Communicable Diseases, Table of Contents
CHAPTER V
ANTHRAX
STATISTICAL CONSIDERATIONS
Table 31 shows 149 primary admissions for the total Armyduring the World War, giving an admission ratio of 0.04 per 1,000 strength.Officers and enlisted men, American troops, contributed 148 of these primaryadmissions, 2 of which were among officers, 123 among white enlisted men, and 6among colored enlisted men. One case was reported among native troops. Therewere reported 22 deaths for the total Army among the primary admissions. All ofthese deaths were among American troops, 19 among white enlisted, 1 amongcolored enlisted, and 2 among enlisted men whose color was not stated. The casemortality was 14.8 per cent.
Anthrax was more common in the Army serving in the UnitedStates than in Europe. There were 94 primary admissions among white troops and 6among colored troops serving in the United States. There were 14 deaths amongthe former and 1 among the latter.
About one-sixth of the total number of primary admissions foranthrax in the United States Army occurred among white enlisted men serving inEurope. There were 26 such admissions. (Table 31.) The admissions ratio per1,000 strength was 0.02. There were no cases reported among colored enlisted menserving in Europe.
The records show 15 cases in the American ExpeditionaryForces from March to August, 1918. Of these, all but 2 occurred in men who hadjust arrived on transports, or who had developed the disease during the voyage.1Of the other two, one developed malignant pustule at the site of an incisioncaused by shaving. In several lots of shaving brushes collected from amongarriving troops, the Bacillus anthracis was found by bacteriologists inEngland and in France.
|
| Deaths, 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 theWorld War period are derived from sick and wounded reports sent to the SurgeonGeneral.-Ed.
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The distribution of primary admissions for anthrax by campsin the United States is given in Table 32. The disease was uncommon among thetroops and occurred sporadically over practically the entire United States. Thelargest 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.
Camps of occurrence |
| Deaths whitea | Camps of occurrence | Admissions | Deaths whitea | ||
| 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; onedeath was reported among colored troops at Camp Dodge.
ETIOLOGY
The exciting cause of anthrax was well understood before theWorld War, and its occurrence in man was well known. It was known that anthraxin man was an industrial disease and occurred commonly among persons working intanneries on hides, or in factories where hair and wool had been obtained fromanimals dead of anthrax.
In England, in 1917, Coutts2reported the finding of anthrax bacilli and anthrax spores in shavingbrushes made of imitation badger hair. He was able to trace the source ofinfection 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 commonsite located on the face, the shaving brush was suspected as being the source ofinfection. Accordingly an investigation of the shaving-brush industry, withspecial reference to anthrax, was made by the United States Public HealthService.3 It was shown that prior tothe entry of the United States into the war all, or nearly all of the horsehairand pig bristles used in the United States came from Russia, China, or Japan,after having been submitted to cleaning and disinfecting processes in France orGermany. When the war began in 1914, the materials came direct to the UnitedStates by way of the Pacific coast. Through ignorance of the danger, or throughan unwarranted confidence in certificates of disinfection that accompanied theimportations, some American brush manufacturers took no pains to insure thesafety of the material going into their products.3
Horsehair, which is the most frequent source of shaving-brushanthrax infection, is of both foreign and domestic source. The largest part ofthat used in the manufacture of shaving brushes in the United States comes fromoriental sources, with China and Siberia furnishing by far the greater portion.With the investigation of establishments in the United States which manufacture
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shaving brushes, a great variance was found in their methodof disinfection. Some were deemed safe, while others were deemed totally unsafe.The methods of disinfection employed were, briefly, boiling for periods varyingfrom one-half hour to 9 or 10 hours; steaming in streaming steam for from 1 to 8hours; treatment in the autoclave for from 15 minutes to 3 hours, subjection todry heat for varying periods up to a total of 24 hours. It was found that thedisinfection process used on light-colored hair was less thorough than that usedon the dark hair. Shaving brushes were secured in the open market and subjectedto bacteriological examination. Some were found to be anthrax-infected.3
Coutts2 reported that thehorsehair from China and Siberia seemed to be particularly involved, especiallygray or yellow hair imitating badger hair. The anthrax organisms were found notonly on the free portions of the bristles, but also on the ends set in thehandles. Anthrax was recovered from a new shaving brush at Camp Jackson inNovember, 1918. The hair was supposed to be badger's hair.3
It is believed that anthrax infection of the skin can occuronly when there is an abrasion. In shaving, these abrasions are not infrequentlymade, and with the use of infected shaving brushes the explanation of the commonsite of the malignant pustule on the face is readily seen. Among tanneryworkers, butchers, etc., direct inoculation takes place through abrasions fromthe handling of infected materials. The mode of infection in intestinal anthraxis through the mouth, either in the form of infected, uncooked meat, or by meansof the hands carrying infection to the mouth. Workers in infected wool, throughinhalation, occasionally contract a pulmonary form of anthrax, which is known as"wool sorters' disease." It is very probable that anthrax is notconveyed directly from man to man.
