FURUNCULOSIS OF THE EXTERNAL AUDITORY 
CANAL 
BY 
S. MacCUEN SMITH, M.D., 
CLINICAL PROFESSOR OF OTOLOGY IN THE JEFFERSON MEDICAL COLLEGE 
SURGEON IN CHARGE OF THE EAR AND THROAT DEPARTMENT 
OF THE GERMANTOWN HOSPITAL, PHILADELPHIA. 
FROM 
THE MEDICAL NE.WS, 
January 19, 1895. [Reprinted from The Medical News, January 19, 1895.] 
FURUNCULOSIS OF THE EXTERNAL AUDITORY 
CANAL. 
BY S. MacCUEN SMITH, M.D., 
CLINICAL PROFESSOR OF OTOLOGY IN THE JEFFERSON MEDICAL COLLEGE ; 
SURGEON IN CHARGE OF THB EAR AND THROAT DEPARTMENT 
OF THE GERMANTOWN HOSPITAL, PHILADELPHIA. 
Attacks of circumscribed inflammation in the 
external auditory canal, known as boils or furuncles, 
are of such frequent occurrence, and cause the suf- 
ferer so much pain and inconvenience, that the neces- 
sity for a more extended recognition of their exist- 
ence, and especially a knowledge of the efficient 
means we have for their relief, has induced me to 
submit a few practical hints upon their treatment. 
Notwithstanding the fact that furuncle of the exter- 
nal meatus is one of the most common ear-affections 
that the physician is called upon to treat, the condi- 
tion is, nevertheless, often difficult to recognize and 
troublesome to combat successfully. Here, as else- 
where, the furunculous inflammation is limited to a 
small area, and has a strong tendency to the formation 
of pus, owing probably to the fact that the canal is 
abundantly supplied with excretory glands, and 
when inflammation is once inaugurated it usually 
runs an uninterrupted course to the stage of suppu- 
ration. 
Inflammatory diseases of the auditory meatus are 
plainly and properly classified as being either acute 2 
or chronic, circumscribed or diffuse. They may 
involve simply the integument, or may extend more 
deeply into the subcutaneous structures, and impli- 
cate both the periosteum and bone. 
The lining membrane of the external auditory 
canal is a continuation of the integument covering 
the auricle, being, however, considerably modified 
as it reaches the osseous meatus. As the membrana 
tympani is approached, this same integument under- 
goes still greater changes, and forms the outer layer 
of the drum-head. Notwithstanding the striking 
alterations observed in the appearance of the skin 
of the auricle and of the auditory canal, as in contrast 
to that noteworthy modification each undergoes to 
constitute the outer layer of the membrana tympani, 
yet neither the drum-head nor the skin of the audi- 
tory meatus can be spoken of or treated as a mucous 
membrane, any more than it would be proper to 
consider the integument of the auricle as such. 
Mention of this is made at this time for the reason 
that some writers have described certain affections 
of the canal under the head of " catarrhal inflamma- 
tion;" but, as the word catarrhal can only be ap- 
plied or used in connection with the diseased 
condition of a mucous membrane, it is quite im- 
possible for the external auditory canal to be the 
seat of such an inflammatory process, inasmuch as 
the canal is covered with integument and not with 
mucous membrane. 
It has already been definitely established that the 
great majority of pathologic conditions are trace- 
able to the destructive action of disease-germs, and 
that pus-formation does not occur without the pres- 3 
ence of pyogenic microorganisms. The researches 
and subsequent claims of Lbwenberg likewise de- 
monstrate that these microorganisms play an impor- 
tant part in the etiology of furunculosis of the audi- 
tory meatus. If then the disease in question is the 
result of a specific germ-poison, it is reasonable to 
assume that our failure to treat successfully some of 
these cases within a reasonable time is due to the 
fact that the remedies employed for their relief are 
but feebly germicidal, and, therefore, insufficient to 
destroy the infecting bacterium. 
Those actively engaged in this line of work in a 
large dispensary and hospital service must at times 
have been impressed with the thought that boils of 
the external auditory canal occur epidemically. 
Usually, of course, these cases are sporadic; but at 
certain periods of the year (notably in the spring 
and fall) they are seen in large numbers, and come 
so often from a particular locality, that we are in- 
clined to believe them not only epidemic, but also 
infectious and contagious. During the fall of 1890 
I saw 117 cases of boils of the meatus, sixty-two of 
which came from a locality embraced within an area 
of about one square mile. Forty-six of this num- 
ber were males and sixteen females. Fifty-one were 
suffering at the same time from an acute attack of 
influenza, but without severe constitutional disturb- 
ances; while eleven showed no apparent illness 
whatever. As to the situation of the boils, fifty-two 
were in the cartilaginous meatus, four in the deep 
osseous portion, and six at the extreme outer end of 
the canal. 
