A furuncle is usually painful, of a throbbing nature, which persists until suppuration has taken place and the contents discharged. The intensity of the inflammation gives rise to considerable areolar swelling and hyperæmia. There may be but one lesion present, or, as more frequently happens, several may exist at the same time scattered over different regions. In the latter case, after a partial or complete disappearance of the first crop, a second outbreak frequently occurs, to be followed later by a third, and so on, constituting furunculosis. The lesions are usually isolated. No region of the body is exempt; the face, neck, back, and buttocks are favorite localities. Sympathetic constitutional disturbance, more or less marked in severe cases, is usually present. Boils sometimes occur in association with eczema. In general, they are the result of a depressed state of the system. Friction, a contusion, or similar local irritation is often the exciting cause. They are met with in association with diabetes, pyæmia, uræmia, chlorosis, fevers, and like conditions. Although observed at all periods of life, they are more common during adolescence and in old age. The view has been advanced that a furuncle is due to the presence of a microbe (Torula pyogenica). According to Pasteur, this bacterium is identical with that of abscesses of the soft parts, etc.
The lesion usually has its starting-point in a sebaceous gland in the upper part of the corium, or, deeper, in a sweat-gland or hair-follicle. Beginning in a sweat-gland in the deeper structures it constitutes the so-called connective-tissue furuncle, or hydroadenitis of some authors. The core, or central suppuration, is usually made up of the tissue of the gland in which the boil had its origin, and pus, and when cast off appears as a whitish, tough, pultaceous mass. A more or less permanent cicatrix usually results. There is only one affection with which a furuncle is likely to be confounded—namely, carbuncle. In this latter, however, the lesion is considerably larger, flattened instead of rounded and pointed, the pain of an intense character and in a measure independent of touch or injury. Moreover, a carbuncle has several points of suppuration, the boil having but one, and the former, moreover, is rarely multiple.
When occurring in crops, the affection is often rebellious to treatment. Both constitutional and local measures, especially the former, are demanded. Functional disorders are to be regulated, and any faulty condition of the general health corrected. Tonics, such as quinine, iron, strychnia, mineral acids, and arsenic, are not infrequently of service. The last remedy usually proves of most value in those cases in which the lesions appear in crops. The preparations of sulphur are of positive service in many cases of the disease; hyposulphite of sodium, ten or fifteen grains three or four times daily, is one of the most valuable remedies we possess, and with the same view calx sulphurata, one-tenth to one-half grain five or six times daily, may be prescribed. Alkalies, especially liquor potassæ in ten or fifteen minim doses, are not infrequently beneficial. The compound syrup of the hypophosphites may also be employed with the hope of obtaining relief. In regard to the diet, the most nutritious food, liberally partaken of, is, as a rule, to be advised. At times change of air and scene will act most happily.
Concerning the local treatment, the lesion in the first stage may possibly be aborted, or at least modified in its course, by the application to the forming core of a strong solution or of a crystal of carbolic acid. This procedure is preferable to the actual cautery. If the lesion be farther advanced, a drop of carbolic acid and glycerin, equal parts, will often give instantaneous relief and arrest the progress of the boil. A few drops of a 5 per cent. carbolic-acid solution may also be injected into the apex of the boil with good results. For the same purpose painting the parts with tincture of camphor or tincture of iodine is advised. An ointment of carbolic acid—as, for example, resin cerate an ounce, carbolic acid from fifteen to thirty grains—applied as a plaster will be found useful. The application of poultices affords ease in some cases. As soon as suppuration has been fully established evacuation of the contents will shorten the course of the process. If the boil is open and discharging, boric acid in powder, freely applied, has been recommended.
