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U. S. DEPARTMENT OF LABOR BUREAU OF LABOR STATISTICS ROYAL MEEKER, Commissioner BULLETIN OF THE UNITED STATES \ / WH O L E o n c i BUREAU OF LABOR STATISTICS/ • • • I NUMBER ^ U J IN D U S T R IA L A C C ID E N T S AN D H Y G IE N E S E R IE S : No. 10 ANTHRAX AS AN OCCUPATIONAL DISEASE By JOHN B. ANDREWS, Ph. D. JANUARY, 1917 WASHINGTON GOVERNMENT PRINTING OFFICE 1917 ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D. C. AT 26 CENTS PER COPY A CONTENTS. Page, 5-7 Introductdry summary.............................................................................................. Chapter I.—General description and history of anthrax..................................... 9-13 Early studies of the disease............................................................................... 9 Discovery of the bacillus................................................................................... 10 Characteristics of bacillus and spore................................................................. 11,12 Animals subject to anthrax, and countries where the disease is prevalent.. 12 Conditions of soil and temperature favorable to the development of anthrax. 13 Modes of infection............................................................................................... 13 Chapter II.—Medical aspects of human anthrax................................................... 15-18 Symptoms............................................................................................................ 15,16 Treatment............................................................................................................ 16-18 Chapter I I I .—Industries affected............................................................................ 19-23 Agriculture and other industries involving direct contact with animals........ 19 Leather industry................................................................................................. 19,20 Animal hair and bristle industry...................................................................... 20, 21 Wool industry...................................................................................................... 21, 22 Horn and bone industry..................................................................................... 22 Transportation..................................................................................................... 22 Nonoccupational anthrax................................................................................... 23 Chapter IV.—Anthrax in the United States......................................................... 25-93 Early experience................................................................................................. 25-32 Recent experience.............................................................................................. 32-80 Experience of a leading morocco-leather center................................. 32-35 Cases reported under New York occupational disease reporting law........35-37 Cases reported under New Jersey occupational disease reporting law. . 37, 38 Cases reported under Pennsylvania infectious disease reporting law. . . 38, 39 Cases on record in a Philadelphia hospital.............................................. 39-41 Cases on record in a Massachusetts hospital........................................... 41-43 Cases reported by tanners and leather manufacturers............................ 43-46 Fatal cases reported in registration area of the United States, 1910 to 1915............................................................................................................ 46-77 Distribution by industry, place of death, etc................................... 47-55 Statistical summary............................................................................ 55-59 Individual histories of fatal cases...................................................... 60-78 Probable ratio of deaths to total number of cases................................... 78-80 Legislation......................................................................................................... 80-93 Reporting.............................................................................................*.___ 80-82 Prevention.................................................................................................... 82-88 Agriculture............................................................................................ 82, 83 Trade and manufacture....................................................................... 84-88 Compensation............................................................................................... 89-93 Chapter V.—Anthrax in Europe............................................................................ 95-114 Private activity................................................................................................... 95-98 Anthrax Investigation Board for Bradford and District......................... 95, 96 German employers’ mutual trade associations......................................... 96,97 3 4 CONTENTS. Chapter V.—Anthrax in Europe—Concluded. Private activity—Concluded. Association of French Manufacturers for the Prevention of Industrial Page. Accidents................................................................................................. 97 Milan Labor Clinic and other private activity in Italy.......................... 97,98 International organizations and congresses............................................... 98 Governmental investigations............................................................................ 98,99 Systematic reporting and resultant data......................................................... 99-106 Great Britain.............................................................................................. 99-102 Germany....................................................................................................102-104 104 France.................................................. ................ ....................................... Holland..................................................................................................... 104,105 Italy.............................................................................................. ............105,106 Russia............................................................................................................ 106 Protective legislation.......................................................................................106-111 Wool, hair, and bristles........................................................................... 107-110 Hides and skins..................................................... .................................. 110, 111 Compensation for anthrax as an industrial injury....................................... 112-114 Chapter V I.—Present status of the problem of disinfection............................. 115-120 Chapter V II.—Recommendations for control and prevention of anthrax___ 121-125 Recommendations of the subcommittee of International Association for Labor Legislation, 1914.............................................................................. 121-123 Recommendations by Prof. L. Devoto and F. Massarelli.......................... 123,124 Recommendations by C. H. W. Page........................................................... 124,125 Appendix A.—Rules and regulations in the United States............................... 126-135 United States: Treasury Department and Department of Agriculture Joint Order No. 1, Regulations governing the certification and disinfection of hides, fleshings, hide cuttings, parings, and glue stock, sheepskins and goatskins and parts thereof, hair, wool, and other animal by-products, hay, straw, forage, or similar material offered for entry into the United States, 1916.................................................................................................. 126-130 Massachusetts: Rules and regulations suggested for the prevention of anthrax, 1916................................................................................................ 131-134 New York: State industrial commission, division of industrial hygiene, recommendations, 1916............................................................................... 134-135 Appendix B .—Text of European regulations....................................................... 136-150 Great Britain: Regulations for handling dry and dry-salted hides and skins imported from China or from the West Coast of India, 1901....................... 136 Great Britain: Sorting, willowing, washing, combing, and carding wool, goat hair, and camel hair, and processes incidental thereto, 1905......... 137-140 Great Britain: Regulations for the processes involving the use of horsehair from China, Siberia, or Russia, in effect April 1, 1908........................... 141-143 France: Decree relating to special hygienic measures for establishments where the workers are exposed to anthrax infection, 1913..................... 143-145 Germany: Order concerning the equipment and operation of horsehairspinning establishments, of shops where other animal hair and bristles are manipulated, and of brush factories, 1902.......................................... 145-148 Prussia: Order relating to the propagation of anthrax through animal skins, 1902................................................................................................................ 