FURUNCULUS

Synonyms.—Furuncle; Boil; Fr., Furoncle; Clou; Ger., Furunkel; Blutschwär.

Definition.—Funinculus, or boil, is an acute, deep-seated, inflam­
matory, circumscribed, rounded or more or less acuminated, firm,
painful formation, usually terminating in central suppuration and
necrosis.

Symptoms.—A boil usually begins in one of two ways. There
may appear a small painful induration in the skin or subcutaneous
tissue, over which the skin presents a rounded or imperfectly defined
reddish spot; it increases in size, and the surrounding induration and
swelling become more pronounced, and project more or less above
the surface of the circumjacent skin. After several days, when well ad­
vanced, it appears as a pea- to a cherry-sized, circumscribed, reddish,
rounded elevation, with more or less surrounding hyperemia and swelling,
and is painful and tender; it gradually begins to soften, and ends, in
the course of several days to one or two weeks, in the formation of a
central slough and suppuration. The central overlying skin is finally
involved, which becomes somewhat pointed, thin, and yellowish, dis­
closing the pus beneath. This central point soon breaks, the opening
enlarges, and there are discharged more or less pus and a small, grayish-
yellow or greenish-white pultaceous mass, the so-called “core”; the
pain immediately abates, the inflammation quickly subsides, the swelling
and redness disappear, the hollow cavity fills up with granulation tissue,
and healing rapidly takes place, leaving behind for a week or more a
reddish spot, with slight scar­formation, which, in some instances, may
be so slight as later to be scarcely perceptible.

Or instead of a painful cutaneous or subcutaneous nodule, the
lesion first presents as a minute superficial pustule, usually pierced by

¹ Linser (“Ueber die Behandlung der juckenden Hautkrankheiten mit normalem
menschlichen Serum,” Dermatolog. Wochenschr., March 30, 1912, liv, p. 365) records
an instance of cure from an injection of serum from a normal pregnant woman; he also
records instances of other pruritic dermatoses, being relieved by serum injections.

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a hair; gradually the surrounding and underlying parts become red
and slightly indurated and swollen, and the small pustule dries, and
then the lesion gradually assumes, to a great extent, the characters
of an ordinary boil, and goes through the stages described. Or the
small pustule breaks and discharges; it dries over, and then the indura­
tion, redness, and swelling ensue. Gradually this points, presents a
yellowish summit, and the course is the same as above detailed.
Exceptionally the opened apex may dry over once or twice, the boil fill
up again before the core is discharged.

There may be one, several, or more present, and usually in close
proximity, although in some cases they may be widely separated. If
the lesion is a large one, or if several form simultaneously, there may be
slight sympathetic constitutional disturbance. The neighboring lym­
phatic glands may show some enlargement.

At times a boil shows very little, if any, tendency to point or break
down, or to form a distinct core, constituting the so-called blind boil.
This may disappear in its early stage, or may continue and finally go on
forming a soft boggy pea- to cherry-sized elevation, which eventually
breaks and discharges, and then gradually heals up as in the ordinary
form.

Usually, when the one or several lesions which have formed sim­
ultaneously or one after another disappear, the whole process is ended.
In other cases there is a constant recurrence of one or several lesions,
in the same localities, or on different regions, and this sometimes con­
tinues for weeks and months, constituting that condition termed fnrun-
culosis.

While boils may appear on any part of the body, certain regions,
such as the back of the neck, the axilla, buttock, forearms, and legs
are its most common sites, and most frequently the first named.

