TREATMENT OF 
CHROMIC AURAL. DISCHARGES. 
i \ 
■ • ; 
\/ 
BY JULIAN J. CHISOLM. M. I). 
Professor of Eye and Ear Diseases in the University of 
Maryland, and Surgeon in charge of Baltimore 
Eye and Ear Institute. Surgeon of 
Presbyterian Eye and Ear 
Charity Hospital, 
&.C., &c. 
A PAPER READ BEFORE THE BALTIMORE ACADEMY OF MEDICINE. j 
( ftevined from Xortfi Carolina Medical Journal, Mai/ lHiH.) 
BALTIMORE; 
J- H. FOSTER & CO., STEAM PRINTERS AND PUBLISHERS, 
No. 9 South Charles Street. 
1878. TREATMENT OF . 
CHRONIC AURAL DISCHARGES. 
' 
BY JULIAN J. CHISOLM, M. D. 
Professor of Eye and Ear Diseases in the University of 
Maryland, and Surgeon in charge of Baltimore 
Eye and Ear Institute. Surgeon of 
Presbyterian Eye and Ear 
Charity Hospital, 
&c., &c. 
A PAPER READ BEFORE THE BALTIMORE ACADEMY OF MEDICINE. 
(Revised from North Carolina Medical Journal, May 1S7S.) 
BALTIMORE: 
J H. FOSTER & CO., STEAM PRINTERS AND PUBLISHERS, 
No, 9 South Charles Street, 
1878. Chronic Aural Discharges. 
Chronic aural discharges have so long been an opprobrium to the 
profession that it has become the habit with many physicians to ig- 
nore their treatment. Let it alone and the child will outgrow it, is the 
stereotype professional phrase which I hear daily from patients who 
have exhausted their patience in awaiting this outgrowing. I have 
heard of cases of aural discharge lasting through a long life, literally 
from the cradle to the grave, and never were cured. These cases had 
sought relief from more than one medical source, and had derived 
great consolation from this oracular opinion delivered with the positive - 
ness that professional ignorance alone engenders.—Let it alone, it is a 
good vent for the system !!! “ Stop it and your lungs will suffer Iff” Or 
it the patient be old enough he is made to rejoice in the knowledge 
that in this discharge resides his immunity from apoplexy, and he is 
thoroughly scared from seeking relief from this annoying disease, 
by having these words ever ringing in his ears. Check it at your peril! 
On the contrary a long running ear is always a dangerous compan- 
ion. The drum cavity from which the discharge escapes is surrounded 
by bony walls which isolate it from most important neighboring 
structures. The roof of this cavity is separated from the brain by a 
very thin plate of bone, and at times inflammation has extended from 
the ear through this bony partition directly into the brain, causing 
death. Should the inflammation extend in an other direction it will 
cause plugging of the large veins coming out of the skull and equally 
bring about a fatal result. Such serious accidents, and many other 
very dangerous complications, may at any time come on in connection 
with a running ear, and hence attention can not be too early given to 
the arrest of this very annoying and dangerous disease. 
The explanation for the false positions so constantly assumed by even 
good practitioners is found in the recognized difficulty with which 
chronic otorrhoea is checked by the family physician, even when care- 
fully treated; and the impossibility of controlling it under the routine 
advice given to patients of syringing their ears, without being told 
how to do it. 
If the pathology of aural discharges be understood and the rough 
anatomy of the ear kept well in mind, much of the difficulty which 4 
surrounds this important medical subject can be dispelled, and the suc- 
cessful treatment can be made comparatively easy. 
In order to lay down a few simple rules for our guidance in the 
treatment of otorrhcea, we must recall the fact that the hearing appar- 
atus has three natural divisions. The external ear and passage from 
the drum-head out is covered by skin, continuous with that of the face, 
and is therefore a dermic tube, liable to any of the diseases which 
affect the skin proper. The middle ear, or drum cavity, lying behind 
the drum-head with mastoid cell appendages, is a diverticulum from 
the throat, and is lined by the universal mucous membrane which faces 
all cavities of the body having an outlet The susceptibility of mucous 
membranes to inflammation is enjoyed by the drum cavity in common 
with all other mucous sacs, and the extensions of inflammations from 
the throat into this part of the ear is the common cause of ear ache, 
aural discharge and deafness. The serous tissues of the closed sacs, 
pass from the brain envelopes, through the aqueducts of the temporal 
bone into the labarynthine cavities of the inner ear. Thus we have 
external dermic, middle mucous, and inner serous spaces, all represent- 
ed in the auditory apparatus, and of these the mucous is by far the 
most prone to take on suppurative inflammation. 
