FURUNCLE

FURUNCLE, ЕЗ (furunculus, furunculosis). A furuncle represents a purulent inflammation of a hair follicle and sebaceous gland with involvement of the surrounding connective tissue in the inflammatory process (a limited inflammatory lesion of the hair follicle is called folliculitis). At present, the word furuncle has almost entirely replaced the former Russian names chirey (chireyvatost) and vered. According to Cloquet (J. Cloquet), furunculus is derived from the Latin word furiare—to drive to fury. Furuncles are usually caused by infection with various types of staphylococci, much more rarely streptococci may be involved. On this basis, furunculosis was even called limited staphylococcosis of the skin by Kocher (Kocher). The dependence of furuncles on the introduction of microorganisms through friction into the skin was demonstrated on himself by Garre. In furuncles, as a result of the introduction of microbes into the excretory ducts of the sebaceous glands and the hair follicle, purulent inflammation occurs, which immediately spreads to the surrounding connective tissue. Corresponding to the nature of the process caused by staphylococci, central necrosis results, however, the necrotic area is mechanically firmly connected to the surrounding tissues and in the initial stages cannot be removed. Around the necrosis, abundant cellular infiltrate accumulates, either only around the necrotic focus or over a considerable length, many times exceeding the central area. Several days after the onset of the process, the characteristic for staphylococcal infection late formation of dissolving substances begins in the center, while around the dead area, granulation tissue forms. Both processes contribute to the melting of the area of necrosis and its separation from the surrounding tissues. As a result, the necrotic connective tissue, partially or completely, with the gland and hair bulb, is discharged outward, in its place remains a defect, which gapes due to the dense infiltrate; from the center of the defect, a thick greenish pus is discharged, partly with remnants of the necrotic area, around it granulations become visible, which gradually clean out and, growing, fill the defect. Simultaneously with the opening of the furuncle, the surrounding infiltrate is absorbed, the phenomena of inflammation subside, the granulations epithelialize and scar. At the site of the former furuncle, a small irregularly shaped scar remains. Corresponding to these changes, the clinical picture develops. On some area, usually where the sebaceous glands are particularly developed (back, occiput, face), as well as where mechanical friction of the skin by clothing occurs simultaneously (neck, inner surface of the thighs, etc.), a limited induration with redness and tension of the skin appears, in the center of which a whitish-greenish point is determined, from which a hair often protrudes. The affected area hurts by itself and is sharply painful on touch and especially on trauma. After 2-3 days, the central area elevates, the epidermis peels off and the central 'plug' is exposed, which may still hold firmly for some time, but then, together with pus, comes out partially or completely outward. After this, the inflammatory reaction weakens and the process is eliminated. The entire process lasts, depending on the size of the infiltrate and the area of necrosis, 5-15 days. Usually no general phenomena are observed. However, in individual cases, due to the virulence of the microbes or the low resistance of the body, as well as in case of trauma to the furuncle, the infiltrate sharply increases, lymphangitis or lymphadenitis of the regional glands joins. Finally, in rare cases, thrombophlebitis develops, and then to the local phenomena, more or less severe general phenomena of intoxication join with a significant increase in temperature. Traumatized furuncles, with a small hemorrhage in the center, often differ by the dark, almost black coloration of the central area. As the central plug is removed and softening occurs, all these phenomena may subside, and the process may end in the usual order; otherwise, it passes into general purulent infection with all its dangers and consequences. The localization of furuncles also affects their clinical picture: thus, in areas with abundant development of sebaceous glands, furuncles often arise simultaneously in several places. On the occiput and behind on the neck, where the subcutaneous connective tissue is little yielding and is penetrated by dense fibers going in different directions, furuncles are distinguished by special painfulness. In the axillary fossa, where there is abundant development of sweat glands, so-called hidradenitis (hidroadenitis) are obtained when infection is introduced into them, which very much resembles furuncles; however, in the same area, furuncles also develop with their usual course of development. Both, when spreading to the deep connective tissue, are complicated by phlegmons, which also capture the connective tissue behind the pectoral muscle. Furuncles developing on the face, in particular on the upper lip, deserve special attention. These furuncles become very dangerous when complicated by thrombophlebitis of the v. facialis ant. Infected thrombi of the vein through the v. ophthalmica and plex. ven. pterygoideus reach the sinus cavernosus, causing its thrombosis and meningitis. Therefore, trauma to furuncles of this localization is especially dangerous, and many cases are known that ended