148,149 Prussia: Regulations for the protection of workers against the dangers of anthrax, 1910................................................................................................149,150 BULLETIN OF THE U . S. B U R E A U O F L A B O R S T A T IS T IC S . WHOLE NO. 2 0 5 .' W A S H IN G T O N . JANUARY, 1917. ANTHRAX AS AN OCCUPATIONAL DISEASE. B Y J O H N B. A N D R E W S , P H . D .1 INTRODUCTORY SUMMARY. A sudden and startling increase in the number of illnesses and deaths from anthrax in the United States drew public attention to this occupational disease during the closing months of 1915 and the early part of 1916. Most of the increase took place in seaports and tannery towns in the three States o f New York, Massachusetts, and Pennsylvania. New York, for instance, reported more deaths from the malady in 1915 than had previously occurred in any State in any single year since the Census Bureau began to give anthrax a separate place in the mortality statistics. In Massachusetts more cases were reported during the first six months of 1916 than in any preceding whole year since the infectious disease reporting law in that State went into effect. The relative importance of anthrax is shown by the fact that for every five deaths from lead poisoning reported in the United States registration area there is one death from anthrax, and that the total number o f anthrax cases is about five times the number o f fatalities. One Delaware physician was able to furnish, from his own prac tice, data on 48 cases treated within six years. During the same period a single Philadelphia hospital treated 32 cases, 6 of which were fatal. In three years one State workmen’s compensation com mission passed upon 30 claims arising from this occupational disease. Anthrax is primarily a disease of animals such as cattle and sheep, but is transmitted to man in a number of industrial pursuits. In cluded among those who have died of it in this country are hide and skin handlers and other tannery employees, longshoremen, wool1 Of information from scores of physicians, hospitals, and public officials in this country and Europe during the past five years, and of painstaking analysis by two faithful assistants, Anna K alet and Solon de Leon, grateful acknowledgment is here made. 5 6 BULLETIN OF THE BUREAU OF LABOR STATISTICS. sorters, hair workers, brush makers, paper makers, farmers, ranch men, liverymen, and veterinarians. Among nonfatal cases reported in several States and by a number of hospitals the same groups of occupations are strongly represented. Infection has even taken place in a carpenter, a steam fitter, and a stationary engineer, all of whom worked in tanneries, and in a customhouse official who weighed hides and wool on the docks. In some nonoccupational cases the disease has been spread by insects and by pet animals which had been feed ing on diseased carcasses. The bacillus of anthrax is one o f the largest and most easily recog nized o f disease-producing organisms, and its discovery about the middle o f the last century marks the beginning o f modem bacteri ology. The bacillus, however, is not so much to be feared as a cause of disease as the spore, which is so resistant that it is used as a test object for standardizing germicides. The spore can survive for as long as 17 years without nutriment, is easily carried about, and when provided with a favorable environment rapidly germinates and sets up a focus o f infection. In man contagion commonly occurs through an abrasion o f the skin, resulting in the so-called “ malignant pustule ” or in “ malignant edema.” Woolsorter’s disease, or pulmonary anthrax, is a less fre quent but almost invariably fatal form of the malady, caused by inhaling dust or particles of hair or wool from diseased animals. In rare cases the spores find entrance to the digestive system and pro duce a gastrointestinal attack. The method o f treatment most fre quently used hitherto is excision o f the pustule where possible, some times supplemented by intravenous injections o f antianthrax serum. Now, however, some successful physicians are advocating for ex ternal cases nothing more drastic than rest for the affected part, stimulants, and local treatment with iodine and wet bichloride of mercury dressings. Often in internal cases, physicians admit, the disease fails to be diagnosed and its discovery is a “ surprise o f the autopsy.” In Europe both private and public forces have combined to carry on an energetic campaign against industrial anthrax. The Anthrax Investigation Board for Bradford and District, in England, the German and the French employers’ mutual trade associations, and the famous Labor Clinic at Milan, Italy, have all made valuable studies o f the disease and assisted in establishing preventive measures. The governments o f the leading countries long ago drafted and se~ cured the careful enforcement of sanitary rules for the dangerous industries, including wool sorting, washing, combing, and carding, hair sorting, brush making, and tanning. Further researches in efficient and practicable methods of disinfection are still under way. AN TH RAX AS AN OCCUPATIONAL DISEASE. 7 In at least seven foreign countries anthrax is compensated as an industrial accident. In the United States, on the other hand, the problem has as yet been given less consideration, although legislation for the report ing o f anthrax, both as an infectious and as an occupational disease, is now fairly widespread and in some progressive States valuable data are regularly being collected. In the field o f prevention, especially, the United States lags behind. Precautions taken by employers on their own initiative are crude and few in number. Antianthrax serum is scarce and not readily available. No specific factory or workshop regulations for safeguarding working men and women from the disease have yet been enacted by any State. The most effective American provisions on the subject are contained in joint administrative orders of the Federal Departments o f the Treasury and Agriculture, which, be ginning January 1, 1917, prohibits the importation of hides, hoofs, wool, hair, or other products from animals affected with anthrax and establishes detailed requirements for the disinfection o f these products if imported from districts where anthrax is prevalent and for the disinfection of conveyances and o f certain premises. The period during 1915 and 1916 when much laxer requirements were in force corresponds roughly with the period o f highest anthrax frequency yet recorded in the United States, especially among long shoremen and tannery employees, and the connection would seem to be more than accidental. Two States authorize workmen’s compensation for all anthrax contracted in the course of employment, and in one State (Massa chusetts) a score of awards under this enlightened principle have already been rendered. In a few other States compensation pay ments have been made for anthrax contracted as the result of a definite injury received while at work. With the gradual spread of workmen’s compensation to include all personal injuries in the course o f employment, and with the probable development of health insurance in this country, an added incentive will be furnished for the prevention of this deadly disease. CHAPTER I. GENERAL DESCRIPTION AND HISTORY OF ANTHRAX. EARLY STUDIES OF THE DISEASE. It was not until the latter half of the eighteenth century that valuable treatises on the subject of anthrax or splenic fever (French, “ charbon” ; German, “ M ilzbrand” ) began to appear.1 In 1769 Fournier, of Dijon, France, published his historic work “ Charbon Malin,” wherein a step was made toward recognizing the connection between the various forms of anthrax. At about the same time the ravages o f the disease became so serious and the need for a remedy so urgent that the Academy of Dijon offered a prize for essays on the subject. Some of the works submitted were remarkable for the thoroughness and precision with which they described the main symp toms of human anthrax. These first scientific researches practically mark the beginning of the literature. Since then, at more or less regular intervals, treatises on the disease, both in man and in ani mals, have continued to appear. It was not, however, until a century later that the true nature of anthrax was revealed. In France in 1849 an investigation was under taken by a group of medical men, in the course o f which it was established that anthrax in man and anthrax in animals are identical. Then began a search for the causes o f the disease. The theories ad vanced are characteristic o f the ante-Pasteur period when the mys teries of bacteriology were still undisclosed and infectious diseases were explained by spontaneous generation and by other subsequently discarded hypotheses. For anthrax, the influence of soil, the sum mer’s heat, storms, insanitary conditions o f stalls and stables, and errors in d iet2 were some of the causes assigned. l f The origin of anthrax is lost in antiquity. Some authors trace it even to the time of Moses and identify it w ith the sixth plague of Egypt. Allusions to it are believed to be found in Homer. Virgil at the end of the Third Georgic gives a very vivid description of an outbreak among domestic animals, the symptoms of which leave little doubt as to its being anthrax. Hippocrates, Galen, and Pliny the Elder all describe carbuncles, which are diagnosed as anthrax by some modern authorities. Periodic devastating epidemics of the disease are mentioned by numerous writers, medieval and modern. 2 Thus Delafond, a French veterinary surgeon, held at one time that anthrax in sheep was caused by “ an excess of blood circulating in the vessels,” due to “ too copious and too substantial feeding.” (Delafond : T raits sur la maladie du sang des b§tes & laine, 1843. Quoted by J. Cavaille : Le Charbon Professionnel, 1911, p. 8.) A t a still earlier date Chabert, director and inspector general of the Royal Veterinarian College of France, declared that “ anthrax tumors in general may, and should, be regarded as the effects of an effort of nature to rid itself of the humor with which it is surcharged and the expul sion of which it is important to assist by all means that may achieve this result.” (Traite du charbon ou anthrax dans les animaux, Paris, 1782, p. 33.) 10 BULLETIN OF THE BUREAU OF LABOR STATISTICS. DISCOVERY OF THE BACILLUS. The anthrax bacillus was the first bacterium of disease ever dis covered, and its isolation marks the birth of the modern science of bacteriology. In 1850 a French village physician named Rayer, in collaboration with Davaine, found in the blood of a sheep which had died of anthrax what he called “ little threadlike, motionless bodies, about twice the length of a blood globule.” 1 Five years later, in 1855, a similar result was obtained by a German scientist, Pollender. None of these men at the time of their discovery, however, was able to explain the nature of these bodies or their relation to the disease, nor was anyone aware of the greatness of their contribution to human knowledge. Davaine, after a long series of experiments, came to the conclusion that these bodies, constantly present in the blood and organs of animals dying of anthrax, were absolutely distinct from the bacteria of putrefaction which were being studied by his contemporaries, and that in them would undoubtedly be found the cause of the disease.2 This forecast was brilliantly fulfilled in 1876 by Robert Koch, who later discovered the bacillus of tuberculosis. Koch conclusively proved3 the causal relation of the bacterium to the disease, and fur thermore demonstrated that the anthrax organism passed through the two stages of bacillus and spore which had previously been made out by Pasteur in connection with a silkworm blight. At this point Pasteur took up the inquiry. The fact that certain investigators, even after Koch’s demonstration, maintained that the disease often occurred without the presence of bacteria led him to subject the work of his predecessors to rigorous verification. He resorted to the method of successive cultures. In a nutritive liquid he placed a minute quantity of fresh anthrax blood; a large number of bacteria appeared; a drop of this liquid produced a new culture which also showed germs, and so on to 20 cultures. Since the last culture certainly contained not a particle of the original anthrax blood, and since it had the power to produce anthrax by inoculation, Pasteur decided that it was not blood, but bacteria, that constituted the cause of anthrax. He also verified Koch’s observations of the reproduction of the bacteria through fission and by spores. The experiments of these men, by presenting for the first time a complete account of the etiology of anthrax, answered the most important question in connection with this disease and made possible its further scientific study. 