PUSTULA MALIGNA

Synonyms.—Anthrax ; Anthrax maligna ; Malignant pustule ; Splenic fever ; Car­
buncle ; Fr., Charbon ; Pustule maligne ; Ger., Milzbrand ; Milzbrandcarbunkel.’

Definition.—Malignant pustule is a furuncle- or carbuncle-like
gangrenous lesion resulting from inoculation with the bacillus anthracis,
and usually accompanied with constitutional symptoms of more or less
gravity.

The general infective disease (splenic fever) in which the bacillus
gains access through other channels than that of the skin will not be
considered.

Symptoms.—The lesion, almost always single, is seen commonly
on exposed parts, usually the hand or the face, and, according to Korányi,²
who has given a good deal of study to this disease, has an incubation
period of from one to three days. The disease begins with slight burning
and itching at the point of inoculation, and the appearance of a slight
reddish papular elevation, which grows larger. These symptoms are,
in fact, similar to those frequently observed after an insect-bite. In the
course of a few hours or a day or so, or more rapidly in some instances,
a vesicle or bleb forms on the summit, the contents of which may quickly
become bloody or purulent, and intense inflammatory infiltration ensues,
which may involve considerable area. It soon ruptures, showing a
depression, in and around which is disclosed a blackish eschar, which
may increase in extent. The surrounding induration and swelling be­
come more marked and extensive. Around about the central depression
and eschar, on the swollen and inflammatory base, groups or a chain of
vesicles form, and the surrounding tissue may become still more swollen,
tense, and infiltrated. The near-by glands and lymphatics are affected.
The central gangrenous or escharotic area may enlarge, grave symptoms
and complications of general infection supervene, and death result; or
the process halts, and the gangrenous area is cast off, leaving a cavity,
as in carbuncle, and the reparative process begins. As a rule, general
infection in man follows only in a minority of cases.

Instead of the symptoms here outlined, inoculation may be followed
by intense edema and swelling of livid color, which soon involves a large

¹ Bonome, Deutsche med. Wochenschr., 1894, p. 703.

² Korányi, “Der Milzbrand,” Wien, 1897, in Nothnagel‘s Specielle Pathologie und
Therapie, Wien, 1900, vol. v, 1. This contribution is a complete and exhaustive
exposition of the subject, with full bibliography and several cuts, a few of which are
colored.

PUSTULA MALIGNA

419

area, with surface bleb-formation and gangrenous destruction at several
or more points, with usually rapid systemic infection and death, within
a few days to one or two weeks.

Etiology and Pathology.—The cause of the malady is the bacil­
lus anthracis, discovered by Pollender, which is conveyed to man from in­
fected animals, directly or through the mediation of flies or other insects;
or from the hides, hair, etc, of animals that have died of the disease.
The last method seems most common. In animals it is usually observed
in the herbivora, being uncommon in the carnivora. In man the disease
is met with in those who have to do with cattle, and those who have to
work in their products, such as slaughterers, tanners, wool-sorters, etc
Ravenel¹ reports an outbreak in which as many as 12 men and 60 head
of cattle died of the disease near tanneries (in Pennsylvania) in the course
of a year; the men were operatives at the tanneries, while the cattle were
on pastures watered by the streams carrying off the refuse from these
tanneries. Goldschmidt² and Merkel³ have reported cases occurring
among the employees of brush factories. The disease, for obvious rea­
sons, is most commonly seen in male adults.

Inflammatory reaction of the most intense character, as described,
is found following the inoculation of this germ. The usual signs of such
process are to be found, and in the advanced lesion are closely similar to
carbuncle. According to Korányi, Unna, Ziegler, and others the process
is essentially a serofibrinous inflammation, leading rapidly to necrosis,
the microscopic appearances varying according to the stage at which the
lesion is examined. Unna⁴ found in a fresh anthrax nodule of the lip
covered with vesicles that the development of the bacillus had taken
place in the form of a flat area at the level of and around the subpapillary
vascular net, and penetrating into the papillary body above and the
epidermis; in this region the whole cutis is swollen, and the bacilli lie so
closely that their number must be reckoned by thousands; there were
found a marked dilatation of the blood-vessels and a severe interstitial
edema of the skin and hypoderm, the escaped lymph in many places
formed into fibrinous nets. The bacillus is rod-shaped and multiplies
rapidly; in the body it multiplies by fission; in culture the rods may de­
velop into filaments, undergoing segmentation and producing spores.
These retain their vitality for a long time.

