Malignant Pustule, a specific disease, essentially septic and gangrenous, confined to the cutaneous tissue, and generally to those parts of the surface that are habituallv uncovered. It appears most commonly on the face, and next on the hands, neck, and arms. It first appears in the form of a painful swelling, which, after a lapse of time varying from one to three days, rarely more, develops upon its central part a small reddish or purple spot, accompanied with itching. In the course of 12 or 15 hours more this spot changes into a bleb or vesicle, not usually larger than the head of a pin, containing a reddish brown or yellowish fluid. Owing to continued itching, the vesicle is ordinarily ruptured soon after its appearance; if otherwise, it dries up in about 36 hours, leaving the exposed derma dry, and generally of a livid color. Itching now ceases; and, after a time varying from a few hours to a day, the centre of this discolored and denuded surface begins to grow hard and becomes surrounded by an inflamed areola covered with numerous small vesicles similar to the vesicle which first appeared. The middle of this areola is depressed, and the color varies from yellow to black. It is now hard in the centre and more painful than at any other stage.
But it is a remarkable feature of malignant pustule that severe pain is generally absent; and this character, so different from all other acute inflammations of the skin, is a valuable negative diagnostic of the disease. During the next 24 or 48 hours the subcutaneous tissue becomes involved; the tumor strikes deeper and rapidly extends in all directions, yet it is so indurated as to be easily circumscribed, and its confines determined without difficulty. Meanwhile the central point, now of brown or livid hue, exceedingly hard and insensible, becomes gangrenous. If the disease makes no further progress, an inflamed circle of vivid redness now surrounds the gangrenous portion; the tumefaction, which had before rapidly extended, diminishes; and the patient experiences something like an agreeable warmth accompanied by a pulsatory motion of the affected part. The pulse, which had before grown irritable and feeble, revives; strength increases; if there has been some degree of fever, as occasionally happens, it is now resolved into a gentle perspiration; suppuration sets in between the living and the dead parts, and the detachment of the gangrenous portion leaves a suppurating surface of variable extent in different cases.
When the disease tends to an unfavorable issue, generally no suppuration takes place; the gangrene spreads rapidly from the centre to the circumference of the tumor; the pulse becomes smaller and more contracted; the patient complains of extreme lassitude with inability to sleep, is attacked with fainting fits, and becomes passive as to the result; there is disinclination to take food or medicine, or have anything done, and a total loss of appetite; the tongue is dry and brown; the features shrink; the skin is parched; the eyes are glassy; and increasing debility and a low delirium indicate a fatal termination. Such are in general the ordinary phenomena of malignant pustule, usually terminating in from five to eight days. Exceptional fatal cases have been recorded, varying from 24 hours to 16 days. In the suddenly fatal cases, the forces of the constitution are so quickly and entirely subverted by the malignancy of the disease, that few symptoms are manifested; the powers sink under it, as it were, without resistance.
It is most fatal when attacking the face or neck. - Another variety, which commonly attacks the hands or arms, is of a less regular character, in some cases presenting an appearance and running a course very similar to a circumscribed phlegmon, while in others it is exceedingly violent and fatal in a few hours, and in others still runs on for several weeks, and finally proves fatal rather from the effects of the disorder than from the disease itself. In the majority of these cases there is intense local pain in the affected part from the commencement, with enormous swelling and more or less redness. A small vesicle or pustule forms in the centre, and takes on a gangrenous character. Sometimes it becomes circumscribed and limits its action to the skin; but at other times numerous phlyctinae cover the surface, and the destructive inflammation burrows into the cellular tissue which envelops the muscles, completely surrounding and disintegrating these organs, which become soft, black, and gangrenous. The blood vessels and nerves also become involved, and as a necessary consequence the death of the part ensues. - The pathology of malignant pustule is distinguished by a fluid state of the blood, which is usually very dark-colored; the texture of the heart is softened, and its surface covered with ecchy-mosed spots; the veins are sometimes softened and ecchymosed, and usually contain black or yellowish white clots of blood, of gelatinous consistence.
The lungs are covered with superficial ecchymoses, presenting over their surface a number of deeply penetrating black spots, produced by local sanguineous infiltration. The inner coat of the stomach and intestines presents in different places, corresponding to the course of the vessels, prominent, dark-colored spots, formed by blood effused between the inner coats and the peritoneal covering. - Causes. It is the general conclusion of those who have investigated the nature of malignant pustule, that the germ of the disease consists in an animal poison, usually contracted by man from cattle or their remains. In support of this view, it is found that the disease most frequently occurs among knackers, tanners, veterinarians, persons engaged in the removal of offal, and stevedores, particularly those employed in handling hides from districts and countries where the diseases of cattle most prevail. In other cases it has been attributed to eating diseased animal food. Yet, strange as it may appear, in the whole scope of veterinary medicine no disease is known which accurately resembles the malignant pustule of man.
