NOTES /y ~ / -y C ON THE NON-SURGICAL TREATMENT OF BOILS, CARBUNCLES, and FELONS. BY L. D.UNCAN BULKLEY, A.M., M.D., PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, CON- SULTING PHYSICIAN TO THE NEW YORK HOSPITAL, ETC. REPRINTED FROM THE BRITISH MEDICAL JOURNAL, OCTOBER 1897. NEW YORK . 1897. BY THE SAME AUTHOR. Fourth edition 'ready very shortly) manual of diseases of THE SKIN. With Analysis of Twenty .Thousand Consecutive Cases, and a Formulary. Price, $1.25. SYPHILIS IN THE INNOCENT (Syphilis Insontium) Clinically and Histori- cally Considered, with a Plan for the Legal Control of the Disease. Price. $3 50. ACNE: Its Etiology. Pathology and Treatment. A Practical Treatise Based on the Study of One Thousand Five Hundred Cases of Sebaceous Disease. Price, $2.00. SCZEMA AND ITS MANAGEMENT. A Practical Treatise Based on a Study cf Three Thousand Cases of the Disease. Second edition. Price. $3.00. NEUMANN'S HANDBOOK OF SKIN DISEASES. Translated, with Notes. Price, $4.00. ARCHIVES OF DERMATOLOGY. A Quarterly Journal of Skin and Vene- real Diseases. Vols. i-vin; Vols. i-tv.. $3.00 each. Vols. v-vni., $4.00 each. THE SKIN IN HEALTH AND DISEASE. Health Primer, 140 pages. Price, f'0 cents. THE USE AND VALUE OF ARSENIC IN DISEASES OF THE SKIN. Price, 50 cents. ACNE AND ALOPECIA, Physician's Leisure Library. Price, 50 cents. NOTES ON THE NON-SURGICAL TREATMENT OF BOILS, CARBUNCLES and FELONS. BY L. DUNCAN BULKLEY, A.M., M.D., PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL, CON- SULTING PHYSICIAN TO THE NEW YORK HOSPITAL, ETC. REPRINTED FROM THE BRITISH MEDICAL JOURNAL, OCTOBER id, 1897. NEW YORK 1897. ON THE NON-SURGICAL TREATMENT OF BOILS, CARBUNCLES AND FELONS. * BY L. DUNCAN BULKLEY, A.M., M.D. Physician to the New York Skin and Cancer Hospital; Consulting Physician to the New York Hospital, etc. The knife has long been associated in the minds both of the profession and laity with the treatment of boils, carbuncles, and felons, and incision is the recognized treat- ment on all sides. Poultices are also commonly employed, although perhaps less frequently than formerly. The object of the present paper is to detail the treatment of the writer, who for ten years and more has abandoned both poultices and the knife, and in a large series of cases has had results which seem to warrant bringing the mat- ter forward. I am aware that the views advocated will be open to criticism; but having for so long a time fol- lowed the plan of treatment to be outlined,! feel confident that others will observe the same results, if all the details are carefully and intelligently carried out. I may add that the principles here put forth were presented by the author ten years ago, before the Ameri- can Medical Association, and have received abundant confirmation in personal communications from many phy- sicians in this country and abroad. *Read before the Skin Section, of the British Medical Association Montreal, Sept, ist, 1897. 4 It is needless to discuss in this presence the modem views in regard to the causes of the formation of pus: it will be granted by all, I think, that the pyogenic organ- isms, principally the staphylococci (aureus and albus), are essential features of suppuration. But opinions are beginning to divide in regard to the true pathogenesis of many conditions which were regarded as understood some years ago. It is now recognized that the micro-organisms of disease are almost universally present, and those asso- ciated with the production of pus are spoken of by one writer as " normally present on the skin," even when there is no suppurative disease present. Attention is thus being turned again to the underlying causes which pre-dispose or prepare the tissues for the operation of the pyogenic elements. Bouchard * puts it so strongly that I cannot forbear quoting. " The physi- cian," says he,"ought not to allow himself to be absorbed alone in the research after a microbe. He ought to oc- cupy himself with the infectious agent; but he ought also to retain a good deal of his anxiety for the study and research of circumstances which disarm the organism against the invasion of the agent. When the physician shall be in possession of this double knowledge, that many diseases are produced by microbes, and that these can only act by means of a deterioration of the health, resulting from various pathogenic processes, he will recog- nize that the new discoveries contain nothing subversive, and that the lessons taught by ancient medical observers are not compromised: He will know that the part he has to play is still the same to-day as it was twenty years ago, and that while seeking the means of combating microbes he ought and he always will be obliged to sustain the forces of the organism and make good its defense, inspir- ing himself constantly with this truth, namely, before * Bouchard. Lectures on Auto intoxication in Disease. Phil. 1896; p. 9. 