There are three conditions known as otorrhoea or aural discharge, 
which differ widely in pathological significance. 'The first is an acute 
form accompanied by severe pain, some external swelling, and a 
stuffed sensation in the ear, with rapid deterioration of hearing. After 
a few days and nights of more or less suffering, matter oozes from the 
ear and the stuffed feeling diminishes. As the symptoms subside, 
hearing is restored, and the patient soon feels quite well. This condi- 
tion is known as furuncles, or circumscribed abscesses in the 
lining of the external passage, identi 'al with boils upon the skin. 
These will even disappear of their own accord as common experience 
proves they having run a more or less rapid course. As an evidence of 
disturbed health in young adults, such painful boils in the ear passages 
are very prone to recur, following each other at short intervals, often 
at times in one ear and then in the other. Attention to the general 
condition of the system, with the use of tonics and liberal diet, will 
correct this evil even should the ear be ignored ; although hot sooth- 
ing fomentations, more especially when used as an adjunct to free 
scarification of the swelling, will rapidly expedite a cure. 
A second condition of a running ear is called otitis externa ; a dis- 
charge from the skin surface of the external ear passage, accompanied 5 
by much pain, itching, injection, and swelling of the dermic lining. At 
first the discharge is watery, gradually becoming purulent. When the 
periosteum, which lies between the skin and the bony tube, is involv- 
ed, abscesses may form which may eventuate in necrosis of a portion 
of the bony wall, with fistulous openings, both within the passage and 
behind the ear near the mastoid region. Although the continuance of 
these discharges depend much upon the general depression of the 
system and show a disposition to dry up as the body at large improves, 
the comfort of the patient is much enhanced by daily local cleansing 
with warm water and soothing astringent applications. Should a piece 
of dead bone result from the inflammation, the discharge will continue 
for months or even years until the dead fragment come away. 
When an aural discharge has been of long continuance, the diag- 
nosis of otitis media may safely be made, and most frequently a history 
of acute aural catarrh of the drum cavity, usually called earache, can 
be traced. Its earliest condition was probably an inflammatory ex- 
tention from the throat, causing injections and swelling of the lining 
membrane of the drum cavity, quite enough in these cases to close the 
eustachian openingwhich leads directly from the upper part of the throat 
to the middle or drum cavity of the ear, and makes of the drum a 
shut sac. The products of inflammation soon fill this small cavity. 
Then commences the acute pain of internal distension and nerve 
pressure both upon the promontory or inner wall of the drum space 
and the drum head. Finally after a few days of feverish excitement 
and severe suffering in head, neck and throat, the purulent collec- 
tion bursts through the drum membrane by ulceration, more or 
less extensive, and the distressing symptoms which accompany the 
appearance of a discharge from the ear subside. In many cases of 
acute suppuration of the middle ear, rupture of the drumhead brings 
the same relief as the bursting of the skin in the spontaneous discharge 
of a whitlow. A rapid disappearance of the mucous congestion may 
permit the drum cavity to resume its normal conditions. Even the 
opening ?n the drum head may in time close by firm and complete 
cicatrization and hearing be perfectly restored. This consummation 
often obtained when the drum head is timely incised for the evacua- 
tion of the matter is by no means the rule, especially when the case 
has been allowed to run its own destructive course, without the re- 
straining advantages of judicious treatment. 
When such cases finally come under the observation of a 
specialist he finds a foetid discharge of long continuance accom- 6 
panied usually with very deficient hearing. An examination of the 
affected ear, with the speculum in a good light, will nearly always 
reveal the red exposed congested mucous lining of the drum 
cavity, as seen through an opening more or less extensive in the 
drum head. The view can only be obtained after a thorough 
cleansing of the external meatus by warm water injection. Often 
in these chronic cases the lining membrane of the eustachian 
tube, from the throat entrance to its opening in the drum cavity, has 
thinned to such an extent as to blow agiin air to pass through the 
passage from the throat into the ear ; and the forcible blowing of the 
nose may make the ear whistle, a simple and sure means of diagnos- 
ing a perforation of the drum head. 
