty parts water. The nurse's hands should be thoroughly scrubbed in hot water and soap and disinfected in the same strength of carbolic acid solution, as the disease is very contagious and dangerous to adults. An attendant should not touch her face or hair with her hands unless they have been washed quite clean. The conjunctiva should be brushed with a solution of nitrate of silver of two per cent strength (two parts to one hundred of distilled water) and then neutralized with a salt solution, not strong enough to burn.

When the cornea is diseased one per cent solution of atropine may be necessary once or twice a day.

Caution.--In the cities this disease is disastrous in its results to the sight of babies. This is due to the want of necessary care. Persons who must be with the patient should be very careful not to get any of the discharge upon their clothes or person, as it is very contagious.

ULCER OF THE CORNEA.--Causes.--Poor general health is an underlying cause or the cornea itself may be poorly nourished. Ulcers are common among the poor classes. They often begin through a rubbing of the cornea by a foreign body. They also come from diseases of the conjunctiva. Weakly babies are easily affected.

Symptoms.--The light hurts the patient; there is a feeling of something in the eye. When the ulcer is over the pupil the sight is impaired. The eyeball shows a ring of pink congestion about the cornea, with congestion of the conjunctiva. The form of the ulcer may be irregular, circular, etc.

Course.--The simple ulcers heal in a week or two. Infected ulcers may spread, or they may sink deeply into the substance of the cornea and eat through. The danger to the sight depends upon the kind and severity of the ulcer. There is apt to be more or less film over the eye for some time and if the ulcer eats through it may destroy the sight.

Treatment. Preventive.--When the cornea has been injured and there has been some rubbing off of its tissue (abrasion) mild antiseptic solution in the form of eye drops should be used. Boric acid, as much as will dissolve in warm, distilled water and some dropped in the eye three or four times a day. If there is a foreign body in the cornea, clean instruments should be used to remove it. The cocaine used to render the eye painless must be pure.

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General Treatment.--If the patient is "run down" the general system should be built up.

Local Treatment.--One to two per cent solution of Atropine should be put into the eye three to six times a day to keep the pupil dilated and prevent it from adhering to the cornea. Hot fomentations repeated according to the severity of the case and the amount of "easing" they give. A three per cent solution of boric acid should be used for cleansing purposes. The bowels should be regular. The patient should remain in one room.

FILM ON THE EYE PTERYGIUM.--This is a growth beginning near the inner or outer corner and extending with its point towards the center of the cornea.

Symptoms.--The patient only complains when it has advanced toward the center of the cornea and the vision is lessened or cut off. It occurs more often from the inner corner. It keeps growing for many years and may cease advancing at any time.

Treatment.--Surgical treatment is often necessary. Dr. Alling says: "Dissect off the growth from the cornea and sclera coats, leaving the base attached (toward the corner of the eye) and bury its point under the undermined conjunctiva below. If the growth is dissected off the cornea, which may readily be done, and then cut off (towards its base) it would recur."

IRITIS. (Inflammation of the Iris.)--This is an inflammation of the iris, characterized by congestion, small pupil and posterior synechia.

Causes.--It occurs in the second stage of syphilis, second to eighteenth month, from rheumatism, diabetes, gout, injury, and without any known cause (idiopathic).

Symptoms.--More or less severe pain in the eye, forehead and temple, worse in the night and early morning especially. There is fear of the light and the eyes water very much. The sight is affected and there may be some fever. On examination the lids are found swollen and red, the eyeball shows congestion in the cornea and ciliary body, with some congestion of the conjunctiva. The cornea looks hazy. The anterior surface of the iris looks muddy and does not look so fine and delicate. The pupil is small and the light does not make it contract readily. If atropine is put in the eye (one per cent solution) the pupil will not dilate regularly, because at different points the pupillary edge of the iris is held to the lens by an exudate that lightly holds it.

Course and Recovery.--The disease may occur at any age, but it is most common in children. It may last from one to six weeks.

Chances of recovery are good if treatment is begun early. There is a tendency to recurrence.

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MOTHER'S REMEDY.--1. Iritis.--Sensible Remedy for.--"Doctor the blood with sulphur and lard, a teaspoonful three times a day. Refrain from using the eyes. This disease is said to be brought on by rheumatic fever, and rheumatism is a disease of the blood." This is a very serious disease and a physician should be called.

