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Chapter V

Communicable Diseases, Table of Contents

CHAPTER V

ANTHRAX

STATISTICAL CONSIDERATIONS

Table 31 shows 149 primary admissions for the total Army during the World War, giving an admission ratio of 0.04 per 1,000 strength. Officers and enlisted men, American troops, contributed 148 of these primary admissions, 2 of which were among officers, 123 among white enlisted men, and 6 among colored enlisted men. One case was reported among native troops. There were reported 22 deaths for the total Army among the primary admissions. All of these deaths were among American troops, 19 among white enlisted, 1 among colored enlisted, and 2 among enlisted men whose color was not stated. The case mortality was 14.8 per cent.

Anthrax was more common in the Army serving in the United States than in Europe. There were 94 primary admissions among white troops and 6 among colored troops serving in the United States. There were 14 deaths among the former and 1 among the latter.

About one-sixth of the total number of primary admissions for anthrax in the United States Army occurred among white enlisted men serving in Europe. There were 26 such admissions. (Table 31.) The admissions ratio per 1,000 strength was 0.02. There were no cases reported among colored enlisted men serving in Europe.

The records show 15 cases in the American Expeditionary Forces from March to August, 1918. Of these, all but 2 occurred in men who had just arrived on transports, or who had developed the disease during the voyage.1 Of the other two, one developed malignant pustule at the site of an incision caused by shaving. In several lots of shaving brushes collected from among arriving troops, the Bacillus anthracis was found by bacteriologists in England and in France.

TABLE 31.-Anthrax. Admissions and deaths, by countries, officers and enlisted men, UnitedStates Army, April 1, 1917, to December 31, 1919

 


Admissions

Deaths, absolute numbers


Absolute numbers

Ratios per 1,000

Total officers and enlisted men, including native troops

149

0.04

22

Total officers and enlisted men, American troops

148

.04

22

Total officers

2

.01

---

American troops, total enlisted men

146

.04

22

    

White

123

.03

19

    

Colored

6

.02

21

    

Color not stated

17

---

 

Total native troops

1

.03

---

U.S. Army in United States, including Alaska, enlisted men

100

.05

15

    

White

94

.05

14

    

Colored

6

.04

1

U.S. Army in Europe, excluding Russia, enlisted men

43

.03

6

    

White

26

.02

4

    

Color not stated

17

---

2

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.


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The distribution of primary admissions for anthrax by camps in the United States is given in Table 32. The disease was uncommon among the troops and occurred sporadically over practically the entire United States. The largest number of primary admissions for any one camp was for Camp Taylor, Ky., where nine cases were reported. Camp Mills, Long Island, N. Y., ranked second, with eight cases.

TABLE 32.-Anthrax. Admissions and deaths, by specified camps of occurrence, enlisted men,United States Army, April 1, 1917, to December 31, 1919

Camps of occurrence


Admissions

Deaths whitea

Camps of occurrence

Admissions

Deaths whitea


White

Colored

White

Colored

Bowie, Tex.

4

---

---

Logan, Tex.

1

---

0

Devens, Mass.

1

---

0

MacArthur, Tex.

1

---

0

Dix, N.J.

1

---

0

Mills, Long Island, N.Y.

7

1

---

Dodge, Iowa

4

1

2

Pike, Ark.

1

---

0

Doniphan, Okla.

4

---

0

Shelby, Miss.

2

---

0

Fremont, Calif.

1

---

1

Sherman, Ohio

1

---

0

Gordon, Ga.

1

---

0

Taylor, Ky.

8

1

1

Grant, Ill.

0

1

---

Travis, Tex.

1

---

0

Greene, N.C.

1

---

0

Upton, Long Island, N.Y.

4

---

2

Hancock, Ga.

5

---

2

Wheeler, Ga.

1

1

0

Jackson, S.C.

3

---

2

    

Total

54

5

10

Lewis, Wash.

2

---

0

aWhite troops only; one death was reported among colored troops at Camp Dodge.