ALEPPO BOUTON, BOIL, OR EVIL, DELHI BOIL, AND BISKRA BOUTON.—The first of these diseases, the Aleppo bouton, boil, or evil, is observed at Aleppo, Bagdad, and the neighboring regions. Delhi boil is not uncommon in India, and the Biskra bouton is found in Algeria and elsewhere along the African coast. In fact, these diseases are more or less epidemic in these countries. They have been considered as allied to furuncle, but their true nature is somewhat obscure. The three affections are probably examples of the same disease, modified, it may be, by climate, habits, etc. They begin as a papule or tubercle, soon becoming a pustule, and then ulcerate, leaving a cicatrix.
Carbunculus.
Carbunculus (anthrax, carbuncle) is a firm, more or less circumscribed, painful, deep-seated inflammation of the skin and subcutaneous structures, variable as to size, terminating in a slough. General malaise, slight fever, and chilliness precede and usher in the disease. Locally, there appears at first a more or less circumscribed, circular redness, with swelling, tenderness, and pain. Soon a phlegmonous inflammation develops, the surface at times showing vesiculation, the lesion involving an area several inches in diameter and of considerable depth. The progress of the disease is not uniform. At the end of a week or two suppuration is fully established, the first signs of this process appearing about the hair-follicles. The tissues are now soft and boggy; the skin becomes gangrenous, breaking down at numerous points, disclosing centres of suppuration, giving the lesion a cribriform appearance. Finally, the whole mass sloughs away either as an entirety or in portions, and results in an open, deep ulcer with hard and raised edges, which gradually granulates and heals, leaving a pigmented cicatrix. The area involved varies, and may be extensive, sometimes as much as six or eight inches in diameter. The favorite localities for its development are the nape of the neck, shoulders, back, and buttocks. As a rule, the process ends in three to six weeks. Usually only one lesion exists. When there are several or where they follow each other in succession, the general condition is apt to become markedly depressed, and even a fatal result is not at all uncommon.
The causes which give rise to the affection are similar to those which predispose to furuncle. It is generally observed in those whose health is impaired or broken down. It is more common in men, and is usually encountered in those past middle age. The inflammation starts simultaneously at numerous points, usually from the hair-follicles, sweat and sebaceous glands, extends in all directions, and eventually terminates in gangrene of the whole area. The inflammatory centres break down rapidly, from each of which the collected pus finds its way to the surface, thus producing the cribriform appearance. According to Warren, the pus ascends by way of the columnæ adiposæ to the hair-follicles, and thence to the surface. The process may involve fascia, muscles, and even periosteum and bone. The disease is to be distinguished from furuncle by its greater size, flatness, and the multiple points of suppuration. From erysipelas, to which in the beginning it may have some resemblance, it is to be differentiated by the hardness, painfulness, and circumscribed character of the lesion. It is also to be distinguished from malignant pustule. It is always to be looked upon as a serious affection, especially when occurring in those past the age of fifty or sixty and in those in a debilitated condition. Carbuncle when occurring about the face terminates in a large proportion of the cases fatally.
The treatment is both local and general. The local measures are in the main the same as advised for furuncle. In the early stages the actual cautery may arrest the process. Injections of from eight to twelve drops of a 5 or 10 per cent. solution of carbolic acid will be found valuable, often affording speedy relief. Frequently-repeated paintings with tincture of iodine in the early stage may prove of service. Poultices are of value, and will often diminish the tension and the pain. A dressing of white lead, laid on thick, is highly spoken of by Milton and other English observers. When the purulent collections have broken through the skin the application of a cupping-glass to draw out the pus has been advised. The wound should be dressed with carbolized oil. The use of the moist-sponge dressing, with the view of absorbing the pus, as recommended by McClellan, may be advised. Compression may also be resorted to with good results. The weight of authority is against the practice of incision, although in some cases it is to be recommended, the operation being preceded by hypodermic injections of cocaine. The general treatment should be of a tonic character. Iron—preferably the tincture of the chloride—and quinine in large doses are to be advised. A liberal diet of nourishing food, with a moderate amount of stimulants, is indicated in almost every case.