Definition. An acute, circumscribed, cutaneous and subcutaneous inflammation, characterized by multiple foci of necrosis and sloughing of the superficial tissues.
Carbunculosis is a condition where the lesions occur singly or in crops, more or less continuously for some time.
Symptoms. Mild prodromata usually precede the carbuncle, such as chill, fever and malaise but when the lesions are extensive, numerous, persistent or situated on the head, the prostration may be alarming. A burning, tense pain is felt at the site of the beginning lesion which appears as a deep, flat, hard swelling at first covered by reddened skin, which soon becomes more darkly tinted. From the size of a boil or larger, the infiltration may spread until it reaches the size of a boil or larger, the infiltration may spread until it reaches the size of the palm, rarely larger. At the end of a week or ten days, the carbuncle appears as a flatly convex, hard tumor, livid in color, gradually merging into the surrounding skin, with its surface studded with several pustules or circular openings which mark the site of previous pustules. These openings exude a sanious pus, and pus-soaked sloughs can be seen beneath. As the process goes slowly on, the latter break down and are discharged through the enlarged opening or the skin may give way with the slough and be thrown off in large pieces, leaving a well defined crateriform ulcer with uneven floor and overhanging edges. The process of repair is identical with that of a furuncle; namely, healing by new granulation tissue and closure by cicatricial tissue. The scar in time becomes whitish, but may retain a violet or purple tint for some time. The amount of systemic disturbance present and duration of a carbuncle depends upon its size and location and upon the age and general condition of the patient. It usually lasts from two to six weeks. Carbuncles are usually single, and are most often located upon the nape of the neck, upper part of the back, buttocks and lateral aspects of the thighs. It may, of course, appear anywhere and in one case of diabetes I have seen about eighty carbuncles appear within two years on nearly every part of the body. It is especially dangerous, but fortunately rarely present, on the scalp, face or abdomen. While a carbuncle may occur at any time in life, it is usually after the thirtieth year and more frequently in men.
Etiology and Pathology. the predisposing and cooperating causes are identical with those of a furuncle and the exciting cause is the introduction of the same staphylococcus pyogenes aureus. The pathology of carbuncle is similar to that of furuncle is that the process starts from numerous points in the hair-follices, oil or sweat glands. Beginning in the subcutaneous tissue, the affected parts are enormously swollen and include in their midst yellowish-white necrotic plugs. The process extends in the direction of least resistance, perhaps downward into the fat of the subcutaneous tissue, or infiltrates the cutis and crowds the papillae with pus which finally oozes to the surface through the undermined epidermis.
Diagnosis. The larger size and multiple openings of carbuncle differentiate it from furuncle. Appearing on the face it might be mistaken for erysipelas but the edema of the later is never a board-like hardness nor is it followed by the development of necrotic plugs as in carbuncle.
Prognosis depends entirely upon the influence of predisposing factors. In conditions like nephritis and diabetes or in the aged, debilitated or alcoholic or in such locations as the scalp, face or abdomen, the progenosis is far from good. Nevertheless, recovery may be looked for in a great majority of cases under proper treatment.
Treatment. Supportive measures will nearly always be in order because carbuncles rarely occur in the vigorous. Rest in bed is wise in nearly all severe cases and a direct attention to the underlying disease, if any exists, is eminently fitting. Local antisepsis is the safest way to reduce temperature although antipyretics are occasionally needed. While the local treatment of carbuncles may be the same as that of boils, especially in the application of creolin in glycerin, there are many cases that are benefited by parenchymatous injections of pure carbolic acid or of carbolic acid 10 per cent. in glycerin or oil. It may be necessary to resort to surgery for relief and when it is done, no detail of surgical technic should be neglected. The crucial incision followed by the complete removal of all diseased, tissue is the best method. After the deposit has broken down, Bier’s suction or exhaustion glasses may be employed in preference to the abominable habit of squeezing and pressing. Ichthyol, 25 per cent. in ointment, may be applied after the injections, incisions and cupping. Poulticing is as harmful in this condition as in the treatment of boils, because it favors the growth of the cocci and may extend the affected area. A vaccine made of the staphylococcus aureus is often worth a trial.
The importance of the internal remedy can only be appreciated when the constitutional involvement as well as local disease is considered. See especially indications for Anthrac., Apis, Arsen., Belladonna, Calcarea sulph., Carbo veg., Crotal., Hepar, Kali brom., K. phos., Lachesis, Lycopodium, Murex acid, Nit. acid, Phyto., Pic. acid, Rhus tox., Secale, Silicea, Tarent., Vipera.