In all such cases, the muco-purulent discharge, however copious, 
is the pathological excretion from the mucous lining of the drum cavity. 
It must accumulate in the drum before it escapes through the abnor- 
mal opening in the drum head, and finally finds its exit at the outer 
ear. This thick secretion must take some time to traverse this pas- 
sage of 12 inches in length. Often 24 hours are consumed before 
the secretion of one day formed in the depths of the ear can make its 
appearance at the outer orifice, as the discharge which escapes has 
to be pushed forward by later formations. 
We all know that pus when first formed is a bland, innocuous, taint- 
less fluid, organized like the blood with liquid and solid elements. 
The floating, fleshy particles, which we call pus cells, under the high 
temperature of the body 98° must, ifre tained for many hours become, 
as putrescent as would blood or flesh after a sufficiently lengthy ex- 
posure to a summer’s heat. This decomposed fluid, offensive and 
irritating in its nature, excoriates the surfaces which it overlies, and 
through a continuous excitation promotes the formation of more mat- 
ter. The presence of the discharge therefore keeps up the disease ; 
or as we may more tersely put it, the running ear Causes the contin- 
uous running of the ear. Such are the cases to be found in the 
practices of every active physician, who often being weariecf by their 
obstinate persistence seeks refuge in advising patients to put up with 
these diseases as a supposed safe guard against more serious maladies. 
In mapping out a course of treatment I will make in the onset a 
very bold statement which any one can verify, viz: that cleanliness 
alone will cure many of these most obstinate cases of otorrhea, and that 
really the question of most importance in the treatment of these dis- 
gusting as well as dangerous affections, is how can we obtain this 7 
desirable cleanliness ? Washing with simple \warm water will secure it if 
properly done; and the mode of doing it when once known is 
found exceedingly easy. 
There is one point which admits of no question, viz : that an offe?i- 
sive ear is a foul one, regardless of the number of times per day it is 
syringed, or the diligent care bestowed upon it by patient or friends. 
Foetid pus always means pus some time secreted, and which must have 
had many hours to metamorphose itself from its primitive bland state to 
that of an offensive irritating liquid. Ip the ear is always allowed to 
contain fcetid pits it will continue to discharge whether the duration of 
the disease has already been months or years. 
Successful surgery secures its greatest triumphs in close attention to 
little things, and the surgeon who wishes good results must see to it 
that all the detailed arrangements for carrying out his plans are clearly 
understood by nurse or patient. The aurist cures patients of chronic 
discharges which have so long baffled the family physician by a course 
of treatment often identical in its wording with that previously used. 
Thoroughly syringe your ear with warm wrater and use a prescription 
of astringent drops, are the instructions given by both family physi- 
cian and aurist. The physician believes that he has done his full duty 
to his patient when he has advised the purchase of a syringe, and has 
written the prescription. The patient doing as directed, buys a syringe, 
usually a small glass one because it is cheap, and with such an instru- 
ment-it is impossible to thoroughly cleanse the ear. Let him with it 
throw in warm wTater for ever so long a time, he still leaves the drum 
cavity and the depressed portion of the passage full of thick offensive 
pus, upon the top of which he now instills a few drops of the astringent 
solution. Of course, there can be no commingling of these thick and 
thin liquids. The astringent never comes into contact with the diseased 
surface, so completely covered with the tenaciously sticking pus, and 
persistence in the medicated application brings no good results. The 
aurist gives the same advice and writes the usual zinc and carbolic acid 
ear drops. But he goes further ! He tells his patient to buy only the 
proper ear syringe that can be worked with one hand alone ; and of 
these the simple rubber bag is the best. He explains how the other 
hand must be used to straighten the passage, by drawing the ear up- 
wards, backwards and outwards. Then he shows how the water is to 
be thrown by the syringe into the ear passage, downwards and inwards 
which will surely carry the stream into the very drum cavity and thor- 
oughly cleanse it. If after a few syringe fulls of warm water have 8 
been in this way injected into the ear, a bit of raw cotton attached 
to the end of a match stick be carefully pushed to the very bottom of the 
ear passage, it will bring out with it no foul odor and should appear 
free from all stain. After such a proper cleansing, let the drops be 
applied. Now they are brought into direct contact with the congested 
membrane, and will do the healing work designed. 
