Complete Text (Part 16)

employed in these cases is evacuation of the contents and removal or destruction of the walls. What is pulsating tumor of the orbit ? It is usually due to an arterio- venous intercommunication taking place in the cavernous sinus, whereby the veins and arteries in the orbit be- come abnormally distended and pulsation ensues. It is usually the result of traumatism. What is exophthalmic goitre? It is a disease due to a disturbance in the sympathetic nervous system in which the action of the heart is greatly accelerated, the thyroid gland becomes enlarged, and the eyes protrude. The upper lid becomes some- what retracted, particularly when the patient looks downward, making the appearance of the projection of the globe more pronounced. In exaggerated cases it becomes impossible to close the lids over the globe, and ulceration of the cornea from exposure results. The treatment is directed mainly to the general condition. If ulcera- tion from exposure is liable to ensue, the eye may be protected by the employment of a bandage, or the palpebral fissure may be made some- what shorter and narrower by freshening the edges of the lids at the outer canthus, stitching them together, and permitting them to heal. REMEDIES AND FORMULA. 123 REMEDIES AND FORMULA. What are the antiseptics used in the treatment of diseases of the eye? Mercuric bichloride is the most serviceable. Hydrogen dioxide in a two- volume solution may be employed in suppurative processes with good results. Creoline in a 1 per cent, solution may be used, but is somewhat irritating to the conjunctiva. Chlorine- water is also effectual in suppu- rative conditions. Nitrate of silver is an excellent antiseptic as well as stimulant and astringent. Alcohol and boiling water for the cleansing of instruments are superior to carbolic acid. Mercuric bichloride should be used according to the following formula : R . Mercuric bichloride, 1 part ; Sodium chloride, 5 parts ; Aquae, 2000 to 12,000 parts.— M. Sig. The stronger solutions may be employed for cleansing the lids and ad- joining parts, the weaker solutions for dropping into the conjunctival sac and for protracted bathings of the eye. Boric acid is of little account as an antiseptic, but is aseptic, and may be used to advantage to cleanse the eye at frequent intervals in suppu- rative conditions in solutions of 2 to 3 per cent. What astringent solutions are employed in diseases of the eye ? The following formulae will be found useful : R . Nitrate of silver, gr. j-xx ; Water, gj.— M. Sig. Solutions of nitrate of silver are very valuable in all cases where puru- lent or muco -purulent discharge is taking place from the eye. It should be applied by the surgeon, and the strength of solution used modified according to his judgment. In mild cases of muco-purulent conjunc- tivitis applications of a weaker solution made at intervals of twenty- four to forty-eight hours are very beneficial. In severe cases applica- tions of a stronger solution made at more frequent intervals must be employed. R . Sulphate of zinc, gr. j-ij ; Distilled water, ^j.— M. Sig. This is a stimulating and astringent collyrium, and may be employed in 124 THE EYE. the subacute and chronic stages of conjunctivitis to drop into the eye two or three times daily. R . Alum, gr. j-ij ; Distilled water, gj. — M. Sig. To be used as the formula for zinc. The sulphocarbolate of zinc, sulphate of copper, acetate of lead, and chloride of zinc may be used in the same proportions and in the same manner as the sulphate of zinc and alum. A stimulant astringent of some value is a solution of tannic acid in glycerin in the proportion of 1 part to 8. This is used particularly in granulated lids by painting it freely on the everted lid once or twice daily. What are the mydriatics, and how are they used? Mydriatics are medicines employed to dilate the pupil. Chief among them are atropine, homatropine, daturine, duboisine, hyoscyamine. Atro- pine is the principal one used, and is employed in the following solution : R. Sulphate of atropine, 1-4 gr.; Distilled water, 1 oz. One or two drops are dropped into the eye at intervals of one to twelve hours. It is used for the purpose of dilating the pupil in cases of iritis and of paralyzing the accommodation in the determination of