1 Comptes rendus de la Soci€t6 de Biologie, 1850, p. 141. Charbon Professionnel, 1911, p. 11. Quoted by J. C a v a illg : Le 2 Comptes rendus de l’Acad&nie des Sciences, 1863, vol. 57, pp. 320, 351. Cavaillg, op. cit., p. 14. Quoted by J. 3 Robert Koch : Die Aetiologie der Milzbrandkrankheit begriindet auf die Entwicklungsgeschichte des Bacillus Anthracis, 1876. Leipsig, 1910. 47 pp. AN TH RAX AS AN OCCUPATIONAL DISEASE. 11 CHARACTERISTICS OF BACILLUS AND SPORE. The bacillus o f anthrax (B a cillu s anthracis) is a cylindrical or rodlike body o f to inch in length and about y bI iju inch in diameter. Viewed with a microscope it is motionless, straight, and transparent. In the blood and other fluids o f a living animal, which form the most favorable media, the bacillus multiplies very rapidly by fission. The rodlike body becomes longer and divides into two or more individuals similar to the parent. The multiplication of the bacillus can take place only in the presence o f substances entering into the composition o f the bacillus itself, namely, water, nitrates, carbohydrates, and minerals; a temperature o f 53.6° to 113° F. and a supply o f oxygen are also necessary. Another mode of reproduction is by means o f spores. Spores can be formed in a medium similar to that favorable to the segmentation o f the bacillus, except that free oxygen is necessary; for this reason spores never form in the blood o f a living animal. Given the pres ence o f free oxygen, sporulation takes place when the medium be comes “ impaired, either because it was deprived by the bacillus of some of its essential substances or because it became adulterated by the accumulation of products secreted by the microbe.’51 Under such conditions the bacillus instead of dividing into segments grows into a long thread inside of which oval-shaped spores appear, regularly spaced, “ like peas in a pod.” The surrounding protoplasm is dissolved or reabsorbed, and the spores are liberated. Thus the spore seems to be formed at the expense of the bacillus itself; it is, so to speak, the bacillus in a condensed form, and when placed in a fa vorable medium it germinates and again becomes a bacillus. The spore has been the subject of numerous researches and its nature is well known. It has been discovered that, unlike the bacillus, the spore is marvelously resistant, a circumstance which makes the struggle with the disease particularly difficult. The spore contains in itself the elements necessary for life and can subsist for years in an environ ment entirely devoid of nutritive materials, while the bacillus, left to itself, very soon dies. Dr. Kebentisch,2 of Offenbach, Prussia, states that after having lain dormant for 17 years the spore is still capable o f germination. In their susceptibility to heat, the microorganisms also differ con siderably. Blood of anthrax-infected animals, containing bacilli only, loses its virulence if exposed for 15 minutes to a temperature o f 131° F. The spore, however, is much more resistant. Two hours o f boiling are required to kill all spores contained in a liquid culture; raised in such a medium to 221° F. a few spores may resist for about 1 J. C a v a ille : Le Charbon P ro fe ssio n a l, Berger-Levrault, editeurs, Paris, 1911, p. 48. 2 Gewerbliehe Milzbrandvergiftungen, in Zentralblatt fur Gewerbehygiene, M ay, 1913, p. 201. 12 BULLETIN OF THE BUREAU OF LABOR STATISTICS. 15 minutes. In a dry medium the spores stand a temperature o f 248° to 266° F. Drying, if carried out rapidly, destroys the bacillus but hardly affects the spore. Equally resistant is the spore to antiseptics; numerous experi ments have shown that while the bacillus is easily destroyed, only very high doses and prolonged exposure have any effect on the spore. Nammack states that “ even catgut, prepared from the sub mucosa o f the intestines o f infected sheep, has been known to defy all the elaborate preparations of modern surgical technique, and still convey anthrax infection to a wound.” 1 In fact, so hardy are the spores that they have long been used as test objects for determin ing the efficacy of germicides and o f other destructive agencies.2 This circumstance explains the difficulties in the way of sterilization o f materials, a question which will be taken up later in detail. ANIMALS SUBJECT TO ANTHRAX, AND COUNTRIES WHERE THE DISEASE IS PREVALENT. Anthrax is primarily a disease of animals, from whom it is con tracted directly or indirectly by human beings. It is particularly frequent among cattle and sheep, but may also be transmitted to goats, horses, hogs, dogs, cats, and certain kinds o f game. Mice, rabbits, and guinea pigs, in the laboratory experiments, are very susceptible, while fowl are practically immune. This considerable variety o f animals subject to anthrax aggravates the dangers of the disease. Another serious factor is its world-wide distribution. Hardly a country in the world is known to be entirely exempt, while a number o f localities are reputed to be particularly affected. O f the European countries, Russia and Italy are reported to be most severely affected by both animal and human anthrax. Well-enforced laws prescrib ing preventive vaccination of animals and complete destruction of carcasses have succeeded in making it comparatively rare in Eng land, Germany, France, and a few other European countries. In the United States, anthrax is frequent among animals in the lower Mississippi Valley, in the Gulf States, in the East (chiefly on the banks o f the Delaware R iver), and in some of the Western States. On the South American Continent it is prevalent in the less civ ilized districts of Argentina, and in Patagonia and Uruguay. The worst ravages o f the disease, however, are reported from Asiatic countries, mainly Siberia, Persia, Asia Minor, Tibet, China, and India, where physiographical conditions, deplorable ignorance, and utter indifference conspire to make the materials exported from those countries the most dangerous known to anthrax experts. 1 Charles E. Nammack : A Case of A n th ra x ; E xcision ; Recovery, in New York Medical Journal, 1897, vol. 66, p. 80. 2 E. O. Jordan: General Bacteriology, 1912, p. 217. AN TH RAX AS AN OCCUPATIONAL DISEASE. 13 CONDITIONS OF SOIL AND TEMPERATURE FAVORABLE TO THE DEVELOPMENT OF ANTHRAX. The frequency o f animal anthrax in certain countries is explained not only by the absence o f precautionary measures, the most urgent o f which are preventive vaccination, complete destruction of car casses, and rational disposal of waste products of manufacture, but also by conditions of soil and temperature. Anthrax is mainly observed on black, loose, humus soils, also on swampy land under which impervious strata are found. Outbreaks are frequent in places where spring inundations, which frequently wash over un buried carcasses, are followed by a dry hot summer. The moisture contained in these kinds of soil, and the organic matter always abun dant, furnish, if combined with favorable temperature, an excellent medium for the development of bacilli and spores when, after the inundation, the land dries, and the germs are either left in the ground or disseminated by the wind. MODES OF INFECTION. Most cases of animal anthrax are attributed to infection from fodder, either through grazing on fields where carcasses o f victims of the disease have been left, or through eating hay cut from such fields. Water from streams receiving discharges from establish ments using infected material, artificial manure, and imported food stuffs are also frequent causes.1 Transmission through blood-sucking insects has been experimentally demonstrated,2 but only rarely is the disease due to the entrance o f germs into the air passages, and seldom does it occur in animals through infection of wounds. Human beings contract the disease mainly through the handling o f infected animal materials, either when these materials are ob tained by them directly from animals or else when they are being transported or manipulated in industrial processes. Workers handling infected goods sometimes transmit the disease to members o f their families, either by means of clothing3 or through contact, while they themselves may escape. Bites of insects and even of pet animals which presumably had been feeding on diseased material have been known to convey the infection, and in some cases the eating of dis eased meat has been suspected. A certain number of cases are also due to the spores which have sometimes been found in shaving brushes. 1 In November, 1915, for instance, an anthrax outbreak occurred among the cattle of farmers owning grass lands along the Johns River, N. H., who fed their live stock hay cut from those lands. According to the State department of agriculture, the trouble seemed to arise from a tannery which emptied its waste into the river. A State veteri narian contracted the disease while making a post-mortem examination, but recovered. See also pp. 28 and 30. 2 M. B. M itzmain : Experimental Transmission of Anthrax, reprint No. 162 from the U. S. Public H ealth Reports. 3 The Journal of the American Medical Association for Apr. 26, 1918, for instance, contained an account of a woman in London who contracted anthrax presumably from the clothes of her husband, who was a laborer handling hides. APPEARANCE O F A N T H R A X BACILLI AND S P O R E S . (MAGNIFIED ABOUT 800 diameters). (magnified about 1200 diameters). C O M M O N APPEARANCE O F A N T H R A X O N T H E SKIN. FIG. 5.— LATER STAGE. A.HnensCn.Baltima™. C H A P T E R II. MEDICAL ASPECTS OF HUMAN ANTHRAX. SYM PTOM S. Human anthrax is caused by the entrance into the body of anthrax bacilli or spores, and by their rapid development and multiplication in the favorable media there encountered. In a majority o f cases in oculation takes place through a scratch or cut in the skin; in such case external anthrax results. This can be of two kinds, (1) malignant pustule, (2) malignant edema or erysipelatous anthrax. More rarely the germs are inhaled and infect the respiratory organs, or enter with food into the digestive tract; this is the origin of internal anthrax, with its two forms, (1) pulmonary and (2) gastrointestinal. Many exaggerated ideas o f the deadliness o f the disease have been current,1 but it is now known that the vast majority of cases end in recovery. Rebentisch2 describes the main symptoms o f malignant pustule as follow s: The disease begins with a red pimple o f the size of a pin’s head, formed at the point of inoculation. As there is hardly any pain, very little attention is paid by the patient to the disease in this stage. The pimple rapidly increases in size. It becomes sur rounded by a peculiar, resilient swelling, often o f considerable extent, the so-called anthrax edema. In the center of the pustule there is a black spot around which the skin rises in blisters, this black spot having given to the disease its French name of charbon. The ap pearance of the affected place is very characteristic and makes a last ing impression on anyone who sees it. On the third or fourth day the lymphatic glands in the vicinity of the pustule are usually swollen and painful. In cases where the pustule is situated in the front part of the neck, the inflammation may attack the larynx and thus endan ger the patient’s respiration. Pustules may appear on several parts of the patient’s body, but such cases are rare.3 Except for the local symptoms, slight cases are uneventful. Se rious attacks are marked by fever and by accelerated heart activity. In critical cases the patient complains of weakness and pain, and 1 An up-State New York paper in 1913 even went so far as to print the remarkable statement: “ So malignant is the disease that there is no known remedy for it, infection being invariably fatal.” 