BOILS and CARBUNCLES: THEIR Gives Way Pus the Condition Sometimes TREATMENT by X-RAYS Sloughs Discharge

82 THE INDIAN MEDICAL GAZETTE [Feb., 1942

The skin then and thick and BOILS AND CARBUNCLES: THEIR gives way pus The condition sometimes TREATMENT BY X-RAYS sloughs discharge. extends widely, and fresh openings appear in By G. GHOSH, m.b., b.s., d.t.m. the skin, and tend to coalesce with those pre- Roentgen Clinic, Allahabad viously formed.

These frequent and unwelcome visitors are Treatment always due to an infection. The greatest pre- Treatment in the first in local is consists, place, ventative constant cleanliness. The back of cleanliness, improving the general resistance of the neck is the most in for frequent place, men, the patient by means of tonics, fresh air, boils and carbuncles to as in this situa- occur, ultra-violet rays and vaccines. tion the skin is coarse and ill-nourished and in Pusey and Ormsby consider x-ray therapy a some cases abrasions caused a stiff collar by very valuable method of treatment in recurrent invasion Dia- encourage by micro-organisms. furunculosis in circumscribed areas. Roentgen betes particularly predisposes to boils and car- therapy gives such excellent results in carbun- buncles. Carbuncles are more in old frequent cles and boils that in my opinion it should be than in young men; they develop more often the treatment of choice, particularly in those on the back of the neck than on other any part which are considered bad surgical risks. The of the body. beneficial effect of irradiation on lesions of this Carbuncles and boils on the cheeks, upper character?furuncle, carbuncle, cellulitis, phleg- and nose are lip particularly dangerous, owing mon or abscess of soft tissues?especially when cavernous via to the risk of sinus thrombosis treated early, before the stage of suppuration, the facial and or the ophthalmic veins, deep has been demonstrated by many workers. It and facial vein the pterygoid plexus. is surprising that the value of such a simple and

Fig. 2. Fig. 1.1. effective treatment is not generally realized by It is practically impossible in the beginning the profession. tn determine in most instances that a patient The rapidity of improvement, the relief of has a carbuncle. An apparent boil may develop pain and the abortion of the development and with several into several boils, openings, and regression of the inflammatory process are all become a carbuncle. The patient complains of so striking and spectacular by x-ray treatment tenderness and stiffness at the site of origin of that they have to be seen to be believed. the carbuncle. The subcutaneous tissues be- Prompt and marked benefit is derived in most come painful and indurated, and the overlying cases. Pain is relieved in about 24 hours, skin is red. Gradual extension occurs and but in a small percentage of cases this after ft few days areas of softening appear. relief may be preceded by a temporary increase Feb., 1942] BOILS AND CARBUNCLES : GHOSH 83 in the pain. The treatment is most effective In single boils and carbuncles MacKee and to have during the early stages when other methods of Niles claim obtained good results with r v a dose of 230 of treatment are least effective; it is painless and single x-rays filtered with mm. aluminium. has re- Jnexpensive and does not interfere with a 3 of Goyle obtained the use of Patient's activities; it often relieves pain in a few markable results by intensive filtered radiations in carbuncles. Dunham obtained hours, makes hot or other dressings unnecessary, or shortens the period during which they must be prompt cures in 11 cases of carbuncles with the confirms applied; it often obviates an operation; and it same technique. Ruggles Dunham's cures in yields a better cosmetic result. work, obtaining quick both boils and carbuncles. Dunham has obtained excellent The dose of .T-ray should preferably be small, and results with similar treatment in cases of usually a single exposure is sufficient. In strep- cases which do not react promptly to the initial tococcal palmar abscess. and Morton state that when a lesion exposure, the treatment may have to be repeated Leddy at is in before has intervals, depending on the dose, which may the indurated stage suppuration set cause in about vary between 25 and 75 per cent of an erythema in, x-rays rapid regression 50 cent of cases and considerable relief skin dose. The quality of the rays should be per the graded according to the depth and thickness of in the remainder. They had 74 cases of boils the lesion. With such doses there should not and 26 cases of carbuncles. They found that he boils and more any skin or general systemic reaction; responded much better rapidly than carbuncles. 135 4 mm. therefore, the treatment may be given to weak They used kv., and febrile patients without danger. Irradiation al. filter 16-inch distance, 5 ma. for 10 minutes for boils and the same factors for 15 to 18 minutes for carbuncles. They found that irradiation of affected areas prevents the infection of other follicles. Desjardins believes that radiotherapy may render surgery unnecessary and that small doses (10 to 15 per cent erythema dose) give the best results. Baensch treated 103 cases of furuncle of the face with x-rays and the same number of cases with other measures. The mortality in the irradiated cases was 1.9 per cent and in the others 10.7 per cent. In a few hours after treatment, the pain stopped and the tempera- ture fell. The time required for treatment was shortened and there were no recurrences in the treated area. His dosage was 150 to 250 r filtered with 0.5 mm. zinc and 3 to 5 mm. of aluminium at 30 cm. focal distance. Firor reported on 56 carbuncles treated with x-rays, in only one of which was .excision required. He found that smaller doses were just as successful as large. Hodges believes that in furuncles filtered x-rays give better results than small doses of unfiltered, low-voltaee x-rays. He uses doses of 125 r at 125 kv. filtered with 4 to 6 mm. of aluminium at 10 inches distance for several weekly treatments and with this method causes disappearance of existing furuncles and almost Fig. 3. always aborts newly-forming ones. With M.S. Case 374.?A case of carbuncle carbuncles, on the other hand, he considers that showing the result of x-ray treatment. small doses (100 r at 85 kv.) of unfiltered rays for two or three treatments the best is give uring the suppurative stage less effective, results. Irradiation limits the of the ut even then it relieve and spread may pain may lesion, lessens pain, increases drainage, shortens v'orten the course of the inflammatory process. the course and lowers the mortality. ~arbuncles treated in the early stages will Meyer reports on 50 cases of furunculo'is of aPidly localize, cease to extend and readily the lip, which were treated with x-rays, without Permit surgical drainage. a failure or mishap. A single dose of 100 to Technique 200 r at 100 kv. was applied through a 1 to } have collected here some of the techniques 5 mm. of aluminium filter and Occasionally a opted by various authorities and the results second dose was given on the third day. chieved by them, in treating boils and I have recorded here a series of 20 cases of carbuncles. carbuncles and boils treated by me during the 84 THE INDIAN MEDICAL GAZETTE [Feb., 1942