in death after 'squeezing out' a facial furuncle. In general, the prognosis for individual furuncles is favorable: in the vast majority of cases, even without any treatment, the process ends with scarring. The treatment of furuncles has as its task to promote the favorable course of the inflammatory process and to prevent the development of new furuncles around it. For the latter purpose, careful care of the surrounding skin is necessary. To facilitate keeping it clean, the hair is shaved if necessary and the skin is treated with alcohol. In the initial stages, when there is no liquid pus yet, most surgeons do not make an incision, limiting themselves only to applying an ointment (counter-irritant or antiseptic) dressing. The application of heat and causing hyperemia is very useful, but not in the form of warming compresses; the maceration of the skin caused by the latter can easily contribute to the dissemination of infection around. Dry heat procedures are preferable; in recent times, especially in the West, very favorable results are obtained from the use of ultrashort waves, using their property to cause an increase in temperature in the depth of the tissues. The impregnation of the tissue around the furuncle with the latest antiseptics (rivanol), which was used several years ago, is now almost abandoned as not achieving the goal. Cases of successful abortive treatment by freezing with liquid CO₂ have been described. However, both these and other (see below) general measures are rather indicated in the presence of multiple furuncles and furunculosis. For individual furuncles, the main task is their opening, which, however, in a number of cases is achieved simply by removing the central plug. This removal is still possible only in the stage of softening and formation of liquid pus. Incisions made in earlier stages do not achieve the goal and are therefore contraindicated. Only in large furuncles with a prolonged course is a central, sometimes cruciform incision useful to accelerate softening and eliminate tension of the tissues. Furuncles on the face, i.e., above the horizontal line passing through the angles of the mouth, according to the experience of most surgeons, are not subject to incisions at all and are treated conservatively. Lawen (Lawen) and other surgeons strongly recommend injecting the patient's own blood around the furuncle. After an incision or removal of the plug, no tamponade is required. It is sufficient to apply a dry or moist drying dressing for the absorption of pus and to protect the furuncle from trauma, so that the healing process proceeds favorably. The periphery and after the operation should be kept clean, treating it with alcohol, a 5% solution of formalin, gasoline, but not rubbing at the same time, as any trauma only contributes to the spread of infection. After treatment, the skin is protected from pus with ointment. The treatment of complicating diseases of furuncles, such as lymphangitis, lymphadenitis, thrombophlebitis, etc., is carried out according to the general rules for this. Along with individual furuncles, multiple ones are sometimes observed, and the matter is not limited to one area, but the process captures extensive areas, in a number of cases even as if the entire surface of the skin. The healing of some furuncles is replaced by the eruption of new ones, and at the same time one can see a whole series of furuncles in different stages of development. Such a condition is called furunculosis. The course of each individual furuncle does not differ from the one described above, but the replacement of some by others continues for months and the difficulties lie precisely in eliminating the conditions especially favorable for the constant easy occurrence of furuncles. Such conditions include: unsatisfactory domestic sanitary-hygienic conditions, a state of exhaustion, depending on various causes (insufficient nutrition, suffering from severe, especially infectious, diseases), a state of depression in diseases of the psychic sphere, senile marasmus, cachexia in malignant tumors, and especially diabetes mellitus, in which the resistance to microbes of suppuration is generally reduced.

Depending on the presence of predisposing conditions, the treatment of furunculosis appears more difficult mainly due to the persistence with which new F. develop. First place should be given to attention to the cleanliness of the body and clothing. Frequent baths (with the possible addition of Kalii hypermanganici), frequent changing of linen and changing of outer clothing that contains infectious material can already have a beneficial effect. Further, elimination of the debilitating cause, if possible, for which a strengthening diet is prescribed, injections of arsenic, brewer's yeast (vitamin B); in the presence of sugar and acetone in the urine and elevated blood sugar - insulin therapy, etc. Measures directly affecting the process in the skin include the application of radiant energy in the form of illumination with a quartz lamp, under suitable conditions sun baths, radiotherapy, and most recently - ultrashort waves. In the latter, with different techniques and different generators, both the deep thermal effect and the direct bactericidal action play a role. A beneficial effect is observed from autoghemotherapy (Lawen) and especially from autovaccinotherapy. The latter should be regarded as a very effective means that gives a favorable effect in very severe and persistent cases. Furunculosis - see also Pyoderma.