Treatment. What to do first.--Confine the patient in a darkened room and if the attack is severe in bed.

Local Treatment.--Dry or moist heat should be applied, according to the ease they give. Leeches are good in severe cases placed near the outer corner of the eye. Atropine usually made of about the strength of two to four grains Atropine to an ounce of water; or one per cent (1 to 100) may be used, and it should be dropped into the eye from three to six times a day. The pupil must be dilated and kept so from the beginning to keep the adhesions from forming between the iris and lens. If too much is used the throat and tongue will feel dry, face will flush, and there will be dizziness and a rapid pulse. Stop it until that effect is gone and then cautiously use it again. The bowels should be kept open.

The diet should consist of milk to a great extent. Water of course can be taken freely. Soups, broths, gruels, etc., can be used if desired; but meats should be withheld for a time unless the patient runs down.

Caution.--If a person has any of the special symptoms above mentioned it would be prudent to begin treatment at once. The great danger is permanent adhesion of the iris to other parts, especially the lens, and the dilating and contracting power may be lost.

INJURIES OF THE IRIS.--Concussion of the eyeball may produce an irregular dilation of the pupil. This is due to paralysis of the sphincter muscle of the pupil, but it generally disappears. The edge of the pupil may be torn in the form of one or more rents, or the iris may be separated from its root at its circumference, leaving a clear space, or it may be entirely torn from its attachment.

Perforating wounds are accompanied by injury to the lens and other structures; when the cornea is wounded it is often complicated by falling of the lens. When a small foreign body passes through the cornea and iris a small opening may be seen. The greatest danger from wounds is due to infection and if it reaches the iris, it may produce violent iritis. If the lens is displaced or absent the iris being without support, will tremble with every movement of the eye. In some cataract operations, if there is a loss of the "Vitreous" body a part of the iris may be folded upon itself, thus enlarging the pupil in that point.

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CATARACT.--This is an opacity of the crystalline lens or its capsule. The lens is not clear and bright and keeps the light from going through it. Then it is called opaque.

SENILE CATARACT.--The vast majority of these cataracts are found after the age of fifty. They simply come without any known cause. Of course, injury can cause a cataract and it is then called traumatic cataract.

Symptoms of Senile (Old Age) Cataract.--Blurred vision, flashes and streaks of light, dark spots, double vision. There is no pain. Eye strain due to imperfect sight. Sometimes the first symptom is ability to read without glasses (second sight). This is due to the increased refractive power of the lens from swelling. The lens looks a little whitish through the pupil opening and looks more so as time goes on.

Course.--The progress is slow. It usually takes a number of years before it is "ripe" for operation. They may remain in the same condition sometimes. In this kind of cataract both eyes are affected sooner or later, although one eye may be fully matured before the other is much changed.

The result of an operation depends upon the condition of the eye. The eye should be free from evidence of disease. "The anterior chamber should be of normal depth. The pupil should react to light. There should be a homogeneous (all alike) white or gray opacity immediately back of the pupil, with no shadow from the edge of the pupil (except in cases of sclerosis, already mentioned). A candle carried on all sides of the patient while the eye is fixed, should be properly located by him. The tension of the eyeball should be normal."

The operation is very frequently done and it is very successful. The patient should be ready and willing to place himself in the charge of the operator and do as he says.

SYMPATHETIC INFLAMMATION OF THE EYE.--(Sympathetic Ophthalmia.)--A condition in which the healthy eye becomes the seat of a destructive inflammation transferred from the other eye which has been the subject of a similar inflammation usually following a perforating injury of the eyeball. The injured eye is called the exciting eye; the other, the sympathetic eye.

This is a rare disease, but it may occur when one eye is injured or diseased and on the first indication of trouble in the injured eye the other eye should be closely watched for symptoms of sympathetic trouble so that if can be removed.

Symptoms in the Exciting Eye.--This is more or less congested and painful; when pressure is made upon the upper lid, it shows tenderness. The tension is not as strong; the pupil may be blocked with an exudate.