ETIOLOGY

The exciting cause of anthrax was well understood before the World War, and its occurrence in man was well known. It was known that anthrax in man was an industrial disease and occurred commonly among persons working in tanneries on hides, or in factories where hair and wool had been obtained from animals dead of anthrax.

In England, in 1917, Coutts2 reported the finding of anthrax bacilli and anthrax spores in shaving brushes made of imitation badger hair. He was able to trace the source of infection to the use of Chinese horsehair that had been imported as goat's-hair. With the outbreak of anthrax among the American soldiers and its most common site located on the face, the shaving brush was suspected as being the source of infection. Accordingly an investigation of the shaving-brush industry, with special reference to anthrax, was made by the United States Public Health Service.3 It was shown that prior to the entry of the United States into the war all, or nearly all of the horsehair and pig bristles used in the United States came from Russia, China, or Japan, after having been submitted to cleaning and disinfecting processes in France or Germany. When the war began in 1914, the materials came direct to the United States by way of the Pacific coast. Through ignorance of the danger, or through an unwarranted confidence in certificates of disinfection that accompanied the importations, some American brush manufacturers took no pains to insure the safety of the material going into their products.3

Horsehair, which is the most frequent source of shaving-brush anthrax infection, is of both foreign and domestic source. The largest part of that used in the manufacture of shaving brushes in the United States comes from oriental sources, with China and Siberia furnishing by far the greater portion. With the investigation of establishments in the United States which manufacture


225

shaving brushes, a great variance was found in their method of disinfection. Some were deemed safe, while others were deemed totally unsafe. The methods of disinfection employed were, briefly, boiling for periods varying from one-half hour to 9 or 10 hours; steaming in streaming steam for from 1 to 8 hours; treatment in the autoclave for from 15 minutes to 3 hours, subjection to dry heat for varying periods up to a total of 24 hours. It was found that the disinfection process used on light-colored hair was less thorough than that used on the dark hair. Shaving brushes were secured in the open market and subjected to bacteriological examination. Some were found to be anthrax-infected.3

Coutts2 reported that the horsehair from China and Siberia seemed to be particularly involved, especially gray or yellow hair imitating badger hair. The anthrax organisms were found not only on the free portions of the bristles, but also on the ends set in the handles. Anthrax was recovered from a new shaving brush at Camp Jackson in November, 1918. The hair was supposed to be badger's hair.3

It is believed that anthrax infection of the skin can occur only when there is an abrasion. In shaving, these abrasions are not infrequently made, and with the use of infected shaving brushes the explanation of the common site of the malignant pustule on the face is readily seen. Among tannery workers, butchers, etc., direct inoculation takes place through abrasions from the handling of infected materials. The mode of infection in intestinal anthrax is through the mouth, either in the form of infected, uncooked meat, or by means of the hands carrying infection to the mouth. Workers in infected wool, through inhalation, occasionally contract a pulmonary form of anthrax, which is known as "wool sorters' disease." It is very probable that anthrax is not conveyed directly from man to man.

PATHOLOGY

The malignant pustule shows a circumscribed area with a black depressed necrotic center (carbon, of the French). It is raised and surrounded by an inflamed, edematous, indurated area. Vesiculation occurs in the early stages and surrounds the eschar. The lymph glands located on the chain of lymphatics from the malignant pustule show enlargement and acute inflammation. The spleen is enlarged and shows the presence of anthrax bacilli. In the so-called "wool-sorters' disease" the lungs show a pneumonic process. Occasionally the meninges are involved, showing meningitis. The cerebrospinal fluid in such cases is slightly increased and hemorrhagic, contains the Bacillus anthracis, and shows some increase in the cell count.