When the direct cause of an aural furuncle is ob- 4 
scure it has been customary to attribute it to an 
impairment of the general health, which in many 
cases is quite evident and conclusive. However, it 
is interesting to note the large percentage of appa- 
rently healthy people we find suffering from boils of 
the external meatus; furthermore, in these other- 
wise hardy patients, it is the exception to find any 
that have been troubled with boils on other parts of 
their person. Lbwenberg, who was the first to point 
out the parasitic nature of aural boils, has definitely 
proved that furunculosis can be artificially produced 
by rubbing sound skin with staphylococci. We 
have in this demonstration, therefore, a plausible 
explanation of the cause of aural furuncle in persons 
who are otherwise enjoying good health, especially 
when the origin cannot be traced to a chronic sup- 
purative otitis media, the introduction of bacteria 
into the canal through the use of dirty plugs of 
cotton-wool, or to direct mechanic or chemic irri- 
tation. The initial etiologic element, is, therefore, 
shown to be infection by the direct entrance of a 
staphylococcus beneath the skin, through an abra- 
sion or by way of a hair-follicle or ceruminous 
gland. 
In the same manner we have reason to believe 
that the public phonograph is liable to become a 
source of aural infection of no small proportions, as 
it has become quite common for a community to use 
the phonograph placed in a conspicuous place for 
their amusement. The hard-rubber ear-pieces are 
seldom cleansed, and, being passed from one indi- 
vidual to another, it can readily be seen how either 
the public phonograph, or other similar instruments, 5 
may be the means of conveying infectious material 
from diseased to healthy ears. 
Treatment.-Many physicians have doubtless 
been annoyed with the stubborn resistance of aural 
boils and their failure to yield to the various thera- 
peutic agents employed for their relief; moreover, 
the repeated recurrence of this affection has been 
embarrassing to the physician and vexatious to the 
suffering patient. Many lines of treatment, both 
local and general, have been suggested for their 
relief; but unless such therapeutic measures have as 
an object the destruction of disease-germs they 
must in a measure continue to be unreliable and 
disappointing. The auditory canal, and in fact 
the entire ear, presents many obstacles to the at- 
tainment of strict asepsis in the treatment of its 
various diseases. Were it possible to overcome 
these difficulties entirely we could then expect these 
obstinate affections of the ear to be as amenable to 
treatment as when located in other organs. Much 
progress, however, has recently been made in the 
employment of antisepsis in this locality, and we 
are now enabled under proper precautions to operate 
with almost immunity on parts of the ear that 
heretofore would have been regarded as most hazar- 
dous. 
In this, as well as in other similar ailments, the 
important object of treatment is the immediate 
relief of suffering, together with the limitation, 
modification, or abortion of the inflammatory pro- 
cess. Our ability to accomplish one or more of 
these purposes will largely depend on the stage the 
disease has reached before treatment is begun, as well 6 
as the efficiency of the remedies employed for its 
relief. 
The treatment generally accepted for furuncle is 
very simple, and consists in an incision through the 
boil, dividing the periosteum down to the bone. 
This procedure, however, is usually more applicable 
to boils that are well advanced. Our treatment 
will serve a much better purpose if the case is diag- 
nosticated at an early period, when an attempt can 
be made to abort the incipient boil. We know that 
many inflammatory processes might be aborted or 
limited in their destructive action if they could be 
subjected to local antiseptics that were not only 
powerful germicides, but at the same time non- 
poisonous and non-irritant. In the compound 
known as camphor-phenol, which is composed of 
fifty-five per cent, of camphor and forty-five per 
cent, of carbolic acid, we have a preparation that 
meets the requirements, and hence becomes at 
once a valuable addition to our local therapeutics. 
In compounding this preparation we must insist 
that the drugs be chemically pure; otherwise the 
crude elements of the carbolic acid, or the impuri- 
ties present, will be markedly irritating. It has 
been my custom to employ this combination in its 
full strength. 