Table Record of cases of boils and carbuncles treated by x-rays at the Roentgen Clinic, Allahabad, during the last years

Total number Dates on Regis- of ter Clinical history Details of x-ray which the Name Age Sex Diagnosis Results num- and findings treatment treatments sittings ber were given given in each case

61 M.P. 63 M. Painful swelling of Cellulitis Filters?1.0 mm. Al. 5-10-38 and Pain siibsided the whole of the Current?4 ma. at 8-10-38. after the first right hand and 100 kv. sitting. Fever wrist and high Distance?30 cm. and swelling fever (103?-104?). Dose?250 r. gradually went Two weeks ago down. had a prick with a bamboo chip. Factors the same as 80 K.P. 20 F. Painful hard swell- Abscess 30-10-38 and 2 each Complete regres- ing on the lateral above. 1-11-38. sion in 10 days. aspect of both Dose?100 r to each the arms and high area. ? fever?duration 2 weeks.

94 G. 50 A hard A Filters?0.3 cu. 4 M. big painful big 4-11-38 and The pain was swelling in the abscess or 1.0 Al. 6-11-38. less after the first an Current?4 ma. right gluteal region early at sitting. The and high fever. case of 150 kv. inflammation Size of the swell- carbuncle Distance?30 cm. subsided com- Portal?8 10 ing about 8 inches with X cm. pletely in about in diameter. diabetes. Dose?150 r. 2 weeks. Duration?10 days. Diabetes?years

214 P.D. 43 M. A on Filters?4 mm. Al. big swelling Carbuncle 3-3-39 Healed in 2 the back near Current?4 ma. at the with weeks. neck with several diabetes. 150 kv. small openings Distance?30 cm. and fever 10 days. Dose?200 r. Diabetic.

326 Filters?0.5 cu. S.K.G. 42 M. A big painful hard Deep 4- 2-7-39 and The on the 1.0 Al. swelling swelling abscess. 5-7-39. subsided in chest in the Current?4 ma. at right about 2 weeks. subclavicular 180 kv. region and high Distance?30 cm. fever?one week. Portal?8 X 10 cm. Dose?175 r.

327 B.C. A Filters?4 mm. 20 M. swelling about Carbuncle Al. 8-7-39 1 The lesion 1 inch in diameter Current?4 ma. at healed up on the of 150 kv. nape in a week. the neck with Distance?30 cm. several small Dose?200 r. openings. 330 B.K.B. 58 M. A big painful hard Do. Filters?0.5 cu. 4- 3-7-39 and The pain sub- swelling (about 1.0 Al. 6-7-39. sided after the 6 inches in Current?4 ma. at first dose, diameter) on the 180 kv. the swelling back near the Distance?30 cm. gradually neck with Portal?8 X innumer 10 cm. shrivelled up and able small Dose?200 r. became softer. openings. Fever A week later present (sent by the attending Capt. R. C. B.). doctor made a small opening to allow drainage of the pus. The patient made an uneventful recovery. Feb., 1942] BOILS AND CARBUNCLES : GHOSH 85

Table?contd.