2 Gewerbliche Milzbranderkrankungen, in Zentralblatt fur Gewerbehygiene, May, 1913, pp. 202, 203. 8 See colored plate; also Plate 2, facing p. 18. Figs. 1 and 2 are from Associazione degli Industriali d’Italia per prevenire gli infortuni del lavoro: Istruzioni agli operai per prevenire il Carbonchio. Milano, 1909. Figs. 3, 4, and 5 are from Great Britain, Factory Inspector’s office, Form 410, March, 1908. 42806°— Bull. 205— 17------ 2 15 16 B U LLETIN OF THE BUREAU OF LABOR STATISTICS. delirium is not infrequent. I f the bacilli penetrate into the blood stream and are not quickly overcome, the condition of the patient becomes worse and the disease takes a fatal turn. The complete cycle o f the disease occupies on the average 9 or 10 days. Sometimes death occurs much sooner. In the other form of external anthrax, malignant edema, the pus tule is absent. The edema or swelling usually covers an extensive surface and is most frequently situated on the eyelid, neck, or fore arm. 44The local symptoms,” states Bell, 44are the extensive edema, in slight cases, without redness, vesication, or eschar; in severe cases, with redness, vesication, and a gangrenous appearance o f the skin. There may be no pain, no distress, and no fever. Even in fatal cases these are not very marked.” 1 This form o f the disease occurs much less frequently than the pustule. The internal varieties of anthrax are comparatively rare. The symptoms are not characteristic and can be easily mistaken for those of a number o f other infectious diseases; this makes diagnosis very difficult and causes frequent error. According to Nebolioubov, inter nal anthrax is often a 44surprise o f the autopsy ” ; it is also very pos sible that many cases escape diagnosis. Gastrointestinal anthrax, says Straus,2 44begins quite suddenly with general weakness, pains, and shivering; this is followed by digestive troubles, vomiting, colic, distention o f the stomach, diarrhea; the whole body is affected; there is difficulty in breathing, weak pulse, and cyanosis; death, most frequently in a state o f collapse, but excep tionally with tetanus-like convulsions, occurs in from two to five days after the appearance of the first symptoms.” Pulmonary anthrax, more frequent than the intestinal form of the malady, is also known as woolsorter’s disease. According to the authority just cited, one o f its first symptoms is 44extreme weakness, combined with headache and profuse perspiration; soon there appear constrictive pains in the chest, difficult breathing, and cyanosis; aus cultation reveals congestion and edema in the lungs; sometimes there is delirium; the patient dies in a collapse; the disease usually lasts from 4 to 8 days, but sometimes death comes more suddenly.” 3 TREATMENT. In the treatment of anthrax the resistance of the human body to bacterial infection is a factor of considerable importance. A number of physicians have tested the method of 44expectant treatment,” based only on the resistance of the body, and found it successful in both 1 Anthrax— Its Relation to the Wool Industry, John Henry Bell, in Dangerous Trades, by Thomas Oliver, London, 1902, p. 637. 2 I. Straus: Le Charbon des Animaux et de l’Homme, 1887, p. 203. 3 Idem, p. 207. AN TH RAX AS A N OCCUPATIONAL DISEASE. 17 local and general affections. The prevailing tendency among med ical men, however, has been toward more energetic therapeutic methods. The kinds of treatment now' most frequently used are extirpation, medicinal treatment, and serotherapy, either singly or in combina tion. Extirpation of the lesion by excision, when it is in an operable location, has been practiced since the eighteenth century. A vari ant o f this method is extirpation by cautery— either actual cautery with a hot iron,1 or cautery by means of phenol or some other corro sive acid. By some, however, including a number of very success ful practitioners, the method of extirpation, especially by excision, is at present held to be unreliable and dangerous. The excision, it is said, does not always remove all the infected tissue, while the knife in opening the vesicles may facilitate the entrance of the bacteria into the circulation and thus make conditions worse. For the medicinal treatment of anthrax, great -faith was at one time placed in such supposed remedies as oak bark, lemon juice, tobacco leaves, and roast onions, but these have now been discarded in favor o f more scientific applications.2 For instance, one experi enced American physician who in the last eight years has treated more than 42 cases affecting the cutaneous and cellular tissues thus describes his method: The part is thoroughly but gently washed with 1: 2,000 chloride o f mercury solution,3 dried well, then swabbed with 10 per cent tincture o f iodine and some alkali applied. This is repeated daily for several days until the slough has come away. It takes about two or three weeks for an ulcer to heal, which it does, with very little scar as compared with the tissues involved., No systemic treat ment is necessary other than cleaning out the bowels, though some require strychnine and alcoholic stimulants. I f the trachea becomes much involved, nothing will prevent death by suffocation. It has been my experience that if the vesicles are kept unruptured it is better for the patient. The fatal cases I have seen were those in which the vesicles had been ruptured.4 In some cases internal administration of certain antiseptics, chiefly iodine, is resorted to. These antiseptics can not be given in doses suf ficient to destroy the bacteria, but they are effective in impeding their multiplication. Tonics and stimulants such as quinine, alcohol, wine, A Successful treatment of an anthrax case by actual cautery was reported from Riverhead, N. Y., in the summer of 1916. The patient was a prosperous farmer. 2 A. N. Bell, one of the first American writers on anthrax, records a case in which “ a physician was called, who, thinking the disease to be erysipelas, ordered the applica tion of 24 leeches, to be followed by a poultice of cow manure.” (Malignant Pustule in the United States, 1862, p. 16.) 3 The danger attending the use of mercuric chloride in this manner is illustrated by an instance described'by Balderston. A physician called in to a case found the patient suffering from anthrax, and around the pustules a number of punctures made by a hypo dermic needle. On being asked what he had injected, the physician who first had the case in charge replied bichloride of mercury. “ He was not able to say exactly how much had been given, but the man died of bichloride poisoning.” (Journal American Leather Chemists’ Association, July, 1916, p. 341.) 4 John Palmer, jr., in Journal American Medical Association, Nov. 6 , 1915, p. 1670. 18 BULLETIN OF THE BUREAU OF LABOR STATISTICS. or coffee, as well as the inhalation of oxygen, are also reported to be beneficial. Serotherapy, the third modern method, is as yet hardly beyond the experimental stage, but it holds out important promise for the future. It consists of the injection, usually intravenously, of fluids from an immunized animal, containing germicides or having a neu tralizing effect on the germ’s secretions. Several kinds of serum have been tested and found more or less effective. Perhaps the greatest success is credited to the serum produced in 1895 by Prof. Sclavo, of Siena, Italy. A t first he experimented on ani mals, but in 1897 began to use his serum on human beings. After six years he collected the records of all cases in which his* serum had been applied, and found that, out o f 164 cases, only 10 had resulted fatally. This mortality rate of 6.1 per cent is very low as compared with that of 24.1 per cent which is the general rate re ported by Italian statistics. The value of this serum is recognized in Italy to such an extent that in some cities workers in tanneries and hair factories demand vaccination as soon as they notice a suspicious mark on their skin.1 Recently the manufacture of antianthrax serum has been undertaken by a well-known American firm, but even the American article is highly expensive, 80 to 100 cubic centimeters being required for the initial dose, at a cost of from $28 to $35. It is still too early to form a definite judgment of the value of serotherapy, but it is commended by a number of anthrax authorities, and its use is continually extending. It is, for instance, combined with excision when possible in the routine treatment for all cases o f anthrax admitted into certain prominent American hospitals and into the Bradford Infirmary in England. In other anthrax centers serum is given without practicing excision and with very successful results. No matter what mode o f treatment is adopted, prompt diagnosis and rest for the affected part are stressed by leading authorities. 1 J. Cavaiile: Le Charbon Professional, p. 112. A N T H R A X IN FECTIO N. PHOTOGRAPHS OF PATIENT. PLATE 1.— B E F O R E INFECTION. PLATE 2.— M O S T ACUTE STAGE OF INFECTION. PLATE 3.