The following autopsy report and microscopical examination of tissues is that of a fatal case of anthrax, Fort Sam Houston, Tex.:

FORT SAM HOUSTON, TEX., May 1, 1918

Autopsy Report No. 61, Pvt. A -- C -- C --

The body is that of a somewhat slenderly built man, about 167 cm. long. There is slight rigor mortis. There is only moderate livor mortis. The pupils are dilated and equal. The right half of the neck is swollen and slightly indurated. There is a small wound measuring 1 by ½ cm. at the upper angles of superior carotid triangle of the right side of the neck. The margins of the wound are rather sharply elevated above the skin. The center of the wound is depressed and is covered by a very adherent, brownish-black slough. There is an area of great induration about the base. The edema extends up to the lobe of the right ear and somewhat posterior to the ear and downward to the clavicle. The buccal mucous membrane is


226

quite pale. The chest is well formed. The abdomen is not distended. External genitals are negative. There is a slight general glandular enlargement and the glands of the right axilla are about the size of almonds.

The subcutaneous tissues on the upper anterior portion of the chest are edematous. The peritoneal cavity is almost dry. The liver reaches 5 cm. below the ensiform. Diaphragm reaches to the fifth rib on right and fifth interspace on the left. Both pleural cavities are free from fluid. There is slight edema of the mediastinal tissues. * * *

The tissues of the neck are extremely edematous, and just below the lesions described above there is a fibrinous exudate in the underlying fascia and muscle. On section the central portion was found to be made up of a dark-brown eschar. There was no pus in the cervical tissues.

Brain: Lumbar puncture was done at the beginning of the autopsy and only a small amount of very bloody fluid could be obtained. Upon removal of skull cap and incision of the dura a considerable quantity of fluid similar to that obtained on puncture escaped. The brain was found to be entirely covered by a very hemorrhagic exudate, which on the convexity was about 3 mm. thick. The concavity of the brain was covered with a much thinner exudate, which extended down upon the cord as far as visible through the foramen magnum. This exudate is strikingly hemorrhagic. The ventricles do not contain any visible exudate. The dura itself on the inner surface is quite smooth. Smears made from the exudate on the brain and from the spinal fluid showed a large bacilli in long chains in great numbers. The same organism was obtained in pure culture from the heart blood.

Anatomical diagnosis -Anthrax pustule of neck; hemorrhagic meningitis (B. anthracis) calcified tubercles left lung.

Cause of death.-Anthrax pustule of neck; hemorrhagic meningitis (B. anthracis.)

MICROSCOPICAL EXAMINATION OF TISSUES

(Autopsy No. 61)

MAY 3, 1918

Pustule from neck -There is shown skin, subcutaneous tissue, fat, muscle. The epithelium is intact over a portion of the surface. At the site of the infection there is an area of necrosis and the epithelium over this area has disappeared. At the margin of the necrotic area are a few small vesicles. The necrosis extends down into the dermis. Throughout the section there is very extreme infiltration, with polymorphonuclear leucocytes, and there are large areas of hemorrhage. In the fascia overlying the muscle the edema is marked and some fibrin has accumulated.

Lymph gland-From the right side of the neck. There is some edema, but the striking feature is the occurrence of large, mononuclear cells. These cells are found in especially large masses in the germinal centers. The cells have large, pale, vesicular nuclei, and the cytoplasm stains pale blue. Two nuclei are occasionally found in a single cell, and more rarely three nuclei are seen. The cytoplasm of some has clear droplets in it and many of the cells contain engulfed lymphocytes. These large cells are also present to a less extent throughout the gland, and the lymph sinuses are stuffed with them. The blood vessels are dilated and the lining endothelial cells are swollen. Many small hemorrhages are seen.

*    *    *    *    *    *    *

Brain -The pia is edematous and there is an accumulation of polymorphonuclear leucocytes within it. The exudate is strikingly hemorrhagic; indeed, this is the most prominent feature. There are many phagocytic cells loaded with blood pigment. Shadowy outlines of bacilli can be seen in the exudate. There is a narrow zone of edema at the margin of the cortex.