5 every illness there is a disturbance in life-for nutrition is life." I should like to quote much more from this close ob- server and interesting writer, for it follows along so well with what I have felt and taught for many years, but must hasten to the practical matters under consideration. Granted the pyogenous powers of the micro-organisms, my position is that their powers are temporary, and lim- ited by their own nature and the condition of the tissues in which they are found. Witness the different results attending superficial wounds in different individuals; and also in the same individual at different times. In some persons] a scratch or bruise will readily take on suppurative action, while in another it tends to heal in the kindest manner possible, with little or no pus. The same is seen in the same patient at different times, and there is certainly some measure of truth in the common remark that " one's blood must be in a bad condition," because of the occurrence of suppurative areas with slight injury: I am confident that in my own person there is a constant difference in this regard, from time to time. The same may be observed constantly in practice in connection with eczema and many skin lesions. Thus, although the pus bacilli are undoubtedly everywhere present and at all times ready to lodge and do their work, if the soil is proper, yet in comparatively few instances is suppuration set up. This is only in accord- ance with what is continually observed in the prodigality of nature, where, of the masses of pollen produced only an exceedingly small proportion ever fructifies; and of the millions of seeds developed relatively few reproduce the the species, and these only when the soil and other con- ditions are favorable. I may be pardoned for thus dwelling on what is tacitly admitted on all sides, perhaps by every one, theoretically, 6 for, practically, it seems to be forgotten or overlooked by many in the treatment of the conditions which form the subject of this paper. While it is continually granted that attention should be paid to the general condition, of patients with these affections, I find that as a matter of fact very little is generally done. There is commonly so much regard given to the local trouble that there is not the careful investigation of the general condition and direction of the patient's life which will lead to the raising of the vital forces above the pus producing stage. The yielding of one or more points to the attacks of the pus parasite too often attracts attention from the weakened system and debilitated tissues, which may allow of many more successful attacks, as commonly happens in the case of boils. My first point, then, is to urge that the occurrence of these suppurative processes should always and more forci- bly be regarded as evidences of faulty metabolism, and a more serious search be made to discover and rectify what is wrong. For many years the occurrence of boils has been more or less connected in the professional mind with the presence of glycosuria; but, in my experience, while this latter is relatively seldom found, certainly not in a marked degree, there are not infrequently other dis- turbances of liver or kidney action which appear to be thus connected. The acknowledged fact that glycosuria predisposes to boils and carbuncles is a strong argument in favor of the constitutional aspect of the subject under consideration, namely, that there are other conditions, not yet fully identified, which may make the organism more liable to the attacks of micro-organisms. Patients with boils, carbuncles and felons are never in perfect health, although it is sometimes difficult to dis- cover exactly on what particular departure from health the trouble depends; patient investigation, however, will 7 generally afford the line upon which successful treatment will rest. Iron is most commonly needed, but quite ss often there will be digestive and assimilative difficulties also to be overcome. Sometimes the cause lies only in overwork and worry, often in dissipation, though of a relatively harmless kind, involving late hours and irregu- lar eating. I cannot help dwelling as strongly as possible on this constitutional aspect of the question, for in this I find myself at variance with much that is taught even in the best modern text books. In them this aspect appears to be regarded apparently as of relatively minor impor- tance, compared to the local treatment, whereas I regard it as of the first importance, as compared to the relatively simple local treatment, about to be described, which I have found thoroughly satisfactory. The combination of iron which I have most commonly used in the affections is one which is known to us as Startin's mixture, somewhat according to the following formula : R.-Ferri sulphatis, 'j. Magnesise sulphatis, 'vj. Acidi sulphuric! dil, 3 iv. Sy. zinziberis, 3 iv. Aquae, ad 5iij. M.-Teaspoonful in water, through a tube, after meals. Unless there is some counter indication I generally begin treatment also with a good mercurial purge: R.- Massa) hydrargyri, Extract, colocynth. co. aa gr. x, Pulv. ipecac gr. ii, M. Div. in pil. No. iv. Take two at night and two on the second night after. These four pills are generally repeated at the end of a week, and perhaps in other successive weeks. Sulphide of calcium, if a perfectly good and fresh article, and properly used, has, in my experience, a very decided controlling effect over the process of suppuration. 