In the Sympathizing Eye.--There is an inflammation involving the choroid, ciliary body and iris. There is pain, tenderness, small blocked pupil and sight is poor.

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Course.--It usually appears between the third week and the sixth month after the original injury. "The extreme limits are two weeks and twenty years." The sound eye is likely to be attacked when the exciting eye is in a state of active inflammation.

Treatment.--The "exciting eye" should be enucleated (taken out) before any signs of sympathetic inflammation appears in the healthy eye. If it has appeared, enucleation will be of no value; at all events if there is vision in the exciting eye, the operation should not be done then.

INFLAMMATION OF THE RETINA FROM BRIGHT'S DISEASE (Albuminuric Retinitis).--The retina is a very delicate structure and we are often able to diagnose Bright's disease from the peculiar effect it produces upon the retina.

Causes.--The cause is usually Bright's disease, (nephritis) and usually the chronic Interstitial variety. Pregnancy causes it sometimes. Interference of the vision, sight, is what the patient complains of. This may be very slight, when you consider the great changes occurring in the retina. Such patients are subject to attacks of temporary blindness of uremic origin. The vessels of the retina are swollen and tortuous. Bleeding and shining white patches are scattered through the back part of the eye and a peculiar arrangement of glistening white dots around the yellow spot. This disease shows itself late in Bright's disease and the patient is not likely to live more than two years after the appearance of this eye lesion.

Treatment.--It sometimes occurs during pregnancy. Then the question of inducing premature labor arises. There is no local treatment that can be of any use when it is caused by Bright's disease.

FITTING GLASSES.--This is done by lenses and prisms, etc.

Lens.--A lens is made of glass and prisms graded in strength, one surface curved, and has the power of refracting or changing the direction of the rays of light. A prism is wedge-shaped and bends rays of light towards its base. A great many people are troubled with their eyes, much more than years ago. We even see little children wearing glasses. It is unfortunate, but true, that even more children and grown people should wear them. Fitting glasses is an art in itself. It takes more ability to fit glasses well than it does to operate well. Poorly-fitted glasses are not only annoying to the wearer, but dangerous. Glasses rest the eyes, not tire them. When the eyes water and feel tired or strained, even after using them but little, glasses are needed. Headaches are frequently caused by the eye strain. When glasses are needed it does not pay to put off getting them and the person needing them should go to one competent to properly fit them. A great many eyes are hard to fit, and they need not only ability to fit them well, but time and attention must be given to fitting them properly.

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SQUINT OR STRABISMUS.--Both lines of sight are not directed towards the same object of fixation.

Internal or Convergent Squint.--Where one eye is turned inward toward the nose.

External or Divergent Squint.--One eye turns outward toward the temple. Squinting upward and downward are uncommon.

Causes of Convergent (Internal) Squint.--It generally appears between two and five years; at first periodically, later constantly. The patient is generally far-sighted.

Treatment.--Internal squint in very young children may be treated by covering the well eye and forcing the child to use the other. When the child is old enough, proper glasses should be worn. Operation can be done when needed and is generally successful.

External (Divergent) Squint.--This may appear at any age and is often associated with near-sightedness. An operation is necessary and the tendons on both sides must generally be cut and properly placed. Parents should always attend to a child who has this trouble. The operation is not difficult to perform and it will not only, as a rule, give the child good sight, but better looks. Parents who are able to have an operation or glasses fitted when needed, and who neglect their children, should be punished; they are guilty not only of neglect, but cruelty.

MOTHERS' REMEDIES. Inflammation of the Eye. 1. Chickweed a Relief for.-- "The juice of chickweed is good for inflammation of the eyes, when dropped into them."

2. Inflammation of Eyes, Sassafras, Excellent Remedy for.--"Take sassafras bark and make into a tea. Apply this externally to the eyes, and it will be found very beneficial for this trouble." This is a very good remedy, on account of its oily soothing nature.

3. Inflammation of Eyes, Tried Remedy for.--

Boric Acid 10 grams
Camphor Water (not spirits) 1/2 ounce
Water 1/2 ounce

Apply this with a soft cloth.

This trouble usually results from or is associated with constitutional disease and requires treatment for same, but the above wash is good for local applications. This prescription was given me by an oculist."