The law then becomes imperative, a clean ear must be the founda- 
tion for any treatment intended to arrest chronic discharges. 
As to the local medication necessary, after the thorough cleansing has 
been obtained, an ear drop consisting of sulph. zinc, grs. iij ; carbolic 
acid, grs. iij to § i aqua is a prescription of general utility, and will 
cure a large number of cases of running from the ear. When the 
discharge of very long standing does not yield to this application, the 
zinc may be changed for any one of the mineral salts used for astring- 
ent purposes, as alum, borax, chlorate of potash, muriate of ammonia, 
sulphate of copper or bi-chloride of mercury. In some cases nitrate 
of silver in solutions of varied strength, from grs. Hand grs, x, to \ i 
of distilled water, will accomplish what the milder astringents failed to 
do. Even with the caustic solutions, the heroic application of a liquid 
gradually increasing in strength until it contains as much as 480 grains 
to the 3 i. of water, has in a few very rebellious cases proved effective. 
When nitrate of silver drops are used in the ear, they should be al- 
lowed to remain in for only a few minutes, and then washed out by a 
stream of warm water, otherwise they will trickle down the neck leaving 
ugly black stains, which will very slowly disappear by the pealing off 
of the skin. Such marks on the side of the face or external ear indicate 
carelessness either on the part of the patient, or most frequently on 
the part of the surgeon. 
Of late years desiccating powders have to a considerable extent 
taken the place of ear drops. When salicylic acid was brought for- 
ward as a purifier of great potency I experimented largely with it as 
a remedy for chronic aural discharges. I used it in powder, mixed 
one part to three, with oxyd of zinc or calcined magnesia. This 
powder was blown into the ear, after thorough cleansing of the aural 
passage, and with a success sufficiently marked to warrant a publica- 
tion of my experience. 
In latter years I have substituted for this powder, alum, which I 
have found more efficacious than any remedy previously used. By 
means of it I have cured discharges of fifty years standing in one 
week, and I now find very few aural discharges, however chronic, that 9 
withstand its proper application. The method employed in using it 
to secure these good results is, first to thoroughly cleanse the ear, then 
wipe dry the passage by means of a loose cotton swab attached to the 
end of a match or special applicator ; after which I puff into the ear 
powdered alum, filling the drum cavity with it. The very first appli- 
cation will often indicate a diminished discharge at the end of twenty - 
four hours. This ear is then washed out and the alum powder again 
applied. This treatment is renewed once a day until the discharge is 
so reduced that the powder blown into the ear continues dry upon its 
exposed external surface, not enough secretion being formed to per- 
meate the mass of powder. If the powder has crusted in the ear, it 
may be left for a few days as a hard mass giving no pain and causing 
no annoyance. If after a week or ten days interval, the ear has seem- 
ingly stopped discharging, the alum powder remaining dry although 
in a cake, it may be syringed out, as if it were a foreign body. Under 
these conditions it usually leaves a healthy mucous membrane behind 
it. 
Since powdered alum is so constantly and successfully used by me 
in aural discharges, I find it convenient to apply it through a puff 
bottle which expedites much the insufflation, and is far preferable to 
having it blown into the ear through a quill or pipe stem, or even 
rubber insufflator. In damp weather, I was formerly annoyed by the 
caking and lumping of the alum in the bottle which necessitated fre- 
quent drying and repulverization. At the suggestion of Dr. W. J. 
McDowell, I now add to the alum powder a small quantity of lyco- 
podium which when thoroughly triturated with the alum, makes it 
more volatile and not at all disposed to lump: 5 grains of lycopo- 
dium powder to the drachm of alum is ample. In a few cases in 
which the alum has failed to stop the aural discharge, I have substi- 
tuted tannic acid with advantage. With the proper use of these two 
powders, I rarely have need for other local medication in chronic otor- 
rhcea. 
In most cases of ear discharges of long continuance especially in 
children of enfeebled constitution, the general medication with cod 
liver oil and iron tonics must not be omitted. 
In my own practice I have ceased to consider chronic aural dis- 
charges an obstinate disease ; for under the thorough cleansing and 
the insufflation with alum or tannin, I-find they yield more kindly to 
treatment than any other bodily affection that has been of long con- 10 
tinuance. One advantage of no small merit in the powder treatment 
is, thatjt is incapable of abuse. An excessive application can do no 
harm.