— S O R T I N G Chi ef l y imported UNWASHED HORSEHAIR. frorr ^ hi na, Russi a, and Sout h C H A P T E R H I. INDUSTRIES AFFECTED. AGRICULTURE AND OTHER INDUSTRIES INVOLVING DIRECT CONTACT WITH ANIMALS. Anthrax in man is, in the great majority of cases, of occupational origin. In a number of occupations anthrax is transmitted to the workers directly by animals. Farm laborers, shepherds, butchers, flayers, and veterinarians, for instance, contract the infection by coming in immediate contact with the diseased animals or with their carcasses. More numerous are the groups o f persons who handle, for the pur pose o f manufacture, materials derived from infected animals. Such materials are used in several very important industries, including the wool industry, the manufacture of leather and leather goods, work on bristles and hair, and making artificial manure. Protection of the workers is particularly difficult in the leather industry, since reliable and practicable means of disinfection, such as exist for hair and bristles, have not yet been conclusively worked out for hides and skins. LEATHER INDUSTRY. No country in which the leather industry has developed to any de gree of importance can depend entirely on its own supply of hides and skins. These products come in enormous quantities from less highly developed countries, where manufacturing is hardly known but where vast lands furnish favorable conditions for successful stock raising. In these regions sanitation is usually unknown or neglected, and clean materials are packed in the same bale with those which have been infected. Materials imported from China, India, and other Asiatic countries, and from some localities in A frica and South America, are considered particularly dangerous. The hides and skins are usually imported in a raw state. Before being used in manufacture they must be subjected to the process of tanning. Upon their arrival at the tannery the skins are sorted and then soaked. This soaking brings the “ dry ” hides to a moist flexible state, which is necessary for a more complete absorption of the tannin from the subsequent tan liquors. A ll kinds o f skins— “ dry,” “ wet salted,” and “ green” (fresh)— are cleansed, in the “ soak,” from earth, blood, and dirt adhering to them and from any 19 20 . B U LLETIN OF TH E BUREAU OF LABOR STATISTICS. preservatives with which they may previously have been treated. The “ soak ” may consist of fresh water or o f water to which anti septics have been added, the contents of the fluid, the time of ex posure, and the details of the process varying in different establish ments. This treatment, although it does not succeed in destroying the spores, nevertheless diminishes considerably the risk of anthrax infection, because it washes away the blood, dirt, and other sub stances containing spores. The next step is to remove the hair. For this purpose the materials are placed in pits containing a saturated solution o f slaked lime, where they remain for several days, accord ing to the class to which they belong. Even this prolonged lime bath, which is a powerful disinfectant for many purposes, is unable to kill the anthrax spores. As a result of the action of the lime the hair is easily removed with a special knife. Then, any adhering particles o f flesh are scraped o ff; the skins are 46delimed,” that is, the remains o f the lime are washed o ff; and this is followed by the steps immediately preceding tanning and by tanning itself.1 The incidence o f anthrax varies in the different processes. Rebentisch,2 as a result o f his own researches and those o f the German Leather Industry Accident Association, came to the conclusion that only a small number o f cases occurred among workers in the depart ments where dry skins were manipulated, whereas the majority of victims were engaged in the processes o f soaking and washing. Cavaille, from his study of the tawing works in the city o f St. Denis, France, reached a similar conclusion.3 American and British ex perience, however, seems to contradict this, the majority o f tannery cases in both these countries occurring in the early dry processes such as unloading, storing, and sorting. The various manufacturing processes, by additional cleaning o f the skins, still further reduce the danger of anthrax, but are not capable o f removing it completely. There is always the possibility of fin ished leather conveying the disease. In support o f this theory Constant Ponder gives the following evidence collected by him from various authors:4 (1) Shoemakers who have handled only leather have contracted anthrax; (2) horses have contracted anthrax on the flank where a new pair o f reins touched them; (3) it has been shown that the spore sometimes survives, unharmed, the processes of tanning. ANIMAL HAIR AND BRISTLE INDUSTRY* Another group o f industries where the danger of anthrax is pres ent is that involving the manipulation of animal hair and bristles. 1 See Plates 4 and 5. 2 Gewerbliche Milzbranderkrankungen, in Zentralblatt fur Gewerbehygiene, June, 1913, p. 249. 8 J. Cavaill6 : Le Charbon Professionnel, p. 132. 4 Constant Ponder: A Report to the Worshipful Company of Leather Sellers on the Incidence of Anthrax among Those Engaged in the Hide, Skin, and Leather Industries, with an Inquiry into Certain Measures Aiming at Its Prevention. London, 1911, p. 17. AN TH RAX AS AN OCCUPATIONAL DISEASE. 21 The hair is obtained from horses, asses, mules, and oxen; the bristles from hogs and wild boars. The hair is used for making haircloth, cords, gloves, and a number o f other articles, and for stuffing pillows, mattresses, chairs, and saddles. The manufacturing countries do not depend upon their own supply o f hair but import large quantities from China, Russia, South America, and other places, China supply ing more bristles than any other oriental country. O f all the vari eties o f hair, Russian horsehair is considered the most dangerous. The hair reaches the factory in large compressed bales weighing several hundred pounds. Upon the bales being opened the hair is sorted according to color, length, and strength.1 Then it is either shaken on a screen or combed. This process removes the dust from the hair and separates the long hair from the short. The former method is used in weaving, the latter in brush making. To make per manent the curl in hair used for stuffing pillows, mattresses, chairs, and saddles, the hair is steamed for 15 to 20 minutes under a pressure o f 1 to 2 atmospheres; other methods, such as exposure to dry heat under ordinary pressure, are also used for the purpose. After dyeing, if this takes place, the hair is rinsed, dried, and packed. Dyeing is a very welcome process as far as prevention o f anthrax is concerned, because the hair is left for several hours in a solution heated by the passage o f steam. The heat is never sufficient to destroy the ^erms, but the dirt is removed and probably the virulence of the spores is diminished; however, the hair is not often dyed. The early processes o f opening, sorting, and combing involve a greater degree of risk than the subsequent manipulation. This risk is increased by the filth and dust, both o f which are notorious carriers o f anthrax germs. Bristles upon their arrival at the factory are also sorted and sepa rated from the dirt and from all bulky foreign matter; to remove the finer particles of filth the bristles are arranged in layers, sprayed with water, and left for a time. This produces decomposition of the still adhering foreign substances, which are then easily carried away with steel combs. After that the bristles are rinsed in cold water, tied in packages, and dried. Frequently the better sorts of bristles arrive sorted and cleansed. As in the case o f hair, the first operations—unpacking, sorting, and combing— are more risky than the others, and the prevalence of anthrax among the workers en gaged in them has attracted considerable attention.2 WOOL INDUSTRY. The danger o f anthrax is also present to a very marked degree in the wool industry. W ool is obtained chiefly from goats, sheep, 1 See Plate 3, facing p. 19. 2 Two days after he injured his finger while at work in the factory of the New Haven Brush Co., its president, Elmer W . Griswold, died Dec. 24, 1916, of anthrax which the physicians believed was communicated to the wound from an infected bristle of a hairbrush. 22 BULLETIN OF THE BUREAU OF LABOR STATISTICS. and camels and is imported from some of the oriental countries, such as Asiatic Turkey, Arabia, Tibet, and Persia, also from Kussia and from some localities in South America and Australia. Like hair and bristles, it frequently reaches the factory in a filthy state. Upon opening, the wool is sorted according to color and quality, after which it is freed from dust in the willowing machines, and blended so as to obtain a uniform color in bulk. Then each sort is put several times in succession through an alkaline bath at 130° F. This re moves any remaining dust and dirt and dissolves the blood clots, which adhere to the wool with extreme tenacity and which, if from an animal which has suffered from anthrax, contain abundant spores. After rinsing and drying the wool is either-combed or carded, ac cording to the use for which it is designed. The processes in the wool industry, as in the industries previously described, vary in different establishments. Particularly dangerous are the early opera tions, since the dirt and dust are laden with germs; indeed, pulmo nary anthrax owes its special title, “ woolsorter’s disease,” to its appearance almost exclusively among workers in dusty wool proc esses. The liberation of the spores by the alkaline bath accounts for cases in the later processes of carding and combing. HORN AND BONE INDUSTRY. Among other imported animal materials utilized in industry, horns and bones are occasionally a source of infection. They are used in the manufacture of combs, buttons, knife handles, corset bones, and smoking pipes. During the breaking, cutting, and chipping, small sharp fragments are projected which wound the worker and in this way facilitate inoculation. TRANSPORTATION. The simple handling of infected goods during their transportation has also been shown to cause anthrax. Longshoremen, porters in warehouses, and other transportation workers frequently contract anthrax while loading or unloading infected materials. Sometimes anthrax is transmitted to these workers not through immediate con tact with animal products, but indirectly. Cases are known of laborers having become infected from cargoes o f com, wheat, and barley. Apparently the grain had come in contact with infected animal products or was stored in places where such merchandise was previously kept. Cases of anthrax also appear among workers in glue factories, rag-sorting works, felt factories, and establishments where fertilizers and artificial animal food are being prepared. The danger of in fection in these occupations is comparatively slight. AN TH RAX AS AN OCCUPATIONAL DISEASE. 23 NONOCCUPATIONAL ANTHRAX. Anthrax statistics also include many cases of persons between whose occupation and the disease no connection can be traced, such as children, housewives, persons without any occupation, schoolboys, teachers, and professional men. In 1915 and 1916 several widely scattered British cases of the disease, including one death, were definitely traced to shaving brushes, manufactured by one firm from bristles o f Chinese origin; a number of the suspected brushes were examined and found to contain anthrax spores which had survived the processes of manufacture.1 This possibility of unexpected at tack and the fatal consequences which may ensue, even despite energetic treatment, add greatly to the urgency of adequate measures for eradicating the menace. 1 Report of the County Medical Officer and School Medical Officer for the year 1915. London County Council, August, 1916, quoted in M o n t h l y R e v i e w of the U . S. Bureau of Labor Statistics, November, 1916, pp. 108-110. PLATE 4.— S E L E C T I N G RAW SKINS IN W A R E H O U S E O F K I D F A C T O R Y . PLATE 5.