Definition

A circumscribed inflammatory condition of the akin and subjacent connective tissue, characterized by heat, redness, pain, and swelling, and termination in destruction and slough of the tissues involved. This disease must not be mistaken for a disease of cattle, sometimes called by the same name and transmissible to the human subject.

Etiology

The exciting causes of anthrax are not fully understood, but it appears most frequently in men of enfeebled constitution and past middle life. The disease is not infrequently fatal.

Treatment

The general hygiene of the patient demands the first attention. Diet that shall be nourishing without making too great demands on the digestive organs, is of the first importance. Milk, cream, eggs, meat-juices, oysters, tender meats, together with a proper and judicious mingling of farinaceous foods, should be provided. As the disease usually lasts for several weeks, sometimes months, and in its course, especially when prolonged or attended with much suppuration, makes severe demands on the reparative powers of the system, intelligent supervision of the patient's food is of the utmost consequence. Variety should be provided, lest the too frequent repetition of the same articles pall on the appetite, rarely very good, and tend to induce disgust for all food, at least in proper quantities. If the patient's appetite can be maintained, and a reasonable quantity of nutritious food is daily assimilated, this alone may turn the scale in the patient's favor, and prevent what might otherwise be a fatal issue. Stimulants will, in all probability, be demanded. As the affection not infrequently occurs in those who are accustomed to indulge more or less freely in spirituous beverages, the patient's habits should be carefully considered in fixing the daily quantum to be consumed. This general rule, however, may be safely followed: Do not give stimulants, other than the patient is accustomed to, until there are clear indications for their use, and never give more than is necessary. As the disease progresses there will be increased need of them, and if commenced too soon or in too large quantity, the subsequent increase that will be required may prove a matter of serious embarrassment. As to the amount to be used no definite rule can be given. In some cases, the equivalent of an ounce or two of brandy in twenty-four hours may be all that is requisite, while in others six times these quantities may be necessary to avert a fatal depression. In some a single glass of wine at meal-time gives a sufficient encouragement to the stomach to induce it to do its share toward maintaining the patient's nutrition; in others brandy or some other distilled spirit must be given at regular intervals in order to sustain a feeble pulse and flagging heart.

If the case be at all severe, the patient will probably be confined to his bed, or at least his room. Ventilation, therefore, and a constant supply of fresh air should be provided, at the same time draughts and improper exposure should of course be avoided. A little ingenuity, with the aid, perhaps, of some one of the various patent ventilators in the market, will readily secure all that is necessary in most cases. If, however, the carbuncle be a large one and open, and if the exposed surfaces freely secrete pus, and especially if gangrenous sloughs still retain their attachments, additional purifying devices will be required. A dish of chloride of lime in the corner, spraying the air with a dilute solution of permanganate of potassium, of carbolic acid, of thymol and the like, will tend to promote the patient's recovery, and add much to his comfort and to that of his attendants.

The constitutional treatment of anthrax involves the judicious use of quinine, iron, the mineral acids, strychnia, phosphorus, the hypophosphites, and possibly the hyposulphites. Quite recently the sulphide of calcium has been recommended, on the ground that as it is useful in furuncle, it should be, pro tanto, serviceable in carbuncle. None of the agents mentioned should be used to excess, nor commenced too soon. If the suppuration is excessive, either before the carbuncle is open or afterward, the calcium sulphide will certainly control it in a measure, but as this agent is so apt to cause disturbance of the stomach, which should at all hazards be maintained in good order, it may not always be desirable to employ it. The pain and nervous irritability that often accompany carbuncle are best relieved by opium, or one of its derivatives, a dose at night being, perhaps, all that will be necessary. It should be given in suppository or by hypodermic injection rather than by the mouth.

The local treatment of anthrax has given rise to much discussion, and surgeons are by no means agreed as to the means to be adopted. Some claim that if the carbuncle be seen early its spread may be limited by active compression; others, that when fluid is manifestly present it should be evacuated as soon as possible by a number of small openings; others again maintain the old practice of extensive incisions. A recently issued "Manual of Operative Surgery" declares that "the treatment of all forms of carbuncle must be very energetic to prevent the spread of the disease; numerous incisions should be made early to permit the escape of the decomposed putrid tissues and fluids; they should be crucial in form through the whole thickness of the cutis and extending to the healthy skin," etc. Per contra. Sir James Paget* lends the weight of his influence against this practice. He says: "I have not followed this method very often, but I have followed it quite often enough to be sure that it does not produce the effects which are commonly assigned to it. It is commonly said that if you will thus make crucial incisions you will prevent its spreading. If you can find a carbuncle two or three days old, and cut it right across in both directions I think it not unlikely that you will prevent its spread-ing. But even therein is a fallacy; for there is no sign by which, on looking at a commencing carbuncle, you can tell whether it will spread or not, whether it will have a diameter of an inch or of three, six, or ten inches.