4. Inflammation of Eyes, Common Potato Will Cure.--"Scrape raw potato and apply to the temple until relieved." This helps to draw the blood away and relieves the inflammation.

5. Inflammation of Eyes, Milk Curd Relieves.--"Make a curd of sweet milk; that is, set it on the stove till it forms a curd; then add quite a little alum and wash eyes." The milk is very soothing and the alum acts as an astringent. Care should be taken in using this remedy that none of the mixture gets into the eyes.

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6. Inflammation of Eyes, Wild Hairs Cause.--"A few years ago, I had trouble with my eyes. They felt as though there was something in them scratching the eye-ball. I went to an eye specialist, and he gave me two little vials of medicine to drop into my eyes six times a day. I doctored with him several months, and while the medicine reduced the inflammation largely, it did not relieve the scratching sensation in the eyes. Then I was away from home for about ten days and did not use the medicine, and when I returned my eyes were very much inflamed, and very painful. I visited the doctor again, and he said I had a little ulcer on the eyeball, and he pulled out several hairs or winkers from the eyelid. I asked him if wild hairs were the cause of the ulcer and he admitted they were. After a few days' more treatment by the doctor I learned of a neighbor who understood a little about wild hairs in the eyelid and had him examine my eyes. He pulled out more wild hairs, and my eyes got well. Ever since then, when my eyes begin to hurt me as though there was some foreign substance in them, I go to my neighbor and he pulls out the wild hairs, and that was the trouble with my eyes. My experience in obtaining this knowledge cost me twenty dollars in fees to the eye specialist, which I could have saved by going to my neighbor at first,"

MOTHERS' REMEDIES.--Sore Eyes. 1. Rose Leaves Rest.--"Steep rose leaves and apply often." Apply the leaves as a fomentation and relief will soon follow. This is very soothing and very easily applied.

2. Sore Eyes, Soothing Remedy for.--"Use a wash of borax and water. One-half teaspoonful to a cupful of water." This is very good.

3. Sore Eyes. Slippery Elm Excellent for.--"This is a very soothing dressing far the eyes. You can buy a small package of the slippery elm at any drug store, and prepare it by making a tea and using externally.

4. Sore Eyes, Common Remedy for.--"Use a wash night and morning of common table salt and water." This is often sold by druggists for 10 or 15 cents an ounce under a medical name.

5. Sore Eyes, Elder Berry Flowers Relieve.--"In a severe case of inflammation of the eyes apply a poultice of elderberry flowers; bathe the eyes with warm water and witch-hazel." This remedy was given by a mother who tried it a great many times and always had success.

6. Sore Eyes. Borax and Camphor Good Wash for.--"Borax one teaspoonful, spirits of camphor fifteen drops, distilled water one-half cupful. This makes a fine wash for sore eyes, and is perfectly harmless."

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7. Sore Eyes, Tested Eye Wash for.--

"Hydrastis (Golden Seal Root) 1/2 ounce
Best Green Tea 1/2 ounce
Sulphate of Zinc, Pulverized 1 dram

Steep the root and tea for a few minutes in a pint of boiling water; while cooling add the sulphate of zinc; when cold strain well and bottle. Use as an eye wash three times a day. In severe cases a poultice is useful, made of pulverized slippery elm and warm milk and water. All eye washes should be used with caution and especially those containing belladonna or caustic solutions,"

8. Sore Eyes, Borate of Soda and Camphor Water Relieves.--

"Borate of Soda 2 grains
Camphor Water (not spirits) 1 ounce

Mix, drop one or two drops in the eye four times a day.

Camphor water is made by allowing the gum to dissolve in water instead of alcohol, also saturate lint in this mixture and apply on the eyes."

EAR AND ITS DISEASES.

The external ear is called auricle or pinna. It is an oval funnel-shaped organ. The canal leading in to the membrane (drum) is called the external auditory meatus. It extends inward about one and one-quarter inches and terminates in a membrane.

Membrane Tympani (drum) which separates the external ear from the tympanic cavity. To examine the drum, you must pull the ear backward and outward to make the canal straight.