— D R Y I N G HAIR AFTER R E M O V A L F R O M SKINS IN A K I D FACTORY. C H A P T E R IV . ANTHRAX IN THE UNITED STATES. The record of anthrax in the United States forms an absorbing chapter in the annals of the country’s tardy but gradual movement toward the recognition and prevention of occupational 1disease. Practically all the industries in which anthrax occurs are to be found in this country, and cases have been known to medical men for the better part of a century. It is only in recent years, however, that industrial and community responsibility for the disease has been brought to the fore, and social activity for its control is still in the early stages. EARLY EXPERIENCE. Early American experience with anthrax is recorded only in occasional papers by medical men who came in contact with inter esting cases, and the story thus preserved is necessarily very incom plete. Perhaps the first human cases so recorded in the United States occurred in Philadelphia in 1834.1 An epizootic o f “ mur rain ” broke out among the cattle near that city and finally spread to the city itself, prevailing especially among cattle that fed on the common. Several persons who had been engaged in skinning animals that had died of murrain were affected with the malignant pustule. O f the three patients who were treated by the historian of the out break, one stated that “ while he was skinning a cow dead of murrain a mosquito bit him on the back of the hand. With the other hand, which was covered with the blood of the cow, he brushed away the mosquito and rubbed the itching bite.” In all three cases the infec tion was on the hand, and all ended in recovery. A fourth case occurred in the following year (1835). A milkman skinned a cow which had died o f murrain and carried the hide on his bare arm. Several days later he noticed a pustule on his arm, from which he eventually recovered. In all these cases the symptoms o f the malig nant pustule in man were well characterized. By 1835, also, large numbers of human cases had occurred in Lou isiana. Eight o f these were described by one physician,2 who traced 1 C. W. Pennock : On the Malignant Pustule; With Cases, in American Journal of Medi cal Science, Vol. X IX , November, 1836, pp.. 13-25. 2 William M. Carpenter : A Treatise on Malignant Pustule. Thesis submitted to the faculty of the Medical College of Louisiana, 1836; also Southern Medical Journal, Febru ary, 1839, pp. 257-274. 25 26 B U LLETIN OF THE BUREAU OF LABOR STATISTICS. the history o f malignant pustule in the region back to the time o f its settlement by the French and believed that the disease was first noticed in America among deer feeding on the salt marshes near the mouth o f the Mississippi River. Later it attacked the planters5 cattle, returning annually, and by the time he wrote it was prevalent in nearly every part o f the State, but “ seems not to have been even noticed in the medical annals of America.” During 1851 Louisiana was visited by an anthrax epidemic which was compared1 to that described in the first book of Homer’s Ilia d : On mules and dogs the infection first began, And last the vengeful arrows fixed on man. In several cases the disease was communicated to men by fly bites, and once by dressing the lesion of an infected mule. In Mississippi outbreaks o f anthrax among animals occurred at intervals after 1836, the losses o f cattle in 1865 and 1867 being particularly heavy. In New England anthrax seems not to have attracted attention until a later date than in the Southern States. In 1852 detailed accounts of six cases were published by a Salem (Mass.) physician,2 who stated that for some time previously he had seen a case every few years. He enumerated several occupations in which the disease occurred, but, in common with other physicians o f the period, he indicated little knowledge of its nature. Seven years later four cases in New York, three o f which terminated fatally, were described.3 An important addition to the literature on anthrax was made in 1862, in the report on “ Malignant pustule in the United States,” by A. N. Bell, a physician at the Brooklyn (N. Y .) City Hospital. In this work Bell summarizes several previous American publications on the subject and describes cases which occurred in his own prac tice. He states that when a fatal case of malignant pustule came up for discussion before the Kings County Medical Society in July, 1859, members declared the disease had existed in Brooklyn for only about four years. In December o f the same year three other cases were reported to the society. Bell himself saw several other cases, and heard of 10 more in Brooklyn and of several in New York. He also gave the names o f several physicians in the States of Maine, Massachusetts, Rhode Island, and New York who had treated cases of anthrax. Bell’s experience with the disease convinced him of the value o f early diagnosis, the importance of which has been proved by later authorities. “ O f all the diseases that man is heir to,” he states, “ there is none in which an early diagnosis is more im 1 James H. Baldridge: Malignant Pustule, in New Orleans Medical Journal, September, 1851, pp. 200-204. 2 A. L. Peirson: Malignant Tubercle, in Boston Medical and Surgical Journal, Aug. 25, 1852, pp. 75-78. 8 Buck, in New York Journal of Medicine, 1859. AN TH RAX AS A N OCCUPATIONAL DISEASE. 27 portant than in malignant pustule. It is indeed o f such moment that the lapse o f a few hours or a day may entail the most deplorable consequences.” Struck by the repeated occurrence o f anthrax in the vicinity of Walpole, Mass., a Massachusetts physician1 made careful inquiry and found that in 1853 there first appeared in the town a “ most singular disease, which was recognized by the attending physician as charbon, or malignant vesicle, a malady known from remote an tiquity as prevailing among animals, but observed among mankind only within a comparatively recent period.” The malady had been reported from that locality at irregular intervals until during a period o f 17 years 26 cases had come under observation. Twentyfour o f these cases occurred among hair workers, one victim was a carpenter employed in a hair factory, and the remaining case was that of the wife o f one o f the victims. The difficulties in the way of diagnosing anthrax and the conse quent underestimate o f the real number of cases were recognized at a comparatively early period. “ The transmission o f this disease to man,” said one practitioner in 1881, “ is far more frequent than is generally supposed. * * * Under the names o f black erysipe las, carbuncle, diphtheria, etc., many cases occur that are easily traceable to infection from animals. * * * In the last decade I have been personally cognizant of 13 cases, and four of these have occurred within the past two years in a town of 10,000 inhabitants and independently of factories working up hair or hides, which prove the most frequent sources of infection.” 2 The author con sidered the problem of sufficient moment to demand sanitary legis lation and “ the most rigid measures for the suppression of anthrax outbreaks.” The year 1892 is considered an important date in the history o f anthrax in Delaware, a State where outbreaks of the disease among both human beings and animals have been particularly fre quent. In that year, according to Dr. Charles F. Dawson of the Delaware College Agricultural Experiment Station, anthrax was “ officially recognized as existing in Delaware.” This date seems late as compared with 1834, the year of the epidemic, previously discussed, near Philadelphia, and 1836, the date of the earliest re ported outbreak in Mississippi. However, Dr. Dawson admits that “ while anthrax has been known to exist in the State only since 1892, it is highly probable that the first cases occurred much earlier 1 Arthur H. Nichols: On the Occurrence of Charbon, or Malignant Vesicle, in Massachu setts. Massachusetts Board of Health, Annual Report, 1872. 2 James Law : Glanders and Anthrax, in Cyclopedia of Practical Medicine (supp.), New York, 1881, p. 202. 28 B U LLETIN OF THE BUREAU OF LABOR STATISTICS. and that the disease is as old as the morocco industry.” 1 In the outbreak o f 1892, when the officials were admittedly “ inexperienced in the management of this disease,” several farmers contracted pus tules. Since that year outbreaks o f anthrax have been common in Delaware. “ Estimates made by veterinarians practicing in the State show from 175 to 200 farms in Delaware that are perma nently infected with anthrax. * * * The infected territory com prises about one-third o f the total area o f the State.” Information on the prevalence of anthrax in the southern and southwestern parts of the country is comparatively limited. In 1894 an epidemic o f anthrax was reported near Como, La., where live stock perished in large numbers and many people contracted the disease, in some instances with fatal results. In the same year a California medical m an2 stated that in Yentura County, Cal., alone, over 100 cases o f malignant pustule had occurred between the time of its first recognition and the date o f his article, and he suggested that some cases had escaped diagnosis. A remarkable case is recorded by Dr. W . P. McIntosh, o f the United States Marine Hospital Service, as having occurred at Boston. Eighteen months before falling ill the patient worked on a tramp steamer which carried hides from a South American port;' since that time he had been employed on ordinary seagoing vessels. “ The most probable exposure was at the time when the man was employed on the vessel transporting hides from South America. This, however, would presuppose that he had carried the infective agent about with him as part of his personal baggage for a period o f 18 months. This is not inconsistent with the life history o f the anthrax bacillus.” 3 The difficulties encountered by early physicians in the diagnosis of anthrax are well described by Nammack.4 One patient, a young fruit handler in New York City, felt a slight pricking or burning sensation in the right eyebrow and upper eyelid; on the following day the lid became swollen. A surgeon was consulted and ordered a lotion. Next morning the patient went to an eye clinic, where he was told that there was nothing wrong with his eye, but that he had cellulitis o f the lid ; he was referred to the surgical class and again given a lotion. A day later he called at Nammack’s office. The lid then presented the appearance o f phlegmonous cellulitis, and the doctor prescribed hot boric acid lotions and ordered him to return next day for incision. The next morning a messenger called to say 1 Bui. No. 90, Delaware College Agricultural Experiment Station, 1910. Anthrax, p. 17. The manufacture of morocco leather from imported goatskins was established on a small scale in Wilmington, Del., as early as 1840. 2 C. L. Bard, in Southern California Practitioner, 1894, p. 121. SW . P. McIntosh, in Medicine, 1897, Vol. I ll , pp. 459-461. * Charles E. Nammack : A Case of Anthrax; Excision; Recovery, in New York Medical Journal, 1897, Vol. L X VI, pp. 78-80. AN TH RAX AS A N OCCUPATIONAL DISEASE. 