PATHOLOGY
The malignant pustule shows a circumscribed area with ablack depressed necrotic center (carbon, of the French). It is raised andsurrounded by an inflamed, edematous, indurated area. Vesiculation occurs in theearly stages and surrounds the eschar. The lymph glands located on the chain oflymphatics from the malignant pustule show enlargement and acute inflammation.The spleen is enlarged and shows the presence of anthrax bacilli. In theso-called "wool-sorters' disease" the lungs show a pneumonicprocess. Occasionally the meninges are involved, showing meningitis. Thecerebrospinal fluid in such cases is slightly increased and hemorrhagic,contains the Bacillus anthracis, and shows some increase in the cellcount.
The following autopsy report and microscopical examination oftissues 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 builtman, about 167 cm. long. There is slight rigor mortis. There is only moderatelivor mortis. The pupils are dilated and equal. The right half of the neck isswollen and slightly indurated. There is a small wound measuring 1 by ? cm. atthe upper angles of superior carotid triangle of the right side of the neck. Themargins of the wound are rather sharply elevated above the skin. The center ofthe 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 thelobe of the right ear and somewhat posterior to the ear and downward to theclavicle. The buccal mucous membrane is
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quite pale. The chest is well formed. Theabdomen is not distended. External genitals are negative. There is a slightgeneral glandular enlargement and the glands of the right axilla are about thesize of almonds.
The subcutaneous tissues on the upper anteriorportion of the chest are edematous. The peritoneal cavity is almost dry. Theliver reaches 5 cm. below the ensiform. Diaphragm reaches to the fifth rib onright and fifth interspace on the left. Both pleural cavities are free fromfluid. There is slight edema of the mediastinal tissues. * * *
The tissues of the neck are extremelyedematous, and just below the lesions described above there is a fibrinousexudate in the underlying fascia and muscle. On section the central portion wasfound to be made up of a dark-brown eschar. There was no pus in the cervicaltissues.
Brain: Lumbar puncture was done at thebeginning of the autopsy and only a small amount of very bloody fluid could beobtained. Upon removal of skull cap and incision of the dura a considerablequantity of fluid similar to that obtained on puncture escaped. The brain wasfound to be entirely covered by a very hemorrhagic exudate, which on theconvexity was about 3 mm. thick. The concavity of the brain was covered with amuch thinner exudate, which extended down upon the cord as far as visiblethrough the foramen magnum. This exudate is strikingly hemorrhagic. Theventricles do not contain any visible exudate. The dura itself on the innersurface is quite smooth. Smears made from the exudate on the brain and from thespinal fluid showed a large bacilli in long chains in great numbers. The sameorganism was obtained in pure culture from the heart blood.
Anatomical diagnosis -Anthrax pustuleof neck; hemorrhagic meningitis (B. anthracis) calcified tubercles leftlung.
Cause of death.-Anthraxpustule of neck; hemorrhagic meningitis (B. anthracis.)
MICROSCOPICAL EXAMINATION OF TISSUES
(Autopsy No. 61)
MAY 3, 1918
Pustule from neck -Thereis shown skin, subcutaneous tissue, fat, muscle. The epithelium is intact over aportion of the surface. At the site of the infection there is an area ofnecrosis and the epithelium over this area has disappeared. At the margin of thenecrotic area are a few small vesicles. The necrosis extends down into thedermis. Throughout the section there is very extreme infiltration, withpolymorphonuclear leucocytes, and there are large areas of hemorrhage. In thefascia overlying the muscle the edema is marked and some fibrin has accumulated.