Membrane Tympani (the drum) Membrane.--This is situated at the inner end of the canal and separates it from the tympanum or middle ear. It is placed like the membrane in the telephone. It is pearly gray in color. This membrane not only serves as a protection to the delicate structures within the tympanum, but also receives the sound vibrations from without and transmits them to the ossicular (bony) chain of the middle ear.

The Tympanum or Middle Ear.--This cavity just beyond the drum, which forms the greater part of its outer wall, is an irregular cavity, compressed from without inward and situated in the petrous bone. The mastoid cells lie behind. It is filled with air and communicates with the nose-pharynx (naso-pharynx) by the eustachian tube. The upper portion of this cavity, the attic, lies immediately below the middle lobe of the brain, separated from it by a thin layer of bone, which forms the roof of the cavity. This cavity is separated from the internal ear.

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The Eustachian tube.--This is the channel through which the middle ear communicates with the pharynx. With an opening in the anterior of the middle ear, a bony canal passes from this point, inward, forward, and downward through the petrous bone, when it merges into a cartilaginous canal, which terminates in a funnel-shaped protuberance, with a slit-like orifice, located in the nose pharynx. This is the eustachian tube. It is lined with mucous membrane like the throat. The air goes up from the throat, through this canal to the middle ear. The mucous membrane of the middle ear is continuous with that of the nose-pharynx through the eustachian tube. So you can readily understand how easy it is for an inflammation of the throat to extend to the middle ear through the eustachian tube.

The posterior wall which has the greatest height, reveals in its upper portion a passage (antrum) through which the vault of the tympanum (attic) communicates with the cells of the mastoid process, situated posteriorly. From this description you see how near to each other these parts are placed and when one becomes diseased the disease can extend to the other part or parts. The brain is separated from some of these cavities by a very thin shell of bone, and the disease can soon affect the brain through infection or breaking through the thin structures that separates the parts.

Diseases of the middle ear and the mastoid are always to be considered serious, and should be very closely watched. A child with a running ear is in danger, for it may at any time become closed up and serious.

ECZEMA OF THE EXTERNAL EAR (Auricle).--This is an inflammatory disease of the skin, and in the poorer classes it is very frequent. It is quite a common disease in old age. It develops in other parts of the body at the same time in a certain percentage of cases.

Causes.--Soaps, alkalies, foreign bodies in the ear, removing ear wax and a chronic discharge from the middle ear. There is a tendency to it in some families; stomach trouble, improper food are also causes.

Symptoms.--Itching,--and this is very pronounced,--burning feeling. The part is somewhat reddened, fluid oozes out, crusts form, the skin thickens, and scales. Sometimes it swells very much.

Treatment.--Regulate the bowels, give a simple easily digested and proper food for children and adults. Cleanse the inflamed skin gently with castile soap and tepid water once a day. Cloths dipped in some cooling lotion, such as the lead and opium wash, or in plain water to which has been added a little alcohol or eau de cologne, should be wrapped around the inflamed ear during the acute stage and they should be kept wet. Clean vaselin, etc., is good to put on the scabs. The ear should be covered as before directed to keep dirt, dust, etc., out.

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HARDENED WAX OR IMPACTED CERUMEN.--This mass may be mixed with foreign bodies or be made up of "wax" alone.

Symptoms.--A large mass of wax may remain in the ear for many years without causing any special loss of hearing so long as the plug does not rest against the drum and there remains a passage between the mass so that the sound-waves can strike the drum. Generally the hearing gradually grows less. Loss of hearing may take place suddenly, as after washing the head, or after a general bath, or after an attempt to clean the ear with the end of a towel. Patients will often say the dullness of hearing appeared suddenly. This no doubt was due to the fact that the mass of wax was displaced against the drum suddenly by an unusual movement of the head or the jaws, or the mass became swollen through fluids getting into the canal. If the canal is filled there will be more or less deafness, ringing in the ear, and there may be piercing pain produced by the hardened mass, especially if the jaws are moved from side to side. If the mass is thoroughly and carefully removed, the hearing may entirely return if it was caused by this wax.

Treatment.--The mass is best removed by syringing the hardened plug and softening it gradually. Removing it with a currette and forceps without softening it may do injury to the parts. The syringe and hot sterilized, boiled water should be used for some time, and the patient asked occasionally if there is any faintness or dizziness caused by it. It often comes, in a lump after the water has been used for some time. A strong solution of bicarbonate of sodium is also good to use.