errors of refraction. In some individuals the lids are particularly susceptible to the irritating influence of atropine. In these cases it must be discontinued and some other mydriatic employed in its place. Care must be taken in the use of atropine not to produce the systemic poisonous effects. A few drops of the stronger solution placed in the conjunctival sac of a child suffices in some cases to cause the flushed face, dry fauces, and general distressed condition characteristic of atropine-poisoning. The passage of atropine in solution through the nasal duct into the nose and throat, in patients whose cases require the frequent use of atropine, produces a dryness of the fauces which is often very annoying. This condition may be obviated by making pressure over the lachrymal sac for a few minutes immediately after the instillation of the drug. Homatropine in a 1 to 2 per cent, solution is preferable for transient dilatation of the pupil. Its effects disappear after twenty-four hours, while those of atropine and the other mydriatics last from five to seven days, REMEDIES AND FORMULAE. 125 What are myotics ? They are remedies employed to contract the pupil. The principal ones are eserine and pilocarpine : R. Eserin. sulph., gr. sstoiv; Distilled water, §j.— M. Sig. This remedy is used chiefly for the purpose of reducing the tension of the globe in glaucoma and in glaucomatous conditions. It is also em- ployed in ulcerative processes of the cornea. Eserine in a strong solution sometimes produces iritis, and should be employed with caution. Pilo- carpine also acts to contract the pupil, but must be used in about twice the strength of eserine. What local anaesthetics are employed in diseases of the eye ? The one of most value is cocaine, which is used in the form of the hydrochlorate, and is employed in a solution of 2 to 10 per cent, in dis- tilled water. The anaesthesia is produced by instillations of one to three drops into the conjunctival sac at intervals of from three to ten minutes. The anaesthetic effect continues for from ten to thirty minutes, amply sufficient for the minor operations performed on the eye. What ointments are employed in treating diseases of the eye ? There are very many of these employed, for various purposes. The following formula is much used in blepharitis marginalis and in phlycten- ular affections : R . Yellow oxide of mercury, gr. ij ; Vaseline, 3\j— M. Sig. Apply to the margin of the lids twice daily, or rub into the eye once or twice daily, as may be required. An ointment of boric acid, 10 per cent., in vaseline is very service- able, to be introduced between the lids in cases of burns from lime or other escharotic. Ointments of the sulphate of copper, of eserine, and of atropine are at times employed to effect the same purpose for which their solutions are used. What powders are employed in treating diseases of the eye ? Calomel, which is used as an antiseptic and as a stimulant in indolent ulcers of the cornea, in phlyctenular keratitis, in interstitial keratitis, and in a few other conditions ; boric acid, sometimes employed to dust into the eye in cases of conjunctivitis ; iodoform and iodol, for the dressing of wounds. Jequirity is employed to produce an inflammatory process in 120 THE EYE. the conjunctiva in trachoma, for the purpose of effecting the removal of the trachoma-granules. What medication is employed in the solid form? The crystals of the sulphate of copper and of alum, made smooth and of proper shape, are employed for the treatment of granulated lids. The method of employment has been spoken of under the head of the Treat- ment of trachoma. The solid stick of the nitrate of silver is einplo}7ed in certain forms of ulcers of the lids, and by some oculists in the treat- ment of purulent conjunctivitis. The mitigated stick of the nitrate of silver is employed in a similar manner. THE EAR AND ITS DISEASES. ANATOMY OF THE EAR. What constitutes the external ear? The external ear consists of the auricle and the auditory canal. Name the different portions of the au- ricle. Fig. 41. (a) Helix ; (6) antihelix ; (c) concha ; (d) tragus; (e) antitragus; (/) lobule; (g) fossa of the helix ; (h) fossa of the anti- helix. (See Fig. 41.) Name the muscles of the auricle. The muscles of the auricle are divided into