Etiology.—Two factors are to be considered necessary in this
disease, essential and predisposing. The essential factor, and the
immediate exciting cause, is the entrance into a hair-follicle or seba­
ceous gland-duct, or possibly a sweat-gland, of a special micro-organ­
ism. The frequently observed close proximity of boils is indicative of
external cause and auto-inoculability. The contributing influences
are various, but may be, in brief, any depraved state of the general
health. Albuminuria, diabetes mellitus, disorders of the digestive
organs, gouty and rheumatic diatheses, living in close and badly venti­
lated rooms or in damp and musty places, and, doubtless, other factors
may be of influence in bringing about a condition of the skin favorable
to successful inoculation. Too much warmth, with its consequent
sweating, and friction are also of importance in bringing the skin itself
into a favorable state for implantation and multiplication of pyogenic
organisms. Thus boils are quite frequently a part of a persistent miliaria
in dirty and overclad children or even adults; and especially common
about the nape of the neck and axilla, parts subjected to rubbing and
chafing. Workmen in paraffin oils and petroleum and tar products
often present furuncles and subcutaneous abscesses. The administra­
tion of certain drugs, notably potassium iodid, may be in some instances

410                                      INFLAMMATIONS

an important etiologic factor; lesions so produced are not infrequently
seen in those taking “blood purifiers,” many of which contain this drug.

All ages and both sexes are liable, but the formation is more common
between the ages of twenty and forty, and in males.

Pathology.—A boil is an inflammatory formation having its
starting-point in a sebaceous gland, hair-follicle, or possibly a sweat-
gland, the exciting factor being the staphylococcus pyogenes aureus.
Both Bockhart¹ and Garré² have experimentally produced furuncular
lesions on themselves by rubbing in pure cultures of this organism; the
former, a pure mixed culture of the staphylococcus aureus and albus, the
latter of the aureus alone. Its pathogenic importance has been demon­
strated by Pasteur, Sabouraud, Unna, Wickham, and others.³ It is
not improbable, however, that boils may also be produced by other
pus-producing organisms. The core or central slough of a boil is
composed of pus and the glandular and perifollicular tissue in which it
had its origin. The intense zone of inflammatory deposit around the
center, by shutting off the vascular supply, results, along with the
liquefying action of the cocci and leukocytes, in the breaking down of
the central portion and the production of the core mass.

Diagnosis.—A boil is so well known that usually even a layman
can make the diagnosis. In the earliest stage of those which begin
as a superficial pustular point around a hair it might be readily, and
probably properly, looked upon as a simple impetigo lesion; the later
phases of surrounding and underlying inflammation, with the gradual
pointing and discharge, are quite characteristic. A furuncle is, in
fact, to be distinguished chiefly from a carbuncle, and the main dis­
tinguishing point is that a furuncle is a single formation and has but
one point of suppuration and opening, whereas a carbuncle is a large,
flattened, intensely painful formation usually accompanied with con­
siderable or severe constitutional disturbance, and has, moreover, sev­
eral or more points of suppuration.

Prognosis.—An average boil usually runs its course in from one
to two weeks, and even when several or more are present in the same
locality, a favorable issue in many cases soon results. In some of these
latter instances, however, and in those in which there are scattered boils
appearing from time to time (furunculosis), a favorable result is not so
rapidly reached, although complete freedom will sooner or later be es­
tablished. The possibility of a serious underlying factor, such as diabetics
living in a damp, unhygienic atmosphere, etc, must be considered.

Treatment.—Remembering that boils are doubtless due to the
predisposing factors of a weakened organism, a local disturbance of
the skin, and the presence of the specific causative microbe will sug­
gest the plans of treatment.

The constitutional treatment depends, in a measure, upon the
patient‘s general condition, and what may seem to be the etiologic
factor. A generous dietary is to be allowed. In cases of numerous

¹ Bockhart, Monatshefte, 1887, p. 450.

² Garré, Fortschritte der Medicin, 1885, p. 165.

³ See literature under Impetigo, and also under General Etiology.

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411

and recurrent boils, the urine should always be examined. Irrespec­
tive of any such disease as diabetes, albuminuria, and the Kke, the
most successful plan of treatment consists in the administration of
tonics, especially iron, cod-liver oil, strychnin, and similar remedies.
Occasional laxatives are of value. The digestion should be considered,
and if disordered, the necessary treatment instituted. Recently fresh
brewer‘s yeast, a teaspoonful to a tablespoonful, three times daily,
has been again brought forward as a valuable remedy by Brocq,¹ Gordon,²
Turner,³ and others.⁴ Purdon⁵ speaks favorably of lactophosphate of
lime, and Duhring of sodium hyposulphite. Wright, Gilchrist, Engman,
Gaskill,⁶ and others have recently reported good results in furunculosis,
from injections of antistaphylococcic serum or “vaccine,’' the dose and
frequency to be regulated by the opsonic index of the blood (see “Opso-
nins,”) or, as more recently, by the effect of trial doses.