Total number Regis- Dates on ter of Clinical history Details of z-ray which the num- -Name Age Sex Diagnosis sittings Results and findings treatment treatments ber given were given in each case

333 The H.C.M. 30 M. A red angry- Carbuncle Filters?4 mm. Al. 8-7-39 and pain was' looking swelling Current?4 ma. at 10-7-39. relieved after the on the right 150 kv. first sitting. shoulder. Size Distance?30 cm. The swelling 2 inches in Portal?small. gradually sub- diameter. In the Dose?200 r. sided and the centre shows wound healed several minute up in about openings. Fever 2 weeks. present. No sugar in "urine.

339 R.D.S. 75 M. A huge red swell- Do. Filters?0.5 cu. -f- 14-7-39 and The swelling ing on the back 1 mm. Al. 16-7-39. gradually sub- with numerous Current?4 ma. at sided and the openings. 180 kv. whole thing Duration? Distance?30 cm. healed up in 2 weeks. Portal?8 X 10 cm. about 6 weeks. Fever present. Dose?200 r. 374 M.S. 60 M A huge red Do. Filters?0.5 cu. + 10-8-39 Healed up in swelling on the 1 mm. Al. 12-8-39 6 weeks. back with many Current?4 ma. at 19-8-39 and small openings? 180 kv. 23-8-39. 13 days, high Distance?30 cm. fever. Portal?8 X 10 cm. Urine?free from Dose?175 r. sugar. "308 M.K. ! 55 M A painful swell- Cellulitis Filter?0.3 cu. -f 5-10-39 Made a com- ing of the left and osteo- 1 mm. Al. 12-10-39 plete recovery middle finger and myelitis Current?4 ma. at 19-10-39 and without any hand-?discharging (the latter 150 kv. 26-10-39. further surgical pus. Duration? condition Distance?30 cm. aid. 6 weeks. He was verified Portal?8 X 10 cm. was operated by x-ray Dose?125 r weekly twice and is a examina- diabetic (sent by tion). Dr. Ajmal Khan). The 494 K.L. 16 M. A painful swelling Abscess Filter?0.3 cu. + 3-1-40 swelling near the anus? (ischio- 1.0 Al. 10-1-40 subsided com- 2 months. rectal). Current?4 ma. at 17-1-40 and pletely and has 150 kv. 24-1-40. not recurred Distance?30 cm. since. Portal?8 X 10 cm. Dose?125 r weekly.

580 A. A. 50 M. A big red swelling Carbuncle Factors as above. 20-4-40 Made an on the right Dose?150 r. uneventful temporal region recovery. with many small openings in the centre. Size 4" X 3"? 11 days. Sugar in urine. 622 R.S. 40 M. A painful swelling Palmar Factors as above. 17-6-40 and Swelling and of the palm of abscess. Dose?150 r. 19-6-40. pain subsided the left hand with completely. fever?12 days. 623 B.N.S. 65 M. A big painful Abscess Factors as above. 18-6-40 The pain was swelling in the Dose?200 r. much less after right gluteal region the irradiation ?1 week. High and the abscess fever. burst 2 days after. 86 THE INDIAN MEDICAL GAZETTE [Feb., 1942

Table?concld.

Total number Dates on Regis- of ter Clinical history Details of x-ray which the Name Age Sex Diagnosis sittings Results num- and findings treatment treatments ber were given given in each case

707 S.S. 45 A very painful Boil Filter?1 mm. Al. 6-9-40 Marked relief red swelling on Current?4 ma. at and complete the tip of the 100 kv. regression. nose and high Distance?30 cm. fever. Portal?small. Dose?150 r.

741 R.B. 50 M. Painful swelling Abscess Filters?2 mm. Al. 14-10-40 Relief in pain. in the right Current?4 ma. at The abscess was axillary region. 120 kv. subsequently Portal?8 X 10 cm. opened for Dose?200 r. draining pus.

812 B. 39 M. Painful swelling Do. Filters?0.3 cu. + 10-1-41 and Subsided in the region of 1 Al. 14-1-41. completely. the left parotid Current?4 ma. at and fever?1 week. 150 kv. Distance?30 cm. Portal?8 X 10 cm. Dose?150 r.

