CARBUNCULUS

Synonyms.—Carbuncle; Anthrax; Anthrax simplex; Anthrax benigna; Fr., Car-
boncle; Ger., Carbunkel; Brandschwär; Kohlenbeule.

Definition.—A carbuncle is an acute, usually egg- to palm-sized,
more or less circumscribed, flattened, phlegmonous inflammation of
the skin and subcutaneous tissue, terminating in a slough which usually
finds exit at several or more points.

Symptoms.—The first indications of the formation of a carbuncle
consist in some local tenderness and subcutaneous induration, along
with symptoms of constitutional disturbance, such as chilliness and
malaise and febrile action, which, if the disease is situated about the
face, or if involving an extensive area, and especially if the patient
is asthenic, may be of a severe character. Locally the induration
becomes more pronounced, is somewhat flat, and consists of a firm, dense
infiltration of the deeper skin and subcutaneous tissue, with the over­
lying skin of a reddish tinge. It spreads laterally, and finally involves
an area of several or more inches in diameter. It projects slightly above
the surface, and extends deeply, is tense looking and of a dark-red color,
which extends for some distance beyond the hardened area. After a
variable time, usually some days, suppuration and softening take place,
the skin at several or more points shows a tendency to thinning and
discloses the yellowish-red pus beneath. These gradually open and give
exit to a sanious pus. The many openings give the surface a cribriform
appearance. Sloughing is noted at these openings, which slowly or
rapidly become larger; the inclosed pus and necrotic tissue are gradually
cast off, the cavities are filled with healthy granulations, and healing
begins to take place. Or in other cases, as soon as the skin has broken
through at several or many places, a sloughing of the whole mass ensues,

CARBUNCULUS

413

which later falls out, and leaves a large and rather deep-cut ulcer,
which gradually undergoes the reparative process and heals. Or,
after reaching its acme, the whole mass may slough without previous
opening. The necrotic process usually stops at the subcutaneous
fascia, but in exceptional instances (Weber, Monnier) it goes much more
deeply. The formation is painful, often of a dull and lancinating char­
acter. The disease area may, in extreme cases, involve a whole region.
Especially in the latter cases, the constitutional symptoms are of a grave
character. In some instances, particularly in the aged, septic poisoning
ensues, and the patient gradually or rapidly succumbs. Instead of
beginning as a subcutaneous induration a carbuncle may, as also ob­
served in boils, begin as a superficial pustule, and may, in such instances,
in its early stage, be apparently furuncular.

There is usually but one lesion present. The favorite sites are the
nape of the neck and the upper part of the back. It is most common in
middle age and advancing years, and most frequent in men. Several
weeks or one or two months may elapse before recovery is complete.

Etiology.—The etiology of carbuncle is to be considered as essen­
tially the same as that of furuncle; ill health from any cause, a depression
of the vital forces, diabetes, and other constitutional diseases being pre­
disposing. Added to the predisposing factor or factors is the essential
one of microbic invasion, the organism believed to be the same as in
boils, and doubtless always the staphylococcus pyogenes aureus, although
it is possible that other pus-organisms may at times be etiologic There
may be an invasion at many points in this malady, which results in the
production of a lesion seemingly made up of a number of closely aggre­
gated necrotic centers.

Pathology.—The pathology of this lesion is closely similar or
analogous to that of a furuncle. The inflammation starts simultaneously
from numerous points from the hair-follicles, sebaceous, and possibly
sometimes also the sweat-glands, the inflammatory centers break down,
and the pus finds its way to the surface; finally the process ends in gan­
grene of a part or of the whole area. It is not improbable in this, as
well as in furuncle, that the vascular supply is shut off from both beneath
and laterally by the intense inflammatory deposit, with resulting necrosis.
The pyogenic micro-organisms are present in abundance in the tissues.
Investigations have shown that the inflammation may also start deeply
down from some point or points in the subcutaneous tissue. The pus
forms, spreads laterally along the line of least resistance, the overlying
skin becomes necrotic, and the pus finds its way to the surface along the
line of the columnæ adiposæ and along the hair-follicles and erector
pili muscles (Warren).¹ According to Winiwarter,² there is primarily
tissue necrosis, with suppuration and fibrinous coagulation, and early
thrombosis of the vessels.

Diagnosis.—Carbuncle differs from furuncle by its flatness, more
extensive area, and its multiple points of necrosis and suppuration,

¹ Warren, Boston Med. and Surg. Jour., April 17, 1877; Columnæ adiposæ, with their
Pathologic Significance in Carbuncles, etc., Cambridge, Mass., 1881.

² Winiwarter, “Furunkel und Carbunkel,” Chirurgische Krankheiten der Haut,
Stuttgart, 1892.

414

INFLAMMA TIONS

and by the presence, usually, of constitutional disturbance of moderate
or severe character. Erysipelas and phlegmona diffusa may also at
times, more especially in the beginning, bear some resemblance.

Prognosis.—Carbuncle is always a serious malady, and is not
infrequently fatal in old people and those debilitated by disease or
who have a grave underlying condition of ill health. About the face
and head the outlook is still more serious. Septic poisoning is always a
possibility; death from thrombosis or embolus has also occurred. Except
in such instances as named, however, full recovery is to be expected.

Treatment.—The treatment of carbuncle comes usually under
the care of the surgeon. Abortive treatment, by keeping the surface
soaked in a strong antiseptic solution, usually 5 to 10 per cent, carbolic
acid lotion, may exceptionally, in the very beginning, when the forma­
tion begins superficially, prove successful; likewise the application of
ichthyol, pure or with two or three parts water. Mild cases, and even
severe cases, are often successfully treated, as first advocated by Verneuil,
by free injection of carbolic acid in glycerin or oil, 10 per cent, strength,
at several or more points in the lesion; over this can be placed a thick
covering of a 25 per cent, ointment of ichthyol, using equal parts of
lanolin and zinc oxid ointment or spermaceti as a base. When the
growth has broken down at a number of points, the pus and detritus
may be partially drawn out by means of a cupping-glass, and the car-
bolized oil or glycerin injected into the cavities thus made, and over this
the same dressing as above; or the cavities or openings can with advan­
tage be first thoroughly washed out with hydrogen dioxid. The slough
usually comes away in the course of several days or a week or so, and
healing gradually ensues. Others (Woods, Taylor, Manley)¹ prefer a
saturated solution of pure carbolic acid as less likely to be followed by
absorption. Operative treatment has long been the favorite method;
deep crucial incisions have long been in general use, and still have their
advocates; and, more recently, crucial incision, supplemented by com­
plete extirpation of diseased tissue by curet or knife (Riedel, Schleich,
Parker).² In rapidly sloughing cases thorough curetting and the
superimposing of an antiseptic dressing are advisable; ichthyol also
serves well for this purpose.

The constitutional treatment of carbuncle consists in supporting
the patient's strength with the administration of alcoholic stimulants,
ammonium carbonate, strychnin, quinin, and iron. Wright's plan of
opsonic treatment with antistaphylococcic vaccine might be worth a
trial in the more severe cases.

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