Lymph gland-Fromthe right side of the neck. There is some edema, but the striking feature is theoccurrence of large, mononuclear cells. These cells are found in especiallylarge masses in the germinal centers. The cells have large, pale, vesicularnuclei, and the cytoplasm stains pale blue. Two nuclei are occasionally found ina single cell, and more rarely three nuclei are seen. The cytoplasm of some hasclear droplets in it and many of the cells contain engulfed lymphocytes. Theselarge cells are also present to a less extent throughout the gland, and thelymph sinuses are stuffed with them. The blood vessels are dilated and thelining endothelial cells are swollen. Many small hemorrhages are seen.
* * * * * * *
Brain -The pia isedematous and there is an accumulation of polymorphonuclear leucocytes withinit. The exudate is strikingly hemorrhagic; indeed, this is the most prominentfeature. There are many phagocytic cells loaded with blood pigment. Shadowyoutlines of bacilli can be seen in the exudate. There is a narrow zone of edemaat the margin of the cortex.
Weigert stains were made of sections of thepustule, lung, lymph gland, spleen, liver, and brain. Typical bacilli were foundin the pustule, lymph gland, the capillaries of the lung, and in the sinusoidsof the liver. They were however, not numerous. The bacilli were more abundant inthe spleen. The exudate on the brain contained myriads of typical anthraxbacilli. The bacilli did not penetrate into the brain substance, but smallcapillaries in the cortex were frequently plugged with the organisms, and therewas about the vessel a dense halo of bacilli.
Diagnosis -Anthraxpustuleof neck; hemorrhagic meningitis (B. anthracis); encapsulated tubercles,left lung.
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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; anthraxpustule on neck.
Specimen is the right hemisphere of a brain with the stem andstub of cord in excellent state of preservation.
The entire outer surface of the cerebrum is characterized bya thick shriveled mat of subpial hemorrhage, which is most prominent over theparietal and frontal lobes.
There is abundant exudation about the blood vessels, andmasses and streaks of yellowish white material is distributed over all surfacesof the cerebrum. This exudate extends deeply into the sulci where it fuses withlarge amounts of hemorrhagic d?bris.
The blood vessels on all surfaces are notably congested andthe basal surface evidences rusting.
The mesial cerebral surface is covered by a profuselyhemorrhagic pia mater, which strips easily, leaving the gyri covered by, and thesulci filled with pus, coagulated blood and granular d?bris. All vessels arehyperemic and the sheaths filled with pus extensions.
The pia of the cerebellum is filled with pus and there isdiffuse subpial hemorrhage and deposits of blood pigments.
Cut surfaces of the cerebellum show extensions of thehemorrhagic exudate into the extreme depths and ramifications of the fissures.
MICROSCOPICAL EXAMINATION
I. Cerebral cortex.-(1) The pia mater covering theseportions is deeply infiltrated with a hemorrhagic exudate rich in chainedbacilli. Red blood corpuscles, leucocytes, and anthrax bacilli are diffuselyspread throughout the structure.
(2) The pial vessels are dilated and packed with red bloodcells, but the lumina are relatively free from the organisms. Very little fibrinis noted about the vessels.
(3) The deeper cortical vessels contain bacilli and numerousred blood cells, and there is a large amount of perivascular hemorrhage filledwith masses of organisms.
(4) Numerous small capillaries are occluded by pus cells.
(5) The white substance is markedly edematous, but no bacilliare noted.
(6) The ganglion cells are pale and granular withfragmented chromatin material. Many cells are vacuolated and shrunken, presenting eccentricmuclei.
II. Cerebellar cortex.-(1) The sections arecharacterized by a thickened, hemorrhagic, purulent pia containing masses ofchained bacilli and dilated vessels. This process extends deeply into thecerebellar 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 ofthe 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 andmost common variety, the lesion is located on the skin and is known as malignantpustule. The second form is intestinal; the third, pulmonary. An analysis ofanthrax occurring in the Army during the war shows no cases of pulmonaryanthrax. Cases reported as primary admissions commenced with the malignantpustule and, in but one exception, on the shaving area of the face or neck.Several cases of intestinal anthrax and anthrax meningitis followed; the recordsshow anthrax septicemia in the majority of cases.