832 H.S. 50 M. A painful swelling Carbuncle Factors and dosage 3-2-41 Subsided in the left leg as above. gradually. with several _ minute openings? no sugar in the

836 S.N.G. 35 M. A painful swelling Boil Filters?1 mm. Al. 5-2-41 Pain and swell- on the tip of the Current?4 ma. at ing subsided in nose. 100 kv. 24 hours. Distance?30 cm. Portal?small. Dose?125 r.

last two and a half years, by ?-rays. I admit clinical evidence or to ascribe it to over- that the number is too small to make any enthusiasm of the axray therapist. Indeed, sweeping statement about the success of this without a satisfactory and convincing explana- treatment, but I was struck with the rapidity tion it would be difficult to believe that the same of improvement, the relief of pain, and the agent can be therapeutically effective against regression of the inflammatory process in these so many different forms of inflammation in cases. The cosmetic result was extremely good different organs or parts of the body. And yet and the healing was quicker than could be ex- the reason appears to be quite simple and to pected by any other means, including surgery. rest on sound and abundant experimental facts. The accompanying photographs show the re- For radiation to act in much the same way, and sult of rr-ray treatment in one of my cases of at the same time on so many forms of acute carbuncle recorded here. inflammation, the lesions must have some com- I am convinced that with rr-ray treatment the mon factor. Now, what may this factor be? involution occurs more quickly, the amount of The exceptional radio-sensitiveness of certain necrosis is decreased, liquefaction takes place leucocytes, notably the lymphocytes, has been more rapidly and is less extensive, and the demonstrated and established by the early course of the disease is greatly decreased and experiments of Heineke and has since been fully at times aborted when treatment is entirely, confirmed by many others. All the clinical given sufficiently early. circumstances indicate that inflammatory lesions Mode of action of x-rays in such inflam- respond to irradiation in proportion to the degree matory conditions.?Various explanations have of leucocytic infiltration, and that the rays act been advanced to account for the favourable primarily by destroying the infiltrating cells. influence of arrays on inflammatory conditions In favour of this view are the experimentally and the multiplicity of such explanations prob- proved sensitiveness of lymphocytes on the one ably has led many physicians to discredit the hand, and on the other hand the fact that the Feb., 1942] SULFANILAMIDE IN ASCITES : JEEVANADAM & OTHERS 87

rate of regression of acute inflammatory pro- cesses corresponds to the rate at which lymphocytes are known to be destroyed by Eradiation. The rapidity with which the symptoms often abate and the physical signs disappear after exposure to a small or a moderate dose of x-rays Indicate that the destruction of lymphocytes is he primary and direct result of irradiation, the lymphocytes are the only cells in the body, e^cept the basal epithelium of the salivary ?Jands, which react to irradiation in such a short 1I;ne and at such a rate. Also variation in the degrees of leucocytic infiltration in different Patients may explain the partial or complete ailure of irradiation in some cases. If it can e assumed that the leucocytes which the 0lganism mobilizes around the site of infection an effort to localize the infection and ^presento dispose of the infectious material, it must also e assumed that the infiltrating cells contain or elaborate within themselves the protective sub- dances which enable them to destroy or neutral- lz.e the bacterial or other toxic products which give rise to the inflammation. If these assump- i?ns are well founded it seems reasonable to ? e^uce that irradiation, by destroying the nhltrating leucocytes, causes the protective ^stances contained by such cells to be derated and to be made even more readily available for defensive purposes than they were n the intact cells. Conclusion.?'The evidence of the therapeutic value of x-ray treatment in acute inflammatory c?nditions like boils and carbuncles is so abundant and so generally favourable that one bonders why this method of treatment is not ttiore widely, used. Perhaps the very multi- Phcity 0f inflammatory lesions in which x-ray , erapy has been claimed to be effective has leu not unnatural scepticism; or failure to utilize *}e treatment may be due to an excessive fear ot ill-effects?a fear probably springing from rePorts of x-ray injuries incurred during treatment of malignant tumours with very large aoses of x-rays, or from systemic reactions which go often follow irradiation for conditions prolonged exposures. But in view of requiringUle short exposure and small doses required for acute inflammatory lesions, such as those j^entioned in this paper, such fears have no

BIBLIOGRAPHY

Kaplan, I. I. (1937) .. Radiation Therapy. Oxford University Press, London. A(?Kee, G. M. (1938). X-Rays and Radium in the Treatment of Diseases of the Skin. Henry Kimpton, , London. ?j?cK, H. E., Pemberton, Principles and Practice of ^d Coulter, J. S. Physical Therapy, 3. W. F. y<**). Prior p Co., Haggerstown. 0IILE, E. A. (1938) .. Clinical Roentgen Therapy. Henry Kimpton, London.