8 I always give it in gelatin coated pills, which I test my- ■self, for occasionally the drug will be found quite inef- fective, from having changed to the sulphate of lime or -gypsum. To be efficient it should be given freely, one- *quarter grain every two hours, say eight or ten doses during the day: this in connection with the iron tonic. With these measures and a most careful attention to 'the diet and modq of life, including total abstinence from alcoholic or fermented liquors, the tendency to the •suppurative process may generally be quickly overcome, as I have observed almost daily for many years. The local treatment of the diseases under consideration which I have found very satisfactory differs materially from that commonly laid down, but can be briefly de- scribed. We will consider each affection separately. i. Furunculi. The objects aimed at by the treatment -are, first, soothing and protecting an inflamed area; sec- ond, exclusion of air; and, third, a slight antiseptic action. For this purpose a moderately thick layer of absorbent cotton is taken, several times the size of the inflamed surface: for a medium sized boil a piece one by two inches, with the fibres running the long way. Upon the center of the cotton a considerable mass of the fol- lowing ointment is spread by means of a spatula, and this is then laid over the boil, and held in place by strips of adhesive plaster across the ends, but not passing over the boil, as is commonly practiced. The ointment referred -to is generally composed about as follows: R.-Acidi carbolici, gr. v-x. Extr. ergotae, fl'd 3 i- 3 ij. Pulvis amyli, 3 ij. Zinci oxidi, 3 ij Unguent, aquae rosae, = ij. M.-et ft. unguent. 9 The relief often given by this dressing is very marked r the ointment soothes and protects the irritated surface,, while the layers of cotton take up any outside friction, If comfortable, and unless disturbed, this dressing remains untouched twelve or more hours, when it is removed and a freshly spread piece immediately reapplied. If there has been any discharge the surface may be very gently cleansed with absorbent cotton, but I do not allow any' squeezing. In many instances, with proper internal and- general treatment the boil aborts, and subsides without discharging; when this does not happen it ruptures spon- taneously in a relatively short time, and I practically never find it necessary to incise it. This treatment I use in all stages of boils, keeping the ointment on until the boil is quite healed. If other boils- form I direct it to be applied early, and by this means they are frequently aborted. I wish I could adequately express to you some* of the comfort and pleasure given, to patients, when thus dressed, as compared with the sensations and results from other treatment which they had previously undergone. We should, I think, seek for the jucunde in our treatment as well as the cito and certo ; and from no small experience I can say that this treat- ment acts quite as quickly and surely as it does pleasantly> 2. Carbiihculus. .As a carbuncle is in reality but a large boil, or a conglomeration of boils (with, of course, certain anatomical differences), the local treatment with me has been much the same as that just described. Both, early and late in the disease I have put on an ointment like the above, thickly spread on cotton, and fastened at the ends with strips of adhesive plaster. Not only on the back of the neck but also on the face, and elsewhere, this dressing proves most comfortable and serviceable, and I have not had occasion to incise a carbuncle since Novem- ber, 1882, nearly fifteen years ago; the last patient incised 10 died from this and other complications, but there has not been a single case with such result in my practice since. I have applied this treatment to some large and formida- ble carbuncles, and have always, thus far, found that the pus would find exit rapidly enough, and the healing pro- gress satisfactorily with this dressing. Occasionally it is necessary to -aid in its expulsion by very slight squeezing, or by removal of sloughs with the forceps On some occasions febrile and other symptoms have seemed to call for more active interference with the knife; but, although urged to it in consultation, I have adhered to this plan of treatment without incision and have obtained results which warranted its continued employment. From my previous experience with cutting, and from cases thus treated by others, I believe that the method suggested has the preference, both as to time occupied and final results; whereas on the point of pain and general comfort of the treatment it is far superior. I am quite prepared to admit, however, that possibly from neglect or other cause, a very large suppurating car- bunculous area might be formed which would demand very active surgical procedure, such as curetting or even excision, with antiseptic dressing; but under the treat- ment outlined this has never occurred. I may also add that Sir James Paget, in his "Clinical Lectures and Es- says," discountenances strongly the practice of incision. 3 Felon. It will no doubt excite surprise and criti- cism when I urge somewhat the same line of treatment for the various degrees of inflammation about the ends of the fingers, which are known as paronychia, whitlow and felon: but having treated a very considerable number of cases in this manner during the last fifteen or twenty years, I am prepared to advocate it strongly. The cases referred to include not only those of superficial character, about the nail, but also those very deep seated, on the 11 pulp of the finger, even when there had sleepless nights from the deep seated throbbing. The ointment used here has always been the diachylon, or litharge ointment, prepared according to the formula of Hebra. This particular preparation of ointment I con- aider to be important, for I have not found such good results from that made by melting the diachylon plaster- with oil or vaseline, as more recently proposed. The diachylon ointment of Hebra is prepared as fol- lows: R.-Olei olivarum optimi, = xv. Plumbi oxrdi, ? iij+ 3 vj. Olei lavandulee, 3 ij. J/.