Weigert stains were made of sections of the pustule, lung, lymph gland, spleen, liver, and brain. Typical bacilli were found in the pustule, lymph gland, the capillaries of the lung, and in the sinusoids of the liver. They were however, not numerous. The bacilli were more abundant in the spleen. The exudate on the brain contained myriads of typical anthrax bacilli. The bacilli did not penetrate into the brain substance, but small capillaries in the cortex were frequently plugged with the organisms, and there was about the vessel a dense halo of bacilli.

Diagnosis -Anthrax pustule of neck; hemorrhagic meningitis (B. anthracis); encapsulated tubercles, left lung.


227

REPORT OF PATHOLOGICAL EXAMINATION

ARMY MEDICAL MUSEUM, July 30, 1918.

Case of private A. C. B., from Fort Sam Houston, Tex.

Clinical diagnosis: hemorrhagic meningitis; B. anthrax; anthrax pustule on neck.

Specimen is the right hemisphere of a brain with the stem and stub of cord in excellent state of preservation.

The entire outer surface of the cerebrum is characterized by a thick shriveled mat of subpial hemorrhage, which is most prominent over the parietal and frontal lobes.

There is abundant exudation about the blood vessels, and masses and streaks of yellowish white material is distributed over all surfaces of the cerebrum. This exudate extends deeply into the sulci where it fuses with large amounts of hemorrhagic débris.

The blood vessels on all surfaces are notably congested and the basal surface evidences rusting.

The mesial cerebral surface is covered by a profusely hemorrhagic pia mater, which strips easily, leaving the gyri covered by, and the sulci filled with pus, coagulated blood and granular débris. All vessels are hyperemic and the sheaths filled with pus extensions.

The pia of the cerebellum is filled with pus and there is diffuse subpial hemorrhage and deposits of blood pigments.

Cut surfaces of the cerebellum show extensions of the hemorrhagic exudate into the extreme depths and ramifications of the fissures.

MICROSCOPICAL EXAMINATION

I. Cerebral cortex.-(1) The pia mater covering these portions is deeply infiltrated with a hemorrhagic exudate rich in chained bacilli. Red blood corpuscles, leucocytes, and anthrax bacilli are diffusely spread throughout the structure.

(2) The pial vessels are dilated and packed with red blood cells, but the lumina are relatively free from the organisms. Very little fibrin is noted about the vessels.

(3) The deeper cortical vessels contain bacilli and numerous red blood cells, and there is a large amount of perivascular hemorrhage filled with masses of organisms.

(4) Numerous small capillaries are occluded by pus cells.

(5) The white substance is markedly edematous, but no bacilli are noted.

(6) The ganglion cells are pale and granular with fragmented chromatin material. Many cells are vacuolated and shrunken, presenting eccentric muclei.

II. Cerebellar cortex.-(1) The sections are characterized by a thickened, hemorrhagic, purulent pia containing masses of chained bacilli and dilated vessels. This process extends deeply into the cerebellar fissures, and in places into the molecular layer.

(2) A few perivascular hemorrhages are present in the cortex, but only an occasional bacillus is noted.

(3) A few bacilli are seen about and embedded in the walls of the small vessels of the granular layer, and among the Purkinje's cells.

(4) The Purkinje's cells show acute degenerative processes, with cloudiness, and some shrinkage.

Summary -Acute hemorrhagic, purulent meningo-encephalitis (B. anthracis).

SYMPTOMS

There are three recognized types of anthrax. In the first and most common variety, the lesion is located on the skin and is known as malignant pustule. The second form is intestinal; the third, pulmonary. An analysis of anthrax occurring in the Army during the war shows no cases of pulmonary anthrax. Cases reported as primary admissions commenced with the malignant pustule and, in but one exception, on the shaving area of the face or neck. Several cases of intestinal anthrax and anthrax meningitis followed; the records show anthrax septicemia in the majority of cases.