Certain herbivorous animals, especially beasts of pasture, are subject to a disease called malignant carbuncle, characterized by the occurrence of a large uncircum-scribed emphysematous tumor, which yields to pressure and crepitates under the fingers, and exhales a peculiar putrid odor. In its progress it turns black in the centre, and appears as if burned or charred; it is infiltrated with a yellowish colored fluid, and distended with a fetid gas. This disease may be transmitted from one animal to another by inoculation, and by absorption to man, in whom it runs a violent and dangerous course. MM. Salmon and Ma-noury of France have vainly attempted to limit the term malignant pustule to this disease only. Malignant carbuncle and other ulcers which occur in cattle are the eruptive symptoms of grave febrile disorders depending upon a diseased state of the blood, and always consecutive to the febrile symptoms; and the inocula-lation of man with matter from such an ulcer is only equally dangerous with the blood, and possibly the milk, of the same animal in the febrile state before the ulcer appeared. Indeed, cases have occurred where the blood of animals not previously known to have been diseased has caused malignant pustules in man by absorption.
It is the opinion of some observers that malignant pustule may occur spontaneously, without any contact with poisonous animal matter. But from the fact that diseased animal matter is known to cause the great majority of cases, many ways will readily suggest themselves by which inoculation might take place without any knowledge of the circumstance on the part of the person affected. As a general rule, cattle which feed on prairie meadows are exempt from malignant disease; while those which are fed upon dried clover, lucern, and vetch are peculiarly liable to carbuncle. The same may be said of cattle that are fed upon semi-decomposed grain, the refuse of distilleries and breweries. All such things are actively predisposing agents to the blood diseases of cattle, and liable to engender malignant pustule in man. - Treatment. Promote suppuration in the pustule as rapidly as possible, and sustain the constitution. To this end, as soon as the nature of the disease is ascertained, the vesication formed on its surface should be opened, the fluid contents removed, and the denuded part covered with a dossil of lint dipped in a strong solution of muriate of ammonia or other caustic.
Six hours afterward this may be removed and a poultice applied; and 24 hours after this, if pain and burning heat have nearly or quite ceased, and no areola has formed, it may be safely concluded that the caustic has effectually permeated the whole of the diseased tissue, and that it will proceed to a healthy suppuration by the continued application of poultice. But if, on the contrary, a hard and deep-seated painful tumor has formed around the primary seat of the vesicle, we may take it for granted that the disease is extending itself. The tumor should be forthwith divided through the whole width and depth by a crucial incision, the gangrenous parts removed if any have formed, and the nitrate of silver or fused potassa thoroughly applied to the freshly divided surfaces. This proceeding is equally requisite when the slough which forms on the centre quickly becomes hard and impermeable, like a piece of dry hide; this must be removed to admit of the unimpeded action of the caustic. Scarifications and cauterizations, with the continued application of poultice, should be repeated daily until suppuration is established, or until the extent of the pustule is clearly defined.
Internally, the bowels being first cleared by a mild cathartic, quinia (four or five grains every three or four hours), with wine or brandy, and as much food as the patient can be induced to take (there being generally disinclination to take food), and opiates with camphor, as much as may be necessary to allay pain and produce sleep, constitute the basis of treatment. In spite of everything, the peculiar contagion of malignant pustule, being in the blood, frequently proceeds straight on to a fatal termination; and this is sometimes the case even when the pustule seems to have been checked. On recovery from malignant pustule, the deformities consequent upon its ravages sometimes require surgical operations for their relief. - History. Malignant pustule was known to the ancients. Celsus and Paulus AEgineta both described it under the head of carbuncle. Am-broise ParÚ, in the 16th century, distinguished it from plague. Yet it was not until the latter part of the 18th century that physicians began to appreciate its nature. Thomassin, Boyer, Fournier, Montfiels, Veson, Sancerotte, Chambon, and especially ╔naux and Chaussier, contributed to make the medical world acquainted with the nature of malignant pustule.
During the present century, Bayle, Bidault, Vil-liers, Reynier, Rayer, Branell, Wagner, Raim-bert, Manoury, and Salmon, and more recently Bourgeois and Gaujot, have given valuable monographs of cases and epidemics. In the United States, it has at least twice prevailed epidemically: in the vicinity of Philadelphia in 1834 -'6, and in Louisiana in 1837-'9. It is also said to have prevailed in Louisiana soon after its settlement by the French. It is not known to have occurred in the northern portion of the United States otherwise than sporadically; unless, possibly, the "malignant erysipelas" which prevailed in the northern part of the state of New York in 1825 was a variety of malignant pustule; it was immediately preceded by a fatal epizo÷tic of slavers among horses. In the same region, and just subsequent to an epizootic among horned cattle in 1842, there were several cases of genuine malignant pustule, yet no one seems to have recognized its source. Since that time, and it may be added since the common practice of feeding cattle on the refuse of distilleries and breweries, and the more general spread of epizo÷tic diseases, particularly in the northern part of the United States, malignant pustule has become more common.
Both of the epidemics referred to were in conjunction with epizo÷tics.