Carbuncle

Carbuncle (carbunculus), anthrax, in patho-anatomical terms represents a collection of more or less significant amounts of furuncles on a limited area of skin with a common infiltrate. "Malignant boil" - a name sometimes given by older authors to carbuncle - should not be confused with malignant K. (pustula maligna), which has a completely different course and is caused by the bacillus of anthrax. In K., an entire group of hair follicles together with the sebaceous glands opening into them is affected. The process, as with a furuncle, leads to acute purulent inflammation of the hair follicle and surrounding tissues, which ends in necrosis and melting of the connective tissue; the process spreads from the center to the periphery. A section through K. at the stage when extensive tissue melting has not yet occurred reveals in it many foci of suppuration and necrosis. The difference between K. and furuncle in patho-anatomical terms is only quantitative. In K., the area of spread of the process is much more extensive both in depth and over the surface of the skin; the latter sometimes dies off over a considerable extent. With extensive development of the process, infiltration and necrosis of tissues may reach in depth to the muscle fascia, which after the rejection of the dead area of skin and subcutaneous tissue is exposed over the corresponding extent. In very emaciated people, as well as in diabetics, K. often also involves the fascia and destroys it; the process is complicated by the spread of suppuration of the connective tissue, significant necrosis of the skin and deep tissues, thrombosis of veins; such patients b.c. usually die from general blood infection. The causative agents of purulent inflammation of the hair follicles and surrounding connective tissue are most often staphylococci or streptococci, but the process can be caused by all sorts of types of pus-forming bacteria. Israel named metastatic hematogenous nest-like abscess of the kidney carbuncle of the kidney, because its picture resembles that of skin carbuncle; this name has become established in kidney surgery. Pus-forming microorganisms in K. of the kidney can penetrate the blood from various types of local purulent processes, including from skin carbuncles. Clinically, K. manifests as a fairly significant dense infiltrate of the skin, which takes on a bluish-purple color, sharply expressed in the center of the focus; as one moves away from it, the redness gradually fades; b.c. there is lymphadenitis and sometimes lymphangitis. Other clinical symptoms of skin K.: feeling of tension in the inflamed area, pain, elevated temperature. The favorite localization is the skin of the occiput [see separate table (p. 223-224), fig. 16], back, lips and cheeks. K. occurs more often in elderly people and in diabetics; in the latter it often takes a malignant course. After several days, when the corresponding hair follicles die off, necrotic plugs break through the thinned upper layers of the skin, and the entire inflamed area appears as if perforated with small holes like a sieve; each hole in the skin exactly corresponds to the former focus of suppuration and necrosis - the primary furuncle; from the holes, pus is discharged together with sequestra of soft tissues. After rejection of the dead tissues, the purulent process subsides, the reactive redness and swelling decrease, and at the site of the defect, scarring occurs. This is how the process proceeds in most cases. But sometimes with certain localization of carbuncle, most often on the face or in weakened people who have had an infection, suffering from diabetes, the process passes from purely local to general and takes the character of a severe infectious disease. Particular danger is presented by K. of the upper lip and the entire upper half of the face due to the direct connection of the venous system of the face with the intracranial veins. Along with completely benign K. of this area, which are accompanied by swelling of surrounding tissues of moderate degree, remain localized and are eliminated within a few days, sometimes K. are observed that from the very beginning take a stormy course. The latter occurs especially often with insufficient rest of the affected area or with rough manipulations (squeezing). In such cases, the infiltrate quickly takes on a progressive character, and signs of general infection appear: high temperature, small, frequent pulse, shaking chills, clouding of consciousness, collapse. Within a few days, such K., having caused general sepsis, can end fatally. Sometimes death in progressive K. depends on pyemia, and metastatic abscesses can be observed in the most various organs and tissues. Of the complications that can be added to K., erysipelas should be mentioned. In people with impaired nutrition, suffering from diseases of the digestive tract or severe infectious diseases, neglect of the rules of skin hygiene (rare change of linen, shaving in unsanitary conditions, rubbing of the skin by clothing) especially predisposes to the occurrence of carbuncle. Diagnosis as a rule presents no difficulties. From a furuncle, K. differs in that in the first there is one center of suppuration; a furuncle is also more limited, more superficial and is not accompanied by such a sharp infiltration of tissues as K. High temperature and strongly expressed general phenomena may make one