two sets : The first set are those which connect it with the head, and com- prise the attollens aurem, attrahens aurem, and retrahens aurem. The second set connect the various parts of the auricle, and comprise the helicis major, helicis minor, tragicus, antitragicus, trans versus auriculas, and obliquus auris. Describe the external auditory canal. The external auditory canal consists of two portions, a cartilaginous and a bony portion. (See Fig. 42. ) The cartilaginous portion is a continuation of the cartilage of the concha and tragus prolonged inward. The cartilage is deficient in the upper and posterior portion, where there is a layer of fibrous membrane. There are two or three deep fissures in the cartilage known as the incisurae Santonin. (See Fig. 43.) The bony portion is longer than the cartilag- inous, and terminates at the membrana tympani. What arteries supply the meatus? Branches of the posterior auricular, internal maxillary, and temporal. 127 The Auricle: a, helix; c, anti- helix; b, fossa of the helix; d, fossa of the antihelix ; e, tragus; /, antitragus ; h, lobule ; g, con- cha. 128 Vertical Section of the External Auditory Canal, Membrana Tyrnpani, and Tympanic Cavity, viewed in front (Politzer) : a, upper osseous wall of the canal ; ?;, lower osseous wall of the same ; (>, teginen tympani ; c, osseous floor of the tympanic cavity ; d, tym- panic cavity ; e, membrana tympani ; /, head of the malleus ; g, lower end of the handle of the malleus; o, short process of the malleus; h, body of the incus; /, stapes in the oval window ; A-, Fallopian canal ; I, jugular fossa ; m, glandular orifice in the skin of the cartilaginous canal. Fig. 43. The Auricle and the Cartilaginous Part of the External Auditory Canal (left side) (Pol- itzer) : a, cartilaginous meatus ; b, inner pointed end which unites with osseous part of the auditory canal; c, fissures of Santorini. ANATOMY OF THE EAR. 129 Give the nerve-supply. Branches of auriculotemporal branch of the inferior maxillary nerve. Describe the membrana tympani. The membrana tympani is composed of three layers — an external der- moid layer, middle or fibrous layer, and an internal or mucous membrane layer. ( See Fig. 44. ) In shape it is elliptical. The color, though it varies, is usually of a pearl gray. A ridge runs from above downward and back- Fig. 44. View of Outer Surface of Membrana Tympani (Gruber) : A, malleus ; manubrium ; C, short process ; B, the tip of the manubrium ; D, posterior fold. The Normal Membrana Tympani. ward to the centre of the membrane. This ridge is formed by the handle of the hammer. In the centre of the membrane is seen a depressed point which is known as the umbo. Situated in the anterior and lower portion of the membrane is seen a triangular reflex of light. The apex touches the tip of the handle of the hammer, whilst the base lies on the periphery of the membrane. Two folds may be seen passing from the handle of the malleus, the one forward and the other backward. Above these folds is situated the membrana flaccida or membrane of Shrapnell. Describe the middle ear, or tympanum. The middle ear, or tympanum, is an irregular cavity situated within the petrous bone. The cavity is bounded by (1) a roof. (2) A floor, which corresponds to the jugular fossa and presents a small opening for the passage of Jacobson's nerve. (3) An outer wall, which is formed chiefly of the membrana tympani and the ring of bone into which the mem- brane is inserted. It has three openings — viz. the iter chordse posterius, the Grlaserian fissure, and the iter chordae anterius. (4) An internal wall, which has the following parts: fenestra ovalis, fenestra rotunda, promontory, ridge of the aquaeductus Fallopii, pyramid, in which is the opening for the stapedius. (5) A posterior wall, which presents for exam- ination the mastoid cells. (6) An anterior wall, which presents the canal 9— Eye. 130 THE EAR. for the tensor tympani, orifice of the Eustachian tube, processus cochleari- fonnis. Describe the Eustachian tube ? The Eustachian tube connects the tympanum with the pharynx. It is from U to 2 inches in length. It consists partly of bone, partly of cartilage, and partly of fibrous tissue. Fig. 45. Right Malleus: A, from in front; B, from behind (magnified 4 diam., Henle) : a, head; b, short