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A chronic discharge from the ear is no longer looked upon as a “necessary evil," it matters not what may be the character of the secretion. What cures of this condition that can not be accomplished by local and constitutional therapeutic measures can be accomplished by surgical intervention. Chronic middle ear suppuration should be placed in the same category as chronic appendicitis, and like the latter, should receive the same kind of treatment. The general public has become educated upon the necessity of being operated upon for appendicitis, while chronic fetid suppuration from the middle ear they look upon as of no consequence, failing to realize that such patients are calmly resting upon a smoldering volcano which at any time may develop into a sinus thrombosis or a brain abscess, to be followed quickly by death, and in many cases the cause incorrectly stated upon the burial certificate.

Fetid discharge from the ear has been the bete noir of the general practitioner, and even of the specialists for years past, but in the recent development of aural surgery, as exemplified by Schwartze and Stacke, this condition need no longer be allowed to run its indeterminable course, undermining the health of the patient, but by a thorough and radical operation this pathological condition can be removed and the discharge cured.

Allow me to make myself clear as to the meaning of a chronic discharge from the middle ear. There are two kinds of chronic discharges: 1. A catarrhal, mucoid secretion, free from odor except when the ear has not been cleansed for some time, coming from the middle ear through a perforation in the drum, associated with the same kind of catarrhal secretion in the nose and nasopharynx. This condition can nearly always be cured by local therapeutic measures directed to both the ear and the nasal mucous membrane. This form of middle ear discharge is frequently seen in children, especially those with adenoids in the nasopharynx, and in those recovering from measles and scarlet fever. Proper and thorough treatment of this form will produce a cure, frequently the only thing necessary being the removal of the adenoids. However, if the condition is not treated, it will pass into the next form, of which especially I wish to speak.

2. Discharge from the middle ear, of whitish desquamated epithelium, with purulent fetid secretion, destruction of the drum membrane, and in many cases erosion and liquefaction of the auditory canal at the point where the drum should exist. This is the form that must usually be designated as chronic, and is the form nearly always existing if over a year in duration.

All chrot 'c suppurative discharges must have previously been acute in character, but whether due to neglected treatment at the time or to some inherent constitutional dyscrasia, such is frequently hard to decide. There is always some reason why one child suffers with a chronic discharge for months and years, from the middle ear, following an attack of measles or scarlet fever, while another child will have equally as severe an acute condition, and yet the discharge will cease in a few weeks. In such cases as the former, I have never failed to find some

hereditary systemic dyscrasia, it matters not what we call it, whether inherited syphilis, scrofulosis, tuberculosis, cretinism, chronic adenitis, etc. Consequently, when such discharges have become chronic in individuals suffering with any of the constitutional dyscrasias, it is very easy for local changes to take place in the middle ear, such as polypoid degeneration of the mucous membrane, necrosis of the ossicles and walls of the tympanic cavity, the formation of cholesteatomatous masses, which when they have once found a firm foothold, are almost impossible to be eradicated except by surgical measures. In such cases, thorough and appropriate treatment should be used at the time of the acute attack, and thus avoid in many cases the extension of the same into a chronic condition. Proper treatment of these cases in the acute stages will, in the majority, prevent a subsequent chronic trouble. I am firmly convinced that most of the cases of chronic suppuration from the middle ear result from the mastoid antrum having been seriously affected at the time of the acute trouble, and if the same had been recognized at that time and a simple mastoid operation performed then upon the ear, the subsequent trouble would in all likelihood have been avoided, and the necessity for a more radical operation have been removed. In the treatment of such cases, internal constitutional medication plays as prominent a part as all the local remedial measures at our command; consequently, the work of the aurist should go hand in hand with that of the family physician. Coming now to those cases which are chronic when seen by us for the first time, let us consider their symptoms and their proper management should we desire the best results.

Cases of chronic suppuration from the middle ear are multiform in variety. Just as acute cases differ in severity, so also the chronic forms. Objective appearances :

These vary greatly. The longer the time the discharge has existed, the more destructive will be the appearances. In all of these chronic cases, as a rule, if there has been no active treatment, the walls of the auditory canal will be found white and glistening, the epithelial layer of the skin having been entirely eroded by the passage out of the secretion. On syringing one of these chronic ears which has not been treated, we will find coming away with the water large flakes of desquamated epithelium, both from the drum, canal and tympanic cavity. When this is removed, we find that the drum membrane will contain perforations of all sizes, and in many cases only a rim of this membrane will be present. Experience and observation teach us that the longer the chronicity has been present and the more severe has been the purulent process, the more destruction of the drum membrane we are liable to find.

In some cases, the mucous membrane of the middle ear will be white and sclerosed, while in others it will be red and granular in appearance, and in some cases showing a distinct polypoid degeneration.

If, with the destruction of the drum membrane, we find also an erosion of the inner wall of the canal and the tympanic cavity, with the presence also of cheesy, fetid secretion, then we have the suppurative condition in its worst form, and it is just in these cases that complications of a most serious nature are liable at any time to occur. By means of a probe passed up into the tympanic vault or back towards the mastoid, necrosed bone is nearly always likely to be found, and rarely ever have I found that disgusting fetid odor without discovering the presence of dead bone. In fact, experience teaches me that, in nearly all of those cases where the odor is exceedingly offensive, the drum membrane destroyed and the attic filled with

cheesy masses, nothing short of a radical operation will be sufficient to effect a cure. In many of these cases there will have been an involvement of the mastoid bone at the time of the acute attack, but having free drainage by way of the auditory canal and middle ear, the symptoms may not have been severe enough to warrant a mastoid operation at the time, and yet sufficient to cause a disintegration of the cell spaces of the mastoid, and especially of the antrum itself. For this reason, a mastoid operation performed during an acute attack, when every symptom points to the involvement of this bone, even though the classical symptoms of redness and edema over the mastoid be absent, will often be the one treatment which will save the patient years of chronic trouble, save the hearing and be a probable preventive of a more radical operation in this region at some later date. I have rarely ever done a radical operation upon the middle ear where I have not also found some chronic changes in the mastoid and in some cases even a small fistulous opening may be found on the surface of the mastoid, which shows the previous involvement of this bone. In many of these cases, the offensive odor from the ear involved is sometimes terrific, being a symptom which, in itself, will necessitate an operation.

Such a case as this recently came under my care. A young girl, nine years of age, an inmate of the Home for the Friendless, was sent to me with a note saying the discharge and odor from one of the ears of this patient was so offensive that her teacher at the public school had sent her home with the message that the odor was so disagreeable in the schoolroom as to be compelled to request the withdrawal of this girl from school. On examination, I found the left auditory canal with a cheesy cholesteatomatous mass, which when washed away, disclosed the

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