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Commonly, the disease commences as a red papule located atthe site of an abrasion. In a few hours this papule enlarges and becomes avesicle containing a turbid, hemorrhagic fluid. Itching occasionally occurs, butcommonly is absent. The lesion enlarges, becomes depressed in the center, and ischaracteristically black. The surrounding tissue is hard from blocking of thelymphatics, and, bordering the eschar, is usually a ring of vesicles. Febrilesymptoms occur early. The lymph glands draining the involved area becomeinvolved and, where the malignant pustule is located on the face and neck, muchswelling and distortion of the parts occur. The pustule, which is usuallysingular, increases rapidly in size. The Bacillus anthracis can be foundin 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 markedleucocytosis is not present. The spleen is usually enlarged. The cerebrospinalnervous system is not usually involved. Headache, stiffness of the neck, anddisturbed reflexes indicate involvement of the meninges.
The onset of the intestinal form of anthrax is usuallyaccompanied by vomiting, severe abdominal pains, and diarrhea. Cyanosis andcirculatory collapse occurred in the case reported by Norton and Kohman.4 Thefeces often show the anthrax bacillus. In these cases there is an increase offluid in the abdomen. This fluid is cloudy and contains blood. The lesions arecommonly located in the small intestine, with involvement of Peyer's patches.Norton and Kohman believed that the intestinal carbuncle may be formed by ablood 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 exceedinglyhigh, possibly 100 per cent.
COMPLICATIONS AND CONCURRENT DISEASES
Anthrax, being an acute disease, naturally would not resultin soldiers being discharged from the service directly on that account. Therecords show four cases discharged on account of disability following anthrax.The disability following the malignant pustule was usually the deformityfollowing excision, where this form of treatment was applied. Of the 149 primaryadmissions, 25 were reported as having some concurrent disease. Among thesethere were 12 deaths, a case of mortality of 48 per cent.
DIAGNOSIS
Diagnosis of malignant pustule is ordinarily not attendedwith difficulty if one is familiar with the appearance of this lesion. Thecarbonlike eschar of from 1 to 3 centimeters in diameter, reposing in a craterbordered by numerous vesicles and surrounded by a red areola and considerableedema, is characteristic. The absence of suppuration and pain, with systemicsymptoms such as malaise, fever, headache, and prostration should lead to anexamination of the lesion for anthrax bacilli, the finding of which isconclusive proof of the correctness of the diagnosis. The occurrence of a lesionof the above description on the parts of the body habitually uncovered issuggestive. The intestinal form of anthrax is usually diagnosed at autopsy. Thediagnosis of anthrax
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meningitis is based on the presence of symptoms and signs ofmeningitis plus the finding of the anthrax bacillus in the spinal fluid.Pulmonary anthrax is diagnosed by the presence of physical signs of a pneumoniawith anthrax bacilli present in the sputum. Anthrax septicemia is a latemanifestation of any of the above-mentioned forms of anthrax and is diagnosed bythe finding of the Bacillus anthracis in the blood.
PROGNOSIS
The prognosis in anthrax depends very largely on earlydiagnosis and treatment. Where diagnosis is made very early and strenuoustreatment instituted, the mortality is low. The disease is particularly fatal inthe meningitic and intestinal forms. The mortality at the Boston City Hospitalfor several years ending in 1918 was 31 per cent.5 The average casemortality in the United States is 13 to 24 per cent and for the Army during theWorld War it was 14.7 per cent.
PROPHYLACTIC MEASURES
Anthrax is an occupational disease and prophylaxis, from thestandpoint of occurrence in man, rests with the Government in promulgating andenforcing 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 inthe United States, although the occurrence is to a much less degree than inRussia, Siberia, and China. Some of these regulations are contained in a reportissued by the United States Bureau of Labor.6
The carcasses of animals dying from anthrax should be coveredwith quick-lime and buried deeply in the earth. Burning in the open is notrecommended, as bursting from heat follows, with scattering of the infection.The carcasses should never be permitted to remain on the surface to be destroyedby animals, for it has been shown that the vulture, at least, can spread anthraxafter feeding on such carcasses.
The spores of anthrax are particularly resistant to chemicalheat and drying. It has been shown that these spores have remained viable 17years in fields infected by the disease. Spores do not occur in man, but areprobably the most important factor to be considered in controlling the diseasein lower animals. Both active and passive immunization of animals againstanthrax are used in the control of epidemics. Pasteur first practiced the use ofattentuated cultures of anthrax bacilli as a prophylaxis.7 Rand8reported a vaccine that remained potent over a considerable period of time, andthat, when used, rendered the animal immune almost immediately.