FOREIGN BODIES IN THE EAR.--These are not of frequent occurrence. In the case of children these bodies may comprise such objects as pebbles, beads, beans, pieces of rolled paper, fly, bed-bug; insect of any kind may get into ear of adults. If they reach the drum a very unpleasant sensation is produced by the attempt to escape. Sometimes a layer of wax may gather around the dead object. These bodies should be removed, for their presence may produce a swelling or soreness in the canal. If the object is a dried pea or bean the syringe should not be used. The object must be carefully removed. Sometimes an operation is necessary to remove the object.

DISEASE OF THE MIDDLE EAR.--The ordinary cold in the head rarely runs its course without one of the eustachian tubes at least is involved to some extent.

SIMPLE INFLAMMATION OF THE EUSTACHIAN TUBE.--Causes.--Acute colds, inflammation of the nose and pharynx, tonsilitis.

Symptoms.--The ear may feel full and numb, roaring in the ear may occur. There may be pain on swallowing, shooting up through the tube.

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Treatment.--Remove the cause. Treat the nose and pharynx. Spray and gargle with solutions advised for throat trouble. If it continues the throat should be examined for adenoids, enlarged turbinate bones and so on.

ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. Causes.--Acute coryza, acute pharyngitis, influenza, scarlet fever, inflammation of the eustachian tube, gargling, bathing, employing the nasal douche or violently blowing the nose.

Inflammation of the eustachian tube is, in many cases, simply the first stage or onset of this disease. The congestion extends beyond the tube and involves to a greater or less degree this cavity. If it continues for a few hours or an entire day, the watery elements of the blood will begin to escape from the distended vessels into the tissues of the mucous membrane and ooze out upon its free surface. If this is copious enough pressure may be developed within the cavity, middle-ear, to cause pain. These cases vary much in severity. In the mildest ones there may be a few twinges of pain in the affected ear, but nothing more; and even in the most severe cases the pain does not last longer than a few hours, although it may return on several successive days. Very many of the earaches of young children, from two to ten years of age, are due to this disease. The pain is very likely to come on late in the afternoon or during the night, while earlier in the day the child may be free from pain. In the milder forms the condition of the drum is similar to that existing in inflammation of the eustachian tube. It is not then much changed from normal. There may be more congestion than in this condition. In a fairly severe case the membrane (drum) a few hours after the onset presents a most striking change. It is a picture of obstructed venous (dark blood) circulation of a high degree. In some cases one or more of these distended veins may rupture and form a blood tumor in the external ear canal. The drum is red and more or less swollen.

Treatment.--Very little is needed for this kind, except care and watching. Use the simple hot water in the ear carefully or poulticing when there is pain with onions, bread and milk, and puncture of the drum if it bulges or is too tense. Hot water for gargle, steaming of the pharynx. Keep the patient in a room with an even temperature. The patient must not take cold as it might extend farther.

Recovery.--The outcome is usually good in this disease if proper care is taken; Generally in a few weeks the inflammation is gone and the hearing is restored.

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SEROUS MUCOUS EXUDATION INTO THE MIDDLE EAR.--The disease just described is often associated with an (exudation) watery oozing of fluid into the middle ear, but the following condition is different. Sometimes a comparatively normal middle ear is found to contain a variable amount of either fluid or mucus, or a fluid which represents a combination of both. The failure of the fluid to absorb is due first to the fact that the drainage through the eustachian tube is still obstructed; second, that the absorbing process in the cavity is not acting normally.

Symptom.--Sudden change from somewhat poor to good hearing and the reverse. It is due to the changing in the position of the fluid. The hearing may be normal when the head is thrown far backward, for the fluid then escapes into the antrum, or when the chin is resting upon the chest.