After this time of three or four days I have seen a sufficient number of carbuncles thus divided, and have divided enough for myself, to say that it will not hinder the spreading. I have seen carbuncles spread as large a proportion of cases after incisions as in cases that have not been incised. . . . Then it is said that carbuncles are relieved of their pain if they are thus freely cut. Here again is only a partial truth. A carbuncle of two or three days' standing, which is hard, tense, and brawny, is very painful; and cutting it will relieve, in many cases, a considerable portion of the pain. But after this, when the carbuncle begins to soften, and when the pustules begin to form upon the surface, and pus in its terior, it becomes less painful of its own accord, and without incisions.

Thus there are two distinct stages of carbuncle in reference to the pain; the early stage, when it is hard and still spreading, and is generally tensely painful, and the later stage, in which that pain nearly or quite ceases. A carbuncle divided in the first stage, in the first two or three days of its existence, may be relieved of some of its pain; if led in the later stage, what little pain may exist is altogether unaffected by the

And even cut as you may, you cannot always cure the pain that a carbuncle sometimes has, even to its later time. . . . The third point is stated thus: that by the incision of carbuncles you accelerate. their healing, giving facility for the exit of sloughs. But herein is the greatest fallacy of all. When the cutting of carbuncles was more customary in this hospital than it is now, when I did not cut them, and some of my colleagues did, I used to be able to compare the progress of cases cut and of cases uncut, and time after time it was evident that the cases uncut healed more readily than those cut. ... It by no means always follows that the whole carbuncle or its whole base sloughs. Carbuncles, if not divided, not unfrequently suppurate only about their centres, and slough only in their central parts, and the borders clear up by the softening and dispersion of the inflammatory products in them. In every case of this kind you save greatly the amount of healing which has to be gone through. Nay, in some cases, carbuncles completely abort.

* Clinical Lactures and Essays. London, 1875.

"The incisions that I have been speaking of are those made in the old plan - crucial incisions. Another method which I have occasionally tried, but of which I can only state the same general results, is that of subcutaneous incision. This has been supposed to have the same general effect as the other; and I think that the same general conclusions may be drawn respecting it, that it is a measure unnecessary in the treatment of carbuncle, and that it retards rather than hastens the healing. When I speak thus of the incision of carbuncles, however, I do not mean to say that there is no condition of carbuncle in which an incision may be useful. Sometimes a carbuncle sloughs in its central part, with one continuous slough of integument holding in a quantity of pus. In that case you should cut through the slough, or through any adjacent part of the carbuncle to let out the pus, as you would open an ordinary abscess.

"If you ask why you may not cut a carbuncle though it may do no good, I reply that you should never be actively useless, and that there are some cases in which the cutting does considerable harm. Carbuncles, for the most part, occur in persons broken down in health, exhausted by overwork, or by bad food, or in deteriorated general health, as sometimes in diabetes or albuminuria; and in all these persons it is a good general rule to save the blood they need for healing. The loss of blood from the carbuncle, itself would not be considerable; the hard substance of the carbuncle when cut into, does not bleed, or bleeds but little. But to carry out the incision perfectly, you have to cut into the adjacent healthy texture, and this sometimes bleeds very profusely, so as to lead to all the distress and pain of plugging the wound with this or that substance, to arrest the blood."

This very forcible, yet temperate, protest of Sir James Paget, against the still prevalent free incision plan, should, we think, warn the surgeon against the too free use of the knife in carbuncle. The method of treatment recommended by Paget is the application of simple lead plaster or resin ointment, and covering this with a poultice. After an opening occurs, or is made at the hands of the surgeon, the sloughs should be removed as they loosen, and the cavity washed out once or twice a day with a weak carbolic lotion, or some similar fluid. In the advancing stages the writer has used, with apparent advantage, both the belladonna and stramonium ointments. The application of either of these, however, to an extensive surface should be carefully watched, in order to guard against the constitutional effects of the danger.