228

Commonly, the disease commences as a red papule located at the site of an abrasion. In a few hours this papule enlarges and becomes a vesicle containing a turbid, hemorrhagic fluid. Itching occasionally occurs, but commonly is absent. The lesion enlarges, becomes depressed in the center, and is characteristically black. The surrounding tissue is hard from blocking of the lymphatics, and, bordering the eschar, is usually a ring of vesicles. Febrile symptoms occur early. The lymph glands draining the involved area become involved and, where the malignant pustule is located on the face and neck, much swelling and distortion of the parts occur. The pustule, which is usually singular, increases rapidly in size. The Bacillus anthracis can be found in the malignant pustule on examining the contents under the eschar.

Where the infection extends into the lymph and blood streams, there is an increased polymorphonuclear leucocytosis. Commonly a marked leucocytosis is not present. The spleen is usually enlarged. The cerebrospinal nervous system is not usually involved. Headache, stiffness of the neck, and disturbed reflexes indicate involvement of the meninges.

The onset of the intestinal form of anthrax is usually accompanied by vomiting, severe abdominal pains, and diarrhea. Cyanosis and circulatory collapse occurred in the case reported by Norton and Kohman.4 The feces often show the anthrax bacillus. In these cases there is an increase of fluid in the abdomen. This fluid is cloudy and contains blood. The lesions are commonly located in the small intestine, with involvement of Peyer's patches. Norton and Kohman believed that the intestinal carbuncle may be formed by a blood stream infection as well as by the alimentary route. In the former cases, the anthrax bacillus may not be found in the feces. The mortality is exceedingly high, possibly 100 per cent.

COMPLICATIONS AND CONCURRENT DISEASES

Anthrax, being an acute disease, naturally would not result in soldiers being discharged from the service directly on that account. The records show four cases discharged on account of disability following anthrax. The disability following the malignant pustule was usually the deformity following excision, where this form of treatment was applied. Of the 149 primary admissions, 25 were reported as having some concurrent disease. Among these there were 12 deaths, a case of mortality of 48 per cent.

DIAGNOSIS

Diagnosis of malignant pustule is ordinarily not attended with difficulty if one is familiar with the appearance of this lesion. The carbonlike eschar of from 1 to 3 centimeters in diameter, reposing in a crater bordered by numerous vesicles and surrounded by a red areola and considerable edema, is characteristic. The absence of suppuration and pain, with systemic symptoms such as malaise, fever, headache, and prostration should lead to an examination of the lesion for anthrax bacilli, the finding of which is conclusive proof of the correctness of the diagnosis. The occurrence of a lesion of the above description on the parts of the body habitually uncovered is suggestive. The intestinal form of anthrax is usually diagnosed at autopsy. The diagnosis of anthrax


229

meningitis is based on the presence of symptoms and signs of meningitis plus the finding of the anthrax bacillus in the spinal fluid. Pulmonary anthrax is diagnosed by the presence of physical signs of a pneumonia with anthrax bacilli present in the sputum. Anthrax septicemia is a late manifestation of any of the above-mentioned forms of anthrax and is diagnosed by the finding of the Bacillus anthracis in the blood.

PROGNOSIS

The prognosis in anthrax depends very largely on early diagnosis and treatment. Where diagnosis is made very early and strenuous treatment instituted, the mortality is low. The disease is particularly fatal in the meningitic and intestinal forms. The mortality at the Boston City Hospital for several years ending in 1918 was 31 per cent.5 The average case mortality in the United States is 13 to 24 per cent and for the Army during the World War it was 14.7 per cent.

PROPHYLACTIC MEASURES

Anthrax is an occupational disease and prophylaxis, from the standpoint of occurrence in man, rests with the Government in promulgating and enforcing regulations governing the importation of industrial products, especially hair, hides, wool, etc., from countries where anthrax is common. Interstate regulations also are required, as the disease occurs in animals in the United States, although the occurrence is to a much less degree than in Russia, Siberia, and China. Some of these regulations are contained in a report issued by the United States Bureau of Labor.6

The carcasses of animals dying from anthrax should be covered with quick-lime and buried deeply in the earth. Burning in the open is not recommended, as bursting from heat follows, with scattering of the infection. The carcasses should never be permitted to remain on the surface to be destroyed by animals, for it has been shown that the vulture, at least, can spread anthrax after feeding on such carcasses.