Another symptom that is peculiar is a feeling of something moving in the ear. This is only felt when the head is moved suddenly. Sometimes the patient says: "I went in bathing and got some water into my ear, and I am unable to get it out." He thinks the water went into the ear by the way of the external ear canal. It was due to the chilling of the surface of the body, or the water accidentally entered into the ear through the mouth, or nose, throat, and eustachian tube, and this caused an exudation of fluid to take place in the middle ear. Hearing gurgling sounds in the ear during coughing, sneezing and swallowing is an important symptom. The drum on being examined varies greatly. The simplest case is seen when fluid contained in the cavity is small in quantity and consists of a thin serum. The upper level of this fluid can then be seen like a hair crossing the drum in a more or less horizontal direction. It retains its horizontal position when the patient moves his head backward and forward.

Treatment.--The fluid can be evacuated by an opening made into the drum, but it usually accumulates again. The proper treatment is to treat the diseased condition of the nose and throat, as described in other parts of this book.

CHRONIC CATARRHAL INFLAMMATION OF THE MIDDLE EAR.--The expression, acute inflammation of the middle ear, is rightly employed when it is applied to a case in which the underlying cause is of a temporary nature, as for example, a cold in the head, and mild attack of influenza, perhaps also in an attack of hay fever. But when the causes are of a more permanent character and the middle ear continues for an indefinite period to be the seat of all sorts of disturbances the combination of these different diseased phenomena receives the name of chronic catarrhal inflammation of the middle ear.

Causes.--Troubles (lesions) located in the upper pharynx, the naso-pharyngeal (nose-pharynx) vault and the nasal passages. Adenoids may cause it.

The course of this disease has of recent years been growing more favorable, because the causes are being removed more and more.

Symptoms.--Symptoms of the acute inflammation would be present, and impairment of hearing which sometimes comes so gradually as not to be noticed by the patient. It will be better and then worse. A harassing, hissing, blowing, ringing, usually accompanies it. Pains soon or later add to the discomfort. One side is usually affected first.

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Treatment.--It must be devoted to removing the causes just mentioned. Restore the general health. Abstain from alcohol, tobacco and excess of all kinds. Active outdoor exercise, horseback riding, mountain climbing, rowing, walking, etc., are great health producers.

ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR.--This inflammation of the middle ear is one in which, at an early stage of the disease, the free liquid poured out assumes a pus-like character. At the onset the mucous membrane of the eustachian tube and middle ear becomes first congested and afterward oedematous (watery swelling). Then a serous or a bloody-serous fluid is poured out into the middle ear; and finally this assumes all the outward characteristics of pus. In a few exceptional cases this pus fluid will find a sufficient passage through the eustachian tube; but in the great majority of cases this passageway becomes closed almost at the very beginning of the attack, and then the free exudation; under an ever increasing pressure and on account of the softening and breaking down of the tissues of the drum forces an opening for itself directly through the drum membrane.

Causes.--The same causes that produce the acute variety will produce this variety of the disease. It occurs more frequently during the spring and fall months as the result of changes in the climate. Acute and chronic catarrh of the nose and pharynx are causes. It frequently occurs in connection with scarlet fever and measles. It complicates nose and pharyngeal diphtheria.

Symptoms.--Pain in the ear is the most striking symptom noticed by the patient. In infants and young children of two or three years of age it may appear and not be recognized until a slight discharge appears at the opening of the external ear. The child is feverish, fretful and peevish, seemingly suffering great pain, and the parents think it is, not very sick or has only an earache. Sometimes physicians fail to recognize the trouble until the discharge appears in the external ear. The symptoms are more severe at night. Any physical or mental exertion increases the plain. The pain is sometimes very severe, and a spontaneous or artificial rupture of the drum eases the suffering very quickly in some cases, and a bloody, serous, pus-like discharge escapes into the external ear canal. Often a patient will say: "I felt something give away in the ear, a watery discharge appeared, and the pain soon subsided." In many cases the rupture of the drum gives little or no relief from suffering. This is due in some cases to the small and insufficient size of the opening in the drum. If the pain persists, after a free opening has been made, it may indicate that pressure exists in some cavity or cavities other than the middle ear proper. A sensation of fullness and sometimes of throbbing or pulsation in the affected ear; roaring, singing, whistling, etc.; impairment of hearing; increased pain, when the jaws are opened and shut, are symptoms of minor importance. If there are no complications after free discharge sets in the pain disappears, the fever gradually returns to the normal point, and the patient drops to sleep. In the course of a week or two the discharge subsides and if the rupture is not too extensive the wound will close and the patient will soon be well. Frequently, however, on account of disease of one or more of the bony parts, the wall of the middle ear or the mastoid cells, the discharge continues for weeks and may become chronic in its character.