Although it has been supposed that the eating of infectedmeats has caused intestinal anthrax, it was the shaving brush that was the agentof special interest to the Army during the World War. There is nothing on recordto show that food has ever been the cause of anthrax in the Army. With theoccurrence of malignant pustule on the face of soldiers, instructions wereissued by the Surgeon General to sterilize all shaving brushes before issue orsale from Government sources.9 Several methods were tried whichproved entirely unsatis-
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factory, as the brush was destroyed during the process. Thefollowing method seems to have been the best, although none was entirelysatisfactory.9 Immersion for four hours in a 10 per centsolution of formalin heated all the time to 110? F. After this, the brushis dried and ready for issue or sale.
It has been shown that the ends of the hair or bristles setin the handles of shaving brushes are occasionally infected; therefore,sterilization by immersion in chemicals probably had no effect uponanthrax organisms and, in view of the fact that "two hours of boiling arerequired to kill all spores contained in a liquid culture,"6 itis doubtful if the attempts at sterilization had any effect upon the occurrenceof anthrax in soldiers. Since the processes used were not only destructive tothe brush, but detracted from its appearance, it was difficult to have theregulations carried out. No attempt was made to force retail civilian dealers tosterilize their brushes before sale, and it is very probable that thisprophylactic measure was of little or no value in controlling anthrax, or inreducing the number of cases in the Army.
The leather chin strap was supposed to have been the sourceof infection in several soldiers,10 as the malignant pustule appeared wherethe strap rubbed the skin. Toilet soap of two soldiers suffering from anthraxwas shown to contain anthrax organisms and was thought to have been the sourceof infection.11 As the number of cases was small, the institution ofprophylaxis along these lines was not undertaken.
Soldiers suffering from anthrax were transferred to hospitaland confined to contagious wards for treatment and as control measures. A searchof the records fails to reveal any case of anthrax transferred from man to man.
TREATMENT
Treatment of anthrax is both local and general. Successdepends upon early diagnosis and rigorous treatment. Brown and Simpson12 haveshown that the routine cauterization with phenol of all wounds in personsexposed 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 ofdrugs, and subcutaneous injection of immune serum into or around the malignantpustule. The general treatment consisted in the subcutaneous, intramuscular, orintravenous injection of serum.
No one treatment was universally used. Ludy and Rice13 infiltratedthe 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 effortbeing made to remain at least one-half inch beyond the border of the malignantpustule. In addition, immune serum in 75 c. c. doses was given intravenously,after dilution with 50 c. c. salt solution, and intramuscular administration in75 c. c. doses of antianthrax serum was used. The wound was dressed at 24-hourintervals, employing a mixture of camphor, 7 parts; phenol, 3; glycerin, 40; andalcohol, 180. The serum therapy was repeated every eight hours. Gaskill11did not advocate excision. He used sunlight on two cases,with recovery. Mix,14 at the base hospital, Camp Mills, LongIsland, injected antianthrax serum intravenously in from 100 c. c. to 200 c. c.doses. He recommended
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excision of the pustule and emphasized the importance ofearly diagnosis. He reported 6 cases, with 1 death. Local treatment consisted ofboric acid dressings every two hours and an ice bag applied to the head. Mixcompared the effects of serum in anthrax with that of diphtheria antitoxin indiphtheria, as shown by the immediately produced improvement in the local andgeneral condition of the patient. He believed that incision is not alwaysnecessary and that possibly anthrax may be treated with serum in the samesatisfactory manner as diphtheria. Amory and Rappaport10 reported 4 cases atthe embarkation hospital, Newport News, Va., with recovery. The pustule wasexcised under local anesthesia without any attempt to control hemorrhage, as theloss of blood from the site of infection was advisable. Cauterization, andinjection of 5 per cent phenol into the cellular tissues around the lesion,followed by the application of continous alcohol dressings, were consideredindispensable. Later, skin grafting was used for cosmetic purposes and forshortening the period of convalescence. Antianthrax serum was used in two cases.In one the effect was beneficial; in the other, it was commenced but wasdiscontinued 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 arequestioned.
In the intestinal, pneumonic, and meningeal varieties ofanthrax, serum and symptomatic treatment constituted the methods used during thewar. There is no special treatment in the intestinal form as in anthraxpneumonia. Anthrax meningitis is temporarily improved symptomatically by lumbarpuncture.
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 exp?riences faites a Pouilly-le-Fort, pres Melun, sur la vaccination Charbonneuse, avec la callaboration de MM. Chamberland et Roux. Bulletin de l' Acad?mie de M?decine, 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.