The spores of anthrax are particularly resistant to chemical heat and drying. It has been shown that these spores have remained viable 17 years in fields infected by the disease. Spores do not occur in man, but are probably the most important factor to be considered in controlling the disease in lower animals. Both active and passive immunization of animals against anthrax are used in the control of epidemics. Pasteur first practiced the use of attentuated cultures of anthrax bacilli as a prophylaxis.7 Rand8 reported a vaccine that remained potent over a considerable period of time, and that, when used, rendered the animal immune almost immediately.

Although it has been supposed that the eating of infected meats has caused intestinal anthrax, it was the shaving brush that was the agent of special interest to the Army during the World War. There is nothing on record to show that food has ever been the cause of anthrax in the Army. With the occurrence of malignant pustule on the face of soldiers, instructions were issued by the Surgeon General to sterilize all shaving brushes before issue or sale from Government sources.9 Several methods were tried which proved entirely unsatis-


230

factory, as the brush was destroyed during the process. The following method seems to have been the best, although none was entirely satisfactory.9 Immersion for four hours in a 10 per cent solution of formalin heated all the time to 110° F. After this, the brush is dried and ready for issue or sale.

It has been shown that the ends of the hair or bristles set in the handles of shaving brushes are occasionally infected; therefore, sterilization by immersion in chemicals probably had no effect upon anthrax organisms and, in view of the fact that "two hours of boiling are required to kill all spores contained in a liquid culture,"6 it is doubtful if the attempts at sterilization had any effect upon the occurrence of anthrax in soldiers. Since the processes used were not only destructive to the brush, but detracted from its appearance, it was difficult to have the regulations carried out. No attempt was made to force retail civilian dealers to sterilize their brushes before sale, and it is very probable that this prophylactic measure was of little or no value in controlling anthrax, or in reducing the number of cases in the Army.

The leather chin strap was supposed to have been the source of infection in several soldiers,10 as the malignant pustule appeared where the strap rubbed the skin. Toilet soap of two soldiers suffering from anthrax was shown to contain anthrax organisms and was thought to have been the source of infection.11 As the number of cases was small, the institution of prophylaxis along these lines was not undertaken.

Soldiers suffering from anthrax were transferred to hospital and confined to contagious wards for treatment and as control measures. A search of the records fails to reveal any case of anthrax transferred from man to man.

TREATMENT

Treatment of anthrax is both local and general. Success depends upon early diagnosis and rigorous treatment. Brown and Simpson12 have shown that the routine cauterization with phenol of all wounds in persons exposed to anthrax prevents occurrence of this disease.

The local treatment used during the war was excision, incision, cauterizing by actual cautery and chemicals, local application of drugs, and subcutaneous injection of immune serum into or around the malignant pustule. The general treatment consisted in the subcutaneous, intramuscular, or intravenous injection of serum.

No one treatment was universally used. Ludy and Rice13 infiltrated the tissues about the lesion with antianthrax serum of from 30 c. c. to 50 c. c. at a dose. The lesion then was dissected out by the thermo-cautery, an effort being made to remain at least one-half inch beyond the border of the malignant pustule. In addition, immune serum in 75 c. c. doses was given intravenously, after dilution with 50 c. c. salt solution, and intramuscular administration in 75 c. c. doses of antianthrax serum was used. The wound was dressed at 24-hour intervals, employing a mixture of camphor, 7 parts; phenol, 3; glycerin, 40; and alcohol, 180. The serum therapy was repeated every eight hours. Gaskill11 did not advocate excision. He used sunlight on two cases, with recovery. Mix,14 at the base hospital, Camp Mills, Long Island, injected antianthrax serum intravenously in from 100 c. c. to 200 c. c. doses. He recommended