think, especially at the beginning of the disease, of anthrax (pustula maligna). In these cases, for diagnosis, in addition to establishing the characteristic appearance of pustulae malignae, it is necessary to clarify the source of infection, the connection of the patient with production (leather, brush, etc.). In doubtful cases, bacteriological research clarifies the nature of the disease. In the question of treatment of K., the views and trends among surgeons are reflected, which have found their expression in the most varied proposals. Some consider it correct to refrain from any active intervention, limiting themselves to observation of the general condition of the patient. This proposal is based on the view that any intervention opens new paths for the spread of infection. Undoubtedly there are cases of K., well-defined, without sharp edema, which heal exclusively under a sterile ointment dressing. With daily change of the latter, pus and dead melted tissues are removed. After a few days, after cleansing of the focus, the process of granulation and then scarring begins. Most surgeons do not limit themselves to expectant treatment and consider active surgical intervention necessary, the dimensions of which again vary depending on the school. The most common method is a cruciate incision of K. to the boundaries of healthy tissues, penetrating in depth to the fascia or to unchanged muscles. The four resulting corner flaps are separated from the underlying tissues with a knife, and the entire focus is thus exposed. The entire wound is loosely filled with gauze abundantly soaked in hypertonic solution of NaCl or calcium chloride; bleeding from the wound is stopped by tamponade. One should take care that the wet dressing is on the wound itself and not around it, in order to avoid maceration of the skin by moisture. Often developing around K. superficial (impetigo) or deeper pustules owe their origin to the inoculation of bacteria (inoculation) on macerated skin. To avoid this, the skin around K. should be smeared with sterile vaseline. The indications for changing the dressing depend on the general and local phenomena. If the patient's condition has improved, temperature has subsided, the process does not show a tendency to spread, it is sufficient at the first dressings to change the upper layers of it, leaving loosely laid tampons on the wound itself. After 7-10 days, together with the separated gangrenous tissues, at dressing the gauze compresses abundantly soaked with pus also easily come off. Further treatment is carried out in most cases under dry sterile dressings. If the general condition continues to remain severe, local reaction is strong, it is necessary to change the entire dressing and examine the wound with the aim of opening new foci and draining them. Another method of surgical treatment of K. is based on the view according to which the process is treated in the same way as a malignant neoplasm. Proceeding from this (Ostel, Madelung and others), they propose to excise the entire affected area of tissues outside the boundaries of the inflammatory infiltrate. Further treatment is carried out according to the principles just outlined. This method has not found such widespread use as the cruciate or linear incision. Cauterization of K. with carbolic acid, a stick of caustic potash or other cauterizing substances (carbolic acid), which was eagerly used in former times, now does not find a large number of supporters.-K. is sometimes complicated by septic thrombophlebitis; in these cases, the affected area or organ needs absolute rest, for which it is necessary to achieve, by appropriate measures, complete immobilization. If the occluded vein is accessible to recognition, it should be ligated in healthy limits central to the thrombosed area.

Needless to say, rough manipulations should be avoided in C., to which category belongs the occasionally practiced expression of pus plugs, which entails the destruction of the demarcation line and rapid spread of infection. Conservative methods of treatment of C. aim to raise the body's defensive forces by creating a barrier around the inflammatory focus that possesses immuno-biological properties. Among such methods is the injection around the C. of the patient's own blood-autotherapy; to this an incision may be added. Levén (Lawen; 1923) recommends injecting under the skin along the periphery of the focus daily from 20 to 40 cm³ of the patient's own blood. The method of local immunization according to Besredka has also found application in C. Individual authors use the treatment of C. with an antivirus in the form of filtrates of staphylococcus cultures or mixed filtrates (staphylo- + strepto-coccus) and note good results: rapid disappearance and reverse development of the process. Vaccinotherapy is also used in the form of polyvalent heterogenous staphylococcal vaccine or (which is better) autovaccine; the use of the vaccine requires careful dosage. Among other methods used for the treatment of carbuncle, mention should be made of proteinotherapy and radiotherapy. Finally, a prominent place among therapeutic measures is occupied by the congestive hyperemia by Bier using a suction cup or bandage, which often gives good results. Along with local treatment, it is necessary to care for the general strengthening of the body, and in diabetes-to carry out appropriate therapy and regimen.