29 that the patient wasi delirious and that during the night a black pimple had developed on the eyelid. H e was immediately conveyed to a hospital where the area surrounding the “ charbon ” was excised, cauterized, swabbed out with pure carbolic acid, and then inoculated with cultures o f the bacillus pyocyanicus. Portions o f the excised tissue were sent to three laboratories and anthrax bacilli were re ported. “ Three observers had treated the case as one o f ordinary phlegmonous cellulitis.” The probable mode o f infection in this case was very unusual. In most of the cases which Nammack had previously seen the men had been handling hides. This patient was repacking fruit sent to a commission house. Some o f the fruit came from Spain in crates which were bound with strips o f rawhide. A s he cut these strips one would occasionally fly up and hit him in the face. I t is probable, says the writer, that in this way the skin was bruised and a way was opened for the entrance o f the microbe. D uring the closing five years o f the last century, accounts o f anthrax became very frequent. In 1896 the fatal case occurred o f a Philadel phia brush maker, who had been working on hogs’ bristles and horsehair imported from Siberia and from the southern part o f European Russia.1 T h e existence o f the disease was proved bacteriologically, T he next year five cases (fou r fa ta l) occurred among the opera tives o f a F alls Creek, P a., tannery. H ides imported from A sia and infected with anthrax were found to be the source o f contagion.2 The death o f a porter in a Boston leather warehouse was described in 1898.3 T his man had been carrying hides on his shoulders. One m orning while shaving he noticed a small “ pimple ” on his neck. H e continued his work on that and on the follow ing day, but was taken ill the day after and went to the hospital, where the pustule was excised; he died a day later. Smears from the vesicles surround ing the pustule showed abundant bacilli. Another fatal case o f a hide handler was reported the same year from New Orleans.4 T he patient had been employed in one o f the largest hide stores in the city. W h en he was brought to the hospital the two physicians who saw him concurred in diagnosing the disease as anthrax. Antistreptococcic serum was injected, but the patient died on the tenth day o f his illness. In his account o f the case D r. Dabney comments on the “ scant precautions which the dealers in hides and wool in this country take for the protection o f their em ployees against this disease.” Dabney, like several other writers, is 1 M. B. M iller: A Case of Anthrax, in Philadelphia Medical Journal, 1898, Vol. I, pp. 340-342. 2 Medical News, January, 1897. 8 Abner Post, in Medical and Surgical Reports of the Boston City Hospital, 1898, pp. 226-232. 4 T. S. Dabney: A Case of Anthrax (Charbon), in New Orleans Medical and Surgical Journal, 1898-99, Vol. LI, pp. 377-383. 30 BULLETIN OF THE BUREAU OF LABOR STATISTICS. convinced that many anthrax cases remain unrecognized. “ I can not believe,” he says, “ that m alignant pustule is as rare as our hos pital and board o f health reports would lead us to infer. A rather careful look through the incomplete reports o f the Charity H ospital from 1875 to 1897 fails to find a single case treated in that institu tion. * * * W e are forced to the conclusion that m any cases o f anthrax must have died in private practice as well as in our public institutions, under the diagnosis o f erysipelas, cellulitis, carbuncle (ord in ary), blood poisoning, etc.” An th rax, however, is by no means confined to the E ast and South. In W isconsin, which is an im portant tanning center as wall as an agricultural and stock-raising State, an epizootic o f anthrax oc curred during July and A ugust o f 1899 among the cattle in a certain district. N ot less than five persons contracted the disease through skinning anim als; in all these cases the pustules were on the exposed parts o f the body. Investigation by the health authorities led to the conclusion that the cases among animals were produced by drink ing water from a river into which the tannery waste was discharged and by grazing on meadows adjoining this river.1 In the same sum mer an outbreak o f anthrax occurred among tannery workers in another part o f the State. In a Philadelphia case2 in 1900 the patient was a “ card stopper ” in a large woolen m ill. T he illness began when he sustained a punctured wound on his forearm while at work. E ig h t days later he was admitted to the h ospital; the arm was dressed with a solu tion o f bichloride o f mercury, 1 to 10,000, and kept wet constantly. N ext day 1 dram o f 10 per cent carbolic acid was injected; on the day after, 1 dram o f pure carbolic acid was used. A similar injection was made daily during each o f the five follow ing days. A week after admission the patient was up. L e w a ld 3 describes a rapidly fatal case o f anthrax in a New Y o rk stevedore in 1902. The man had been unloading hides, and was admitted to the erysipelas pavilion o f Bellevue H ospital on M arch 1. Three days previously he had noticed a small pimple on his neck; 24 hours after that he was ill and unable to work. U p on his ad mission to the hospital he continued to grow worse and died on the follow ing day. “ A smear was made from the wound a few hours before death, and the examination made at the laboratory confirmed 1 In November, 1916, an anthrax outbreak occurred among the cattle of farmers own ing grass lands along the Johns River, N. H., who fed their live stock hay cut from these lands. According to the State department of agriculture, the trouble seemed to arise from a tannery which emptied its waste into the rivef. A State veterinarian contracted the disease - while making a post-mortem examination, but recovered. See also pp. 13 and 8 8 . 2 E. W. Fisher: A Case of Anthrax Successfully Treated by Local Injection of Pure Carbolic Acid, in Therapeutic Gazette, Detroit, 1900, 3s., Vol. X V I, pp. 508-510. 3 L. F. Lewald: A Case of Anthrax, in Proceedings of the New York Pathological Society, February and March, 1902, pp. 24-26. AN TH RAX AS AN OCCUPATIONAL DISEASE. 31 the diagnosis o f anthrax.” In the discussion on the case the opinion was expressed that anthrax is more frequent in New Y o rk City than was commonly supposed. “ W ith in the last three or four years, four or five cases have come into the dispensary o f the H u d son Street H ospital. Singularly good results have been obtained from early radical excision.” I n 1905 Drs. G . J. Schwartz and B . F . R ayer,1 both o f Philadel phia, described to the Academ y o f Surgery o f that city a case o f anthrax in a farmer, who contracted the illness through skinning a cow. In the pustule which form ed on the wrist anthrax bacilli were found. The pustule was excised and the patient recovered after an illness o f 35 days. In their report o f the case the authors make the follow ing comment on the lack o f serum: in this country: “ F rom data presented by Legge * * * and Sclavo, it would appear that the time had come when we in this country should have a supply o f anti anthrax serum kept by health boards or research laboratories, where it m ight be gotten in a few hours by those called upon to treat anthrax.” W h en the patient came to the hospital requests for serum were sent to two private laboratories, to the Marine H ospital Laboratory, and to the Bureau o f H ealth o f New Y ork , but no serum could be found.2 E a rly cases o f human anthrax were frequent also in several other States, including Texas. In that important stock-raising State out breaks among domestic animals occurred repeatedly, with conse quent infection o f human beings. A young woman, for instance, was bitten in the face by an insect while anthrax was raging among the cattle in the neighborhood.3 She died two days after admission to a hospital. Another Texas victim was a dairyman who contracted the internal form o f the disease from a cow and died on the eighteenth day.3 D uring the first decade o f the present century five States passed laws for the reporting of anthrax, among other infectious diseases. These States are Massachusetts and Illinois (190T ), Pennsylvania and California (1 9 0 9 ), and New Y ork (1 9 1 0 ). In Massachusetts be tween A ugust 1, 1907, and the end o f 1909 nine cases were reported, seven o f which occurred in L ynn, an important center o f the leather and shoe industry. The fatal cases recorded are somewhat more nu merous. Between 1865 and 1906, for example, a period o f 41 years, 128 deaths from anthrax were recorded in Massachusetts alone.4 The U nited States registration area in 1900, the first year fo r which deaths from anthrax were listed separately, included only 40.5 per cent o f the country’s population, and in 1909 had increased only enough to cover 56.1 per cent o f the population. Y e t, in this re 1 Transactions of Philadelphia Academy of Surgery, 1905, p. 76. 2 A few years later the Philadelphia Municipal Hospital and at least one progressive manufacturer began to keep Sclavo’s serum. 8 H. A. Barr : Report of Two Fatal Cases of Anthrax, in Texas Medical News, 19O5~-0, Vol. X V , pp. 277-281. *U. S. Public Health Reports, Dec. 15, 1916, p. 3399. 42806°— Bull. 205— 17------ 3 32 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. stricted area 227 fatal eases o f anthrax were recorded for the 10-year period. Deaths from this disease have steadily increased in number. RECENT EXPERIENCE. EXPERIENCE OF A LEADING MOROCCO-LEATHER CENTER. A Delaware city, for two generations the center o f the moroccoleather industry in this country, furnished a favorable opportunity io r a community study o f occupational anthrax. M ost o f the. im ported goatskins come dry in immense burlap-covered bales, weigh in g often more than 1,000 pounds each, from goat-eating countries, including China, In dia, A rabia, North A fric a , B razil and other parts o f South Am erica, M exico, Spain, Macedonia, and Russia.1 These untanned skins form erly came by steamer to New Y o rk , pre sumably under United States consular certificate to the effect that the foreign agents o f this Government “ have not required disinfec tion under quarantine regulations because the shippers have declared that anthrax, rinderpest, and foot-and-m outh disease do not prevail in the districts in which the skins originate.” 2 T h e usual practice has been to reship the skins, by smaller boats, from New Y o rk to Philadelphia and then again, sometimes by still smaller vessels, to the Delaware city. Cargoes are now frequently shipped by train from New Y ork , and recently the urgent demand has resulted in some railroad shipments direct from the Pacific coast. U pon arrival at the company’s warehouse the skins are unloaded, sorted, and hauled as needed to the factory, where they are dumped into tanks o f water to soak fo r 24 hours. W h en softened they are drawn out and churned in large drums which separate from the skins the most easily dislodged particles o f waste matter. N ext they are thrown into a second series o f vats and immersed for two weeks in a solution o f lime and arsenic or other agents which loosen the hair. These, the preliminary processes o f handling and pre paring the skins, menace the worker with the greatest danger o f infection because the anthrax bacilli and spores have not yet been re duced in number or virulence by the later tanning processes. On the contrary, each process preceding that o f lim ing is well adapted to cause the anthrax germ to flourish. A t other tanneries the especially dangerous prelim inary processes are similar to those just described, differing principally with the kind of skins or hides to be manufactured into leather. The tanners regard the danger as slight after the pelts have passed through the lim ing process. T h at the danger, though in diminished degree, con tinues through later processes is indicated by occasional outbreaks o f the infection among the beamers, fleshers, and splitters. The story is told of an engineer who came from another city to install a new 1 As a by-product one company yearly to be made into blankets infection to other establishments 2 Copied in April, 1916, from a sells in this country about $200,000 worth of goat hair or carpets according to grade. This spreads danger of and to other communities. consular certificate from Hankow, China. AN TH RAX AS AN OCCUPATIONAL DISEASE. 