-Add the oil to two pounds of water with con- stant stirring: the litharge is to be slowly sifted in. while it is well stirred, fresh water being added as re- quired. The ointment is to be stirred until cold and the- lavender added. In winter a slightly larger quantity of oil is required to make a soft ointment. When properly made (and this is difficult to secure) this ointment is of a soft buttery consistency, and quite- sticky. The affected finger is to be plunged into the jar and a considerable quantity taken up, completely envel- oping the first joint, to a thickness of a quarter of an inch, or more. Over this are placed layers of absorbent cottoik and the whole loosely bound; sometimes it is more agree- able to spread the ointment on the cotton. It is generally desirable to renew the dressing about twice daily, but this is done with as little disturbance to the finger as possible, the old ointment being hardly disturbed, unless there is pus discharged. I cannot fully explain the benefit obtained by this dressing, but time and again I have seen the greatest relief, even after sleepless nights had been passed, and for many years I have prescribed this treatment with the- 12 greatest satisfaction and confidence. When applied early and in milder cases, resolution takes place and no pus ap- pears. But in those cases which are seen later, or which are more severe, pus may form, and readily reaches the sur- face, and is either discharged spontaneously or by means of a painless prick through the dead skin. I have never had occasion to make the well known deep incision, even in certain cases where it seemed at first that this would be required. Repeatedly I have been surprised at the ease with which the pus has reached the surface: as re- marked before, when it was necessary to aid its exit this was done with a very superficial .prick, entirely painless, and I have never seen any scar resulting. It is quite possible that the most severe cases have not come under my observation, and I can quite agree that when pus has formed deep in the tissues and is burrowing under the tight fibrous bands which cross the tendons, a free surgical opening, may be called for. But if taken reasonably early, and the treatment, internal and external intelligently carried out, I believe that in the very large proportion of the cases the course will be such as I have before described. This completes what I have to say in regard to the very simple and easy local treatment which I have long used in these three conditions, to the great satisfaction of my patients and myself. But I must repeat what I said ear- lier in the paper, namely, that I place the greatest value in the internal and general treatment of the patient, and recommend the local measures only in connection with the same, carried out in the fullest and most intelligent- manner, on the lines previously described. 4 East 37th Street: SYPHILIS IN THE INNOCENT (SYPHILIS INSONTIUM) CLINICALLY AND HISTORICALLY CONSIDERED, WITH A PLAN FOR THE LEGAL CONTROL OF THE DISEASE. BY L. DUNCAN BULKLEY, A. M., M. D„ Notices of the Press. Internal. Jour, of Surgery, Sept. 1894.-" This work is the most impor- tant contribution to the literature of syphilis which has appeared within recent years." British Medical Journal, Oct. 20, 1894.-" A veritable mine of informa- tion." N. V. Med. Record, April 21. 1894.-" The author has here gathered more facts and figures bearing upon the question of syphilis as a non-venereal dis- ease than have ever before been published or in all probability attempted." The Med. News, Aug. n, 1894. - " The subject is an important one viewed from every light, and has been handled by the author in a masterly and prac- tical manner." Annales de Dermat. et de Syph., April, 1894.-" The book must necessarily be consulted by everyone who has interest in the subject of extra-genital syph- ilis." Univ Medic. Magazine, August. 1894.-"The work is by all odds the best and most extended consideration of the subject in any language." Dublin Journal of Med. Science, June, 1894.-"We are thankful for the book, and value it as a useful contribution to the study of syphilis." Canada Lancet, June, 1894.-" It is a work of great merit." Quar. Atlas of Dermatology, April, 1894.-"This is a book that no physi- cian can be without. It is the only work on the subject, and is so complete that it leaves nothing to be desired. Buy the book and it will be money well spent." Virginia Med. Monthly, July, 1894.-" Every doctor should read this book." Joarnal of Cutaneous and Gen. Urin. Dis., June, 1894.-"One cannot help being impressed with the immense amount of research which must have been required to produce so complete an analytical bibliography as that presented in this work." New England Med. Monthly, April, 1894.-" The book is unique aruEab- sorbing from cover to cover." The Med. and Surg. Reporter, Dec. 8, 1894.-"That it is one of the most exhaustive works which has ever been made on any one medical subject is not too much to say of it." Amer. Journal of Med, Sei., Dec., 1894.-" For the first time the subject of syphilis innocently acquired has been thoroughly studied, and the results of this investigation are perhaps as astonishing to the professional man as to the lay reader. * * * * The work is more than an able and laborious collection of statistics. It teaches a lesson so plain that no technical knowledge is needed to understand it. It should be read by every intelligent man and woman in this country In the hands of moral reformers, the strivers after social purity, it would be a weapon more formidable than any with which they have ever been armed."