The local management of the disease is of importance, and its success
depends upon thoroughness. Absolute cleanliness is essential, and
for this purpose frequent washings, at least once daily, with soap and
water should be enjoined; and in multiple or recurrent cases the tincture
of green soap may be used for this purpose, with 5 or 10 grains (0.33-
0.65) of resorcin to the ounce (32.). The beginning formation may some­
times be aborted by the injection of a few drops of a 5 per cent, solution
of carbolic acid into the lesion or by plunging a wooden toothpick
charged with pure carbolic acid into the apex of the lesion. An ointment
or aqueous solution of ichthyol, 25 per cent, strength, kept constantly
applied, will succeed sometimes. It forms a good method of treatment
of the lesion; when pointing has ensued, an incision and expression
of the contents and its reapplication will hasten the final disappear­
ance. While most boils will pass through their various stages and
disappear satisfactorily without incision, this latter hastens the process.
After incision and expression of the contents a good plan is to cleanse
the cavity with hydrogen dioxid or the carbolic acid solution. Poultices
are, as a rule, not to be employed. In addition to the ichthyol ointment
and the soap-and-water washings, an application of an antiseptic lotion
to the boil or boils and the entire affected region, night and morning,
is a measure of considerable value in the management of the disease and
the prevention of new lesions. Such a lotion is the following: R.
Resorcin, gr. xv-xxx (1.-2.); acidi borici, 5iss (6.); alcoholis, f3j (32.);
aquæ dest., f3v (160.).⁷

¹ Brocq, La Presse méd., 1899, p. 45 (with review of past literature).

² Gordon, Philada. Med. Jour., April 1, 1899.

³ Turner, Therapeutic Gazette, March 15, 1899.

⁴ Aragon and Coutourieux, Bull, méd., July 5, 1899.

⁵ Purdon, Dublin Jour. Med. Sci., Feb., 1898.

⁶ Gaskill, Jour. Amer. Med. Assoc, April 15, 1911, p. 1099, has had good results
from opening with a sharpened cotton applicator dipped in carbolic acid, hypodermic
injection of polyvalent staphylococcus vaccines, and application of a 5 to 15 per cent,
salicylic acid ointment.

⁷ John T. Bowen, “The Treatment of Furunculosis,” Jour. Amer. Med. Assoc,
July 16, 1910,p. 209: green soap and water washing twice daily, the skin then bathed
with saturated solution of acidum boricum—dried without wiping, and then the
individual furuncles dressed with an ointment of boric acid, 3 j (4.), precipitated sul­
phur, 3 j (4.)j and carbolized petrolatum, 3 j (32.)—underwear changed daily.

412

INFLAMMATIONS

When the lesions are small, superficial, and close together, as not
uncommon upon the back of the neck, and occasionally on the lower
part of the leg, the free use of this lotion after thoroughly cleansing
the parts with the tincture of green soap and water, and while still
wet with it putting on a thick layer of boric acid powder and covering
with a light dressing will often act satisfactorily; this is to be done once
or twice daily. When, too, the lesions are on the neck region, it is pos­
sible that the scalp, especially the hair of the lower occipital region,
may be the harboring place of the micro-organisms and give rise to re­
currence; and the patient is, therefore, directed to wash this latter region
thoroughly once daily, and the entire scalp at least twice weekly. The
same is to be advised when the disease is on other parts, where the hair
is in abundance, as in or about the axilla, genitalia, and anal region.
With this plan of management—frequent washings and the general
application of the above lotion and powder, and, in the larger and the
maturing lesions, ichthyol salve application, incision when necessary,
along with the indicated constitutional treatment—most of the recurrent
cases, in these regions, yield comparatively rapidly. I have usually
reserved the staphylococcic injection for trial in rebellious cases.

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