208 REPORT OF A CASE OF CARBUNCLE 
papillae, were gorged with blood. This layer was about equal in thickness to 
the epidermis (which is thin in this region), and corresponds to the part which 
formed the margin of the openings in Davidson’s case, described in the above 
report as being as thin as paper. A superficial observer might suppose this thin 
layer to be the skin, and regard all parts beneath it as subcutaneous tissue ; 
but it required only a little careful observation to perceive its true relations. 
I confess that I had previously been accustomed to look upon carbuncle as 
essentially a disease of the subcutaneous tissue, but this slice convinced me, 
as it did every one to whom I showed it, that in that case at least the cutis vera 
was the seat of the disease ; and it is to be observed that this, like Davidson’s, 
was a fine example of the affection in question. No doubt, the subcutaneous 
textures may, and often do become affected secondarily, but the important 
practical fact which these two cases appear to establish, is that the great mass 
of a carbuncle is composed of thickened dermis, which may be freely incised 
without fear, whereas the subcutaneous textures in some regions contain im- 
portant parts which it is very desirable to avoid. It may be remarked that the 
extraordinary expansion which carbuncle produces on so dense, and, at the 
same time, so sensitive a structure as the dermis, sufficiently accounts for the 
intense pain that always accompanies it. 
With regard to the cause of the disease, it must be confessed that in the case 
above reported, none can be assigned. According to the patient’s own account, he 
was in strong active health at the time when the carbuncle commenced, neither 
plethoric nor the opposite, and no irregularity had occurred either in his diet or 
in his employment. The constitutional vice, of whatever nature, was latent. 
The free incisions made throughout the diseased mass were productive of 
the most palpable benefit, and evidently cut the disease short at once; and 
although the central part was already in the state of slough at the time of the 
patient’s admission, yet considering that the size of the tumour was then still 
increasing, I cannot doubt that the red brawny circumferential parts, which 
afterwards recovered their natural characters, would have sloughed if the in- 
cision had not been carried freely through them. As the disease yielded to the 
local treatment, the patient recovered his appetite, which he had long lost, 
but he never grumbled at his milk diet, although it was inadvertently continued 
much longer than Mr. Syme had intended. 
It will probably be tedious to some to read so minute a description of an 
affection with which they have long been familiar; but to those who do not 
happen to have examined the disease carefully themselves, and who know that 
a different pathology is commonly taught, the importance of the subject will, 
I hope, make the particulars which I have given acceptable. 