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Treatment.--Apply heat or cold first. Open the bowels.

How to apply heat.--With the patient lying on his side with the affected ear turned upward, fill the external ear canal with hot water (about 105 degrees F.), then place immediately over the affected ear a hot flaxseed meal poultice, five or six inches square and one-half inch thick, and spread a folded blanket or shawl over the whole to keep it warm as long as possible. Bread and milk with catnip, or onions will do if flaxseed is not at hand. The flaxseed holds the heat longer. Water is a good conductor of heat, and that which fills the external auditory (ear) canal may rightly be considered as an arm of the poultice which extends down to the drum itself.

Leeches also can be applied in front and below the tragus (front of the opening). If the symptoms do not improve under this treatment and especially if the drum is bulging, an opening should be made at the bulging point of the drum. The canal is now syringed with a warm antiseptic solution--like one part listerine, etc., to twenty parts of warm boiled water, with a clean syringe, or warm boiled water can be used alone. If there is any odor carbolic acid one part, to fifty or sixty of water can be used. A strip of sterile gauze is put into the canal for drainage and protection. This syringing can be done from two to four to five times a day, and gradually decrease the number of times as the discharge lessens. It must be syringed and dressed often enough to allow a free discharge and produce cleanliness.

Recovery.--The result of this disease cannot be told at the outset. The majority of such attacks end favorably, with care and treatment; this in persons of good constitution and health. It may run ten days to three to six weeks. In tuberculous patients the result is not so favorable. Recovery follows as a rule in this disease following scarlet fever and measles, but not so quickly, and there may be a discharge for some time, due to chronic disease of the ears, etc.

Complications and results.--In the majority of cases, in ordinarily healthy persons, this disease runs its course without doing any great amount of damage to the organ of hearing, and without involving any structure lying outside of the middle ear proper. In scarlet fever, measles, la grippe, or nasal diphtheria, actual destruction of tissue often takes place in some part of the middle ear before it is recognized. Sometimes it results the same way even when it is discovered in time.

Caution.--A person who has had this disease should be very careful not to take cold. The patient should take plenty of time to get well and strong. The diet should be liquid mostly.

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CHRONIC SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR.--An inflammation that forms pus; hence called suppurative. This is an inflammation that has become chronic (continued) and has one characteristic at least that is very noticeable, and that is the discharge. This may last for an indefinite period. The acute suppurative (pus-forming) inflammation just described in the foregoing pages, may have inflicted various kinds and degrees of damage upon the mucous membrane which lines the cavities, and as a result of the conditions thus established there will be a discharge which may last an indefinite time.

Causes.--Improper or lack of treatment for the acute suppurative inflammatory attack. This is the chief cause. The first attack may have been caused by scarlet fever, measles, etc. They are prone to become chronic, especially if not recognized early and treated properly.

Symptoms.--The main symptom is the discharge from the ear. This may be abundant or scanty. It may stop for a time and begin again. The hearing may be slightly or seriously impaired. Such patients are not accepted by life insurance companies.

Treatment.--Cleanliness of the parts and perfect drainage must be secured. Syringing with one to fifty carbolic acid solution (acid one part, warm water fifty parts) is good treatment. The opening in the drum should be made large enough to give free discharge to the pus in the middle ear.

The patient's strength must be built up if necessary.

INFLAMMATION OF THE MASTOID' CELLS. (Acute or Chronic Mastoiditis).--This disease represents one of the most serious terminations of an acute or a chronic suppurative inflammation of the middle ear. This is fortunately a comparatively rare event. There are, however, quite a good many cases of this terrible disease.

Causes.--It occurs as a primary or secondary disease. The first condition is rare and the result from injury, exposure to cold and dampness, or from syphilis or tuberculosis. Secondary disease is catarrhal or pus-like in form. This results from an extension of middle ear disease through the antrum, as a rule. The disease may develop at any time and endanger the life of the sufferer.