231

excision of the pustule and emphasized the importance of early diagnosis. He reported 6 cases, with 1 death. Local treatment consisted of boric acid dressings every two hours and an ice bag applied to the head. Mix compared the effects of serum in anthrax with that of diphtheria antitoxin in diphtheria, as shown by the immediately produced improvement in the local and general condition of the patient. He believed that incision is not always necessary and that possibly anthrax may be treated with serum in the same satisfactory manner as diphtheria. Amory and Rappaport10 reported 4 cases at the embarkation hospital, Newport News, Va., with recovery. The pustule was excised under local anesthesia without any attempt to control hemorrhage, as the loss of blood from the site of infection was advisable. Cauterization, and injection of 5 per cent phenol into the cellular tissues around the lesion, followed by the application of continous alcohol dressings, were considered indispensable. Later, skin grafting was used for cosmetic purposes and for shortening the period of convalescence. Antianthrax serum was used in two cases. In one the effect was beneficial; in the other, it was commenced but was discontinued on account of a rather severe reaction.

The action of antianthrax serum is not definitely understood. It is not bactericidal and its agglutinating and precipitating qualities are questioned.

In the intestinal, pneumonic, and meningeal varieties of anthrax, serum and symptomatic treatment constituted the methods used during the war. There is no special treatment in the intestinal form as in anthrax pneumonia. Anthrax meningitis is temporarily improved symptomatically by lumbar puncture.

REFERENCES

(1) War Medicine, American Red Cross in France, Paris, ii, 1918-19, 143.

(2) Coutts, F. J. H.: Report on an Inquiry into Cases of Anthrax (Malignant Pustule or External Anthrax) Suspected to be Due to the Use of Infected Shaving Brushes. Reports to the Local Government Board on Public Health and Medical Subjects n. s., No. 112, London, His Majesty's Stationery Office, 1917.

(3) An Investigation of the Shaving Brush Industry, with Special Reference to Anthrax. U. S. Public Health Reports, 1919, xxxiv, part 1, No. 19, 994.

(4) Norton, W. H., and Kohman, E. F.: Anthrax in a Soldier. Report of a Fatal Case Probably Due to Infection by a Shaving Brush. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 16, 1129.

(5) Hyman, C. H., and Leary, T.: The Treatment of Anthrax with Normal (Beef) Serum. Review of the Literature with Report of a Case. Boston Medical and Surgical Journal. 1918, clxxviii, No. 10, 318.

(6) Andrews, John B.: Anthrax as an Occupational Disease. U. S. Department of Labor, Bureau of Labor Statistics, Bulletin No. 205, Washington, Government Printing Office, January, 1917.

(7) Pasteur, L.: Compte rendu sommaire des expériences faites a Pouilly-le-Fort, pres Melun, sur la vaccination Charbonneuse, avec la callaboration de MM. Chamberland et Roux. Bulletin de l' Académie de Médecine, Paris, 1881, 2nd s., x, No. 24, 782.

(8) Rand, W. H.: Anthrax: Animal and Human. American Medicine, Burlington, Vt., 1918, n. s., xiii, 293.

(9) Circular letter, Office of the Surgeon General, July 2, 1918. Subject: Disinfection of shaving brushes for anthrax.

(10) Amory, O. T. and Rappaport, B.: Anthrax at Embarkation Hospital, Newport News, Va. The Journal of the American Medical Association, Chicago, 1919, lxxi, No. 4, 269.


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(11) Gaskill, H. K.: Two Cases of Anthrax Occurring in Tentmates. The Military Surgeon, Washington, 1918, xliii, No. 1, 96.

(12) Brown, W. H., and Simpson, C. E.: Human Anthrax: Report of an Outbreak Among Tannery Workers. Journal of the American Medical Association, Chicago, 1917, lxviii, No. 8, 608.

(13) Ludy, J. B., and Rice, E. C.: Anthrax at Camp Hancock, Ga. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 14, 1133.

(14) Mix, Maj. Charles L.: Anthrax. The Medical Clinics of North America, Philadelphia, 1918, ii, No. 2, 587.