REEOR I ROr  AICASE OF “CARBUNCLE 207 
both redness and induration. Two days after the incisions were made, he 
regained his appetite, which he had lost ever since the carbuncle became intensely 
painful, though not for several days after the commencement of the disease. 
A few days after I again made a careful examination of the affected part. 
At this time the sections of the carbuncle made by the incisions were assuming 
a healthy appearance, particularly towards the circumference of the mass. 
These sections were now covered with granulations, and this, together with 
their great thickness, gave them an appearance certainly very unlike that of 
sections of the dermis. The incisions had, however, extended a little beyond 
the carbuncle into the healthy skin around, and on tracing the sections outwards 
to the parts where the skin was healthy, I found that the thick diseased parts 
passed insensibly into the sound portions, whose sections were also covered 
with granulations, and differed from the diseased only in their thickness. 
The slough soon separated completely, leaving the external portion of each 
of the four flaps made by the crucial incision, and these gradually assuming 
the character of healthy skin, a granulating sore remained, whose cicatrization 
presented nothing remarkable. 
Remarks.—This case illustrates some important points in the pathology, 
aetiology, and treatment of carbuncle. Mr. Syme long since pointed out! that 
carbuncle is essentially a disease of the true skin, that it is by no means neces- 
sarily connected at its outset with an impoverished or enfeebled state of body, 
although, doubtless, dependent on some constitutional vice, and that being an 
inflammation of peculiar intensity, 1t requires in its early stages general anti- 
phlogistic treatment, and local blood-letting, in the form of free incisions, which, 
if practised sufficiently early, cut short the inflammation, and prevent it from 
running on to sloughing. 
The case before us was a typical example of carbuncle, and its commence- 
ment as a pimple in the skin combines with the appearances which it presented 
on admission to show clearly that the pathology above alluded to is correct, 
so far as this individual case is concerned. 
In a case of extensive carbuncle in the gluteal region which occurred about 
a month earlier, I was fortunate enough to obtain a slice from a part in an early 
stage of diseased action. This slice, which was cut perpendicular to the surface, 
included a small part of the subcutaneous fat, which was perfectly healthy. 
The dermis, however, was greatly thickened, and presented the appearance of 
numerous spots of greenish-yellow lymph intersected by bluish glistening bands 
of fibrous tissue, the dense structure of the corium being expanded into a loose 
network, in whose meshes the lymph lay. The only part of the dermis that 
did not contain more or less of this deposit of lymph was a very thin and highly 
vascular layer immediately beneath the epidermis. The microscope showed 
that the blood-vessels of the most superficial part of the corium, including the 
+ Vide Principles of Surgery, by James Syme, first edition, 1831, p. 610. 