The use of this preparation, when applied lo- 
cally for the alleviation or cure of furunculosis of 
the external auditory meatus, is founded upon its 
inhibitory action on the development of the staphy- 
lococcus pyogenes aureus, and incidentally on its 
marked anesthetic properties. Granting this hypoth- 
esis to be correct, it is only proper to expect that 7 
this solution of camphor and carbolic acid will not 
only shorten the disease in question if seen early, but 
should also lessen the suffering and limit the course 
of a case well advanced. 
From a practical knowledge obtained by an 
experience of more than eight years in the em- 
ployment of this preparation I feel justified in 
offering the claims stated as reasonably correct. 
Many cases of incipient furunculosis can be success- 
fully aborted by introducing a cotton tampon satur- 
ated with carbolized camphor into the meatus. 
Even when the furuncle has so far advanced that an 
incision becomes necessary, the pain incident thereto 
can be greatly lessened by previously introducing 
a similar tampon, a few minutes only being required 
for more or less complete anesthesia to take place. 
Likewise, after the boil has been opened, the pain 
will be almost immediately relieved by the intro- 
duction of a piece of cotton-wool saturated with 
this solution. In the latter case, however, the tam- 
pon should be large enough to fill the circumference 
of the meatus, and extend well beyond the boil, as 
the pressure exerted by the cotton assists in promot- 
ing rapid absorption, and thereby facilitates quick 
recovery. Before each tampon is introduced, the 
canal should be carefully mopped out with alcohol, 
as this is our most efficient means of clearing the 
meatus of all debris, and the alcohol, moreover, is 
an excellent antiseptic. It may be necessary to 
apply a fresh tampon of camphor-phenol every day 
until five or six have been introduced, but two or 
three are usually quite sufficient to destroy all dis- 
ease-germs. An ointment of yellow mercurous oxid 8 
(gr. to 3j) can be substituted for the camphor- 
ated phenol as soon as the inflammation begins to 
show marked signs of subsiding. 
In advocating this line of treatment it should 
not be understood that by so doing we would ex- 
clude other therapeutic measures of more or less 
value. In selected cases blood-letting or blistering 
in front of the tragus is of undoubted service, and 
hot antiseptic irrigation of the meatus should be 
employed when indicated. I should like also to 
mention the value of dry cold in the treatment of 
inflammatory conditions of the external and middle 
ear. This, however, will be treated of more at length 
in a future communication. The use of poultices 
is mentioned here only for the purpose of discour- 
aging their use. The single benefit that could arise 
from the employment of hot poultices is the ques- 
tionable good that may result by promoting suppu- 
ration. In so doing, however, one creates a populous 
hot-bed for the rapid multiplication of bacteria, and 
frequently excites an inflammation of the auricle. 
Moreover, the few cases of middle-ear disease that 
I have seen occur as an extension from the inflamed 
meatus have invariably resulted after frequent poul- 
ticing had been practised. 
In debilitated subjects the general health should 
receive due consideration. The administration of 
selected tonics, and those drugs known as alteratives, 
in conjunction with proper hygienic surroundings, 
will do much to effect the cure of an existing boil, 
and especially to prevent its recurrence. For this 
purpose I would strongly urge the use of arsenic in 
the form of Fowler's solution, given in increasing 9 
doses until the physiologic effects are produced. 
The administration of calcium sulphid, although 
popular for a time, has on the whole been disap 
pointing in my experience. 
In conclusion, I may state my belief that aural 
furuncle is both infectious and contagious, with a 
tendency to recurrence from auto-inoculation, and 
that it occasionally manifests itself epidemically. I 
can only add that I do not recall a single instance 
in which there was a recurrence of the furuncle in 
any portion of the canal, providing strict antisepsis 
was maintained, and all these important therapeutic 
measures were applied to the case. 
To summarize briefly the treatment of furunculosis 
of the external auditory canal : 
1. As antiphlogistic measures, use the leech or 
blister in front of the tragus, and hot antiseptic irri- 
gation, when indicated. Avoid the use of poultices. 
2. As local applications, cleanse the canal with 
alcohol and insert an ample tampon of cotton wool 
saturated with camphor-phenol, renewing this every 
twenty-four hours, or oftener if required. This is 
at once antiseptic and analgesic. 
3. As constitutional remedies, give tonics and 
alteratives, with the especial recommendation of 
arsenic in the form of Fowler's solution. This 
should be administered in increasing doses until its 
physiologic action is obtained. 
4. As an operative procedure, make a free incision 
through the boil, and divide the periosteum down 
to the bone. This will prove necessary in well-ad- 
vanced and chronic cases, especially when pus has 
already formed. 
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