process ; c, long process; d, manubrium ; e, articular surface; /, the neck. Name the ossicles of the tympanum. The malleus or hammer (Fig. 45) ; the incus or anvil (Fig. 46) ; the stapes or stirrup (Fig. 47). Ftg. 46. Right Incus (magnified 4 diam., Henle) : A, inner surface ; B, view in front; Aa and Bo, body; &, short process; p, long process; d, processus lenticularis; /, articular surface for the head of the malleus ; c, surface which lies in contact with wall of tympanic cavity. Name the muscles of the tympanum. Tensor tympani and stapedius. ANATOMY OF THE EAR. 131 Eight Stapes (magnified 4 diam., Henle) : A, from within ; B, from in front ; C, from beneath ; b, foot-plate or base ; d, capitulum ; c, anterior ; a, posterior shaft, or crus of stapes. Name the arteries of the tympanum. Tympanic branch of the internal maxillary ; stylo-mastoid branch of the posterior auricular ; petrosal branch of the middle meningeal ; a branch from the ascending pharyngeal; a branch from the internal carotid. What are the nerves? The nerves which supply the muscles are a branch from the otic ganglion, which supplies the tensor tympani ; a filament from the facial, which supplies the stapedius. The nerves which supply the lining mem- brane are derived from the tympanic plexus. Describe briefly the internal ear. It is composed of a bony portion and 48). The bony portion consists of three parts — the vestibule, semicircular canals, and cochlea. The membranous portion is a sac which contains fluid and endolymph, and has the same form as the vestibule and semicircular canals in which it is en- closed. It consists of two portions: a, vestibular portion, which consists of two sacs, the cuticle and the saccule ; 6, mem- branous semicircular canals. The arteries are the auditory from the basilar, the stylo-mastoid from the post- auricular, and occasionally branches from the occipital. The auditory nerveis the special nerve of the sense of hearing, and divides at the bottom of the internal auditory meatus into two branches, the cochlear and ves- tibular. (For a more detailed description of the anatomy of the ear the student is referred to the volume on Anatomy in this series. ) a membranous portion (Fig. Fig. 48. 4f \ External View of a Cast of the Left Labyrinth (Henle) : /, fenestra cochleae, or round window; a, fenestra vestibuli, or oval win- dow; b, ampulla of superior semi- circular canal ; e, ampulla of pos- terior semicircular canal ; d, com- mon shaft of union of these two canals ; e, ampulla of the hori- zontal semicircular canal ; g, trac- tus spiralis foraminosus. 132 THE EAR. EXAMINATION OF THE PATIENT. In examining a patient suffering from ear trouble, what is the first step to be taken? Test his power of hearing. This may be done in three ways : 1st, by the watch ; 2d, the human voice ; 3d, the tuning-fork. How is the watch employed to test hearing ? Place the patient in a chair with closed eyelids, and bring the watch, held at a distance, toward the ear under examination until the ticking is heard. The distance is recorded in inches by means of a fraction. The denominator of the fraction would be the number of inches heard by a normal ear, and the numerator the number heard by the patient under examination. For example, take 20 inches as the distance heard by the normal ear, and if the patient under examination heard only 8, we would record it as 28o- How is the voice employed as a means of testing the hearing power ? Have the patient close his eyes, and the ear not under observation firmly closed. Speak ordinary words, and note the distance they can be heard in feet, expressing as before in a fraction. For what purpose is the tuning-fork employed? To determine whether the deafness be due to a diseased condition of the sound-conducting apparatus or the nerve portion. If there is ob- struction in the external auditory canal or disease of the middle ear, the tuning-fork placed in vibration on the frontal bone will be heard best in the defective ear. If the deafness is due to a diseased condition of the internal ear, the tuning-fork will be heard least distinctly in the defec- tive ear. Fig. 49. Ear Mirror. EXAMINATION OF THE PATIENT. 133 In making an examination of the external auditory canal and membrane, what instruments are requisite ? First,