Diagnosis.—The appearance and subsequent rupture of the vesicle
or bleb, the central depression and eschar, the rapidly developed ring
of vesicles or blebs around this necrotic center, with the surrounding
induration and swelling, make up a typical picture which is scarcely

¹ Ravenel, “Anthrax—The Influence of Tanneries in Spreading the Disease,”
Philada. Med. Jour., April 22,1899 (with experiments as to the effects of tanning solu­
tions on the germs in the spore stage).

² Goldschmidt, Verhandl. der Gesellsch. der Naturforschen und Aerzte, Nürnberg,
1893 (Leipzig, 1894), p. 428.

³ Merkel, ibid., p. 432; Jopson and Ghriskey, Trans. Philada. Patholog. Soc. for
i899 (Dec. 14 meeting), also report a case in a morocco worker, and give a brief review
of the subject, with some references.

See also De Langenhagen, “Relation de plusieurs cas de pustule maligne chez
l‘homme coexistant avec une épizootie charbonneuse,” Annales, 1899, p. 705.

⁴ Unna, Histopathology, p. 456.

420                                      INFLAMMATIONS

mistakable. In its very earliest stage it might be mistaken for a be­
ginning boil or carbuncle, but the above features would serve as differ­
ential points. Poisoned wounds and facial chancre are also to be ex­
cluded. The latter is relatively indolent, with no gangrenous tendency
and with no febrile constitutional symptoms. Occupation of the patient
may give a clue. In doubtful or suspicious cases a microscopic examina­
tion for the bacillus should be made immediately. Some of the liquid
from the pustule can be dried on the cover-glass or slide or piece of glass,
stained, and examined. A simple staining fluid may be easily improvised
by dissolving a piece of anilin blue pencil in water; the bacilli are so large
that they may be easily seen with an ordinary high-power lens (D. W.
Montgomery).

Prognosis.—The disease is always of serious import, but with an
early diagnosis and prompt treatment most cases of malignant pustule
recover. The cases in which intense and extensive edema follows inocu­
lation, without much initial change at the point of inoculation, are usually
fatal, as active measures of treatment cannot be so well and satisfactorily
carried out. In any case if there is grave systemic involvement, showing
that the bacillus and the ptomains or other septic material have gained
access to the general circulation, the outlook is involved in doubt. The
mortality seems variable in the groups of cases observed, apparently
indicating that there may be some difference in the virulence of the
bacillus at different times or from surrounding conditions. Thus in
Goldschmidt's cases, 30 in number, there were only 3 deaths; in Müller‘s¹
13 cases not a single fatality; on the other hand, according to the statistics
of Nasarow,² among 180 cases 17 per cent. died.

Treatment.—The consensus of experience indicates that the best
plan is excision of the entire diseased area, going well beyond the border,
done under antiseptic precaution to prevent reinfection; subsequently
the ordinary treatment of open wounds, antiseptics being freely employed,
such as weak corrosive sublimate solutions. The injection of iodin tinc­
ture or 5 per cent, solutions of carbolic acid at five or six points around
the border has proved successful, repeated after several hours if the
process is unchecked. Such injections, with free incisions and the appli­
cation of pure or dilute carbolic acid, have been employed in the markedly
edematous cases. Carbolic acid poisoning must be watched for. On the
other hand, Müller had good results in his cases by a purely expectant
treatment.

Constitutional treatment should be with sodium sulphite or hypo­
sulphite, and quinin in large doses, and alcoholic stimulants and ammo­
nium carbonate as supporting measures if indicated, and other appro­
priate remedies as special conditions may demand.

¹ Kurt Müller, “Der Aeussere Milzbrand der Menschen,” Deutsche med. Wochen-
schr., 1894, pp. 515 and 534.

² Quoted from Jarisch, Die Hautkrankheiten, Wien, 1900, p. 466.

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