33 mechanical device in a Delaware morocco factory and who contracted anthrax when he bruised his hand while working among scraps of waste material on the floor beneath the old machine. But in this Delaware city, as among tanneries elsewhere considered in this report, most o f the cases of anthrax have occurred among the handlers and sorters o f imparted dry skins in the receiving warehouses. One physician in this morocco-leather center, who has in recent years been most frequently called upon by the manufacturers to treat victims o f the dread disease, furnished to the investigator the names and descriptions o f 48 cases o f human anthrax treated in his prac tice during the past six years. A l l but h alf a dozen, o f these were from the receiving warehouse o f one morocco-leather factory. T his physician reports that only three o f his cases resulted fatally.1 The infection in the m ajority o f cases was on the face or neck. In a few cases it was on the shoulder, arm, hand, abdomen, or thigh. One patient reinfected him self from the back o f his neck to his cheek. Another suffered two attacks, first on the neck and then, nine months later, on the arm. In no instance was the disease contracted from a previously existing case in a human subject. Other physicians interviewed gave meager accounts o f their anthrax experiences, speaking largely from memory, aided as to names and dates by their cash accounts with leather manufacturers. A ll referred to a local company physician, now several years de ceased, as having treated the greatest number of cases o f anthrax. According to his widow, who had acted as his drug clerk and was familiar with his practice for 20 years,, he often had as many as four or five such cases at a time. Local, hospitals, on the plea that they are “ not equipped,” refuse to receive anthrax patients, although a nurse in charge o f a private institution cared for two or three such patients several years ago, and one o f these, a serious case, is reported to have been sent to the hospital by a physician under the mistaken impression that the workman was suffering with erysipelas.2 One untrained woman told the investigator that she had nursed four cases, including her own son, in a room o f her boarding house, much to the consternation of the other lodgers, whose fear o f the disease made them reluctant to pass through the sick room on their way to their own bedchambers.3 1 For methods of treatment followed by this experienced physician and by others in the same city, see p. 17. 2 The refusal of hospitals to admit cases of anthrax seems not to be confined to Del aware. R. L. Moore, of Elkland, Pa., states: “ In one case which proved fatal the physician in charge was away, and a long automobile ride was necessary to reach the nearest hospital. On being refused admission there, the patient was taken on an all-night trip to the nearest physician who was acquainted with the disease. Although he was in fair condition, it was too late to save the patient.” (Journal American Leather Chemists’ Association, July, 1916, p. 342.) 8 The ghastly appearance of some of the anthrax patients, with heads swollen until their features practically disappear, is terrifying to their friends and leaves an impression not quickly forgotten. 34 BULLETIN OF THE BUREAU OF LABOR STATISTICS. T h is untrained nurse, whose personal dread o f the disease led her to don gloves and a mask, was o f the greatest assistance to the physician in bringing back to health these patients, one of whom suffered two attacks within a year. “ I ran the additional risk of losing m y boarders and lodgers,” said this woman, “ but the hospitals wouldn’t take anthrax patients. W h a t else could I do? ” Conversations with morocco workers’ families brought out the fact that fear o f this disease was common, and this fact probably in fluenced the State board of health in issuing strict orders, which went into effect A p r il 1, 1915, placing anthrax on the list of infectious diseases to be quarantined. The quarantine placards, printed by the State and posted by the city health officials, read as fo llo w s: This notice must be tacked on the front door. ANTHRAX. Until this notice is legally removed all persons not occupants of these premises are forbidden to enter, and no person must leave this house or re move any article except by permission of the health authorities. I t is also required that every house in which a case o f anthrax has occurred or exists shall be “ completely disinfected” upon the recovery, death, or removal from such house o f the patient. Q uar antine shall be continued for 14 days after disinfection. A t the work places precautions against infection from materials handled are not elaborate. A t only one warehouse was a warning notice found posted. I t was in two languages and read as fo llo w s : NOTICE TO EMPLOYEES. Use soap, water, flesh brush, and towels liber ally. Rinse your hands in bucket of disinfectant before drying on towels. Give special attention! to finger nails, always keep them short and clean. Do not scratch or pick any broken surface of the skin. Report to office any form of sickness, cuts, acci dents, bruises, pimples, or sores, for immediate at tention. See that dressing rooms, washbasins, and toilets are kept clean, and report to foreman any violation of above rules, for your own protection. Caution all new employees. Working gloves may be obtained at office. AN TH RAX AS AN4 OCCUPATIONAL DISEASE. 35 Universal was the testimony that the workers paid little or no attention to written or verbal warnings except as the foreman or superintendent with watchful eye detected an abrasion o f the skin or a suspicious looking “ pim ple ” and personally required the use o f a disinfectant. I t was commonly stated that in conform ity with the requirements o f the local health officials a supply o f bichloride o f mercury was constantly kept in readiness for disinfecting pur poses. A t three o f the warehouses visited, special inquiry was made for the disinfectant, and in two cases bottles o f bichloride of mercury tablets were shown at the office, once, however, with the bottle unopened and thickly covered with dust, while at the third warehouse the foreman, with some embarrassment and after a per functory search, remarked that he believed the tablets had been borrowed by the factory in the next block. In the same warehouse there was one sink with a single faucet and one piece o f soap for the ablutionary convenience o f the workmen, but it was admitted that no warm water was available even in winter. “ The men all wear gloves at their work,” said the foreman. Careful inspection h a lf an hour later, however, disclosed six out of eight skin sorters and truckers in a near-by corner working with hands unprotected. “ W e ll, they wear gloves in the winter,” was the forem an’s amend ment. V ery general was the opinion among physicians and laymen that hides and skins imported from districts where anthrax is prevalent should be disinfected before they are landed in this country. One official o f a tannery company, however, complained that the Federal Government, during the preceding week, had required them to dis infect 700 hides, at a cost o f $120, because the hides had come through without a consular certificate from the country o f ship ment to the effect that certain diseases, including anthrax, were not prevalent at the time. CASES REPORTED UNDER NEW YORK OCCUPATIONAL DISEASE REPORTING LAW. The New Y o rk occupational disease reporting la w 1 went into effect on September 1, 1911, and between that date and M arch 31, 1916, 23 cases o f anthrax, 13 o f which were fatal,2 were reported to the State department o f labor. N early twice as m any o f the total number o f cases (15 out o f 23) and three times as many o f the fatal cases (10 out o f 13) occurred in the last 12 months as during the entire preceding period o f 43 months since the law became opera tive. T h is increase is probably due in part to more active compliance o f physicians with the law, but as it coincides with large increases in 1 New York, Laws of 1911, ch. 258. 2 For detailed accounts of 12 of these cases which occurred prior to 1916, see pp. 60 to 78. 36 BULLETIN OF THE BUREAU OF LABOR STATISTICS. the number of cases treated by hospitals in other States, as will later be shown, there can be little doubt that it is, in the main, indicative of a real and startling growth in the prevalence o f the disease. E ig h t o f the cases were reported from New Y o rk City, including B roo k ly n ; four from Gloversville, the center o f the Am erican glove in d u stry; four from Endicott, where there are large tanneries and shoe shops; and one from each o f seven other cities and towns. Tw enty o f t h e ,patients were males, while three were females. H a lf o f them were between the ages o f 41 and 6 0 ; the youngest was a little girl o f 6 ; the oldest a retired lawyer o f 71. The occupational group most largely represented was the hide, skin, and leather workers, o f whom there were 10 (4 o f whom d ied ), including 6 employees o f hide tanneries, 3 workers on sheep skins, and 1 shoemaker. T h e shoemaker was employed in a large factory and m ay have contracted the disease from an infected hide in which the spores had survived the tanning processes.1 The workers on sheepskins are described, respectively, as 44 washer o f sheepskins,” 44trim m ing sheepskins,” and 44limer and general helper,” who had, however, just before infection, been “ helping store away raw sheepskins.” A m o n g the hide-tannery employees were one beam hand, two who apparently worked in a freight gang conveying green hides to one tannery only, two whose exact occupation was not stated, and— worthy o f special note— one steam fitter. A second occupa tional group was the transportation workers, represented b y three cases (two fa ta l). One was a dock laborer, one a baggage-master on a dock, and one a driver. There were three farm ers (two o f whom d ie d ), and one from each o f the follow ing ca llin g s: 44 Laborer in skin m ill— drying sheep wool,” spinner in rug m ill, veterinarian, candy packer, and la w y er; two were not engaged in industry. There were, therefore, at least seven persons, and possibly nine, who became in fected through the transportation and early treatment o f hides and skins before actual tanning was begun. The rug-m ill employee had a pustule on the thumb 46 follow ing scratch from piece o f tin on floor o f spinning ro o m ” ; anthrax bacilli were fcund. T he veterinarian was infected while vaccinating cows, suffering from anthrax, on three lip-State farms. One farm er, who died, is believed to have caught the disease from a sick cow which he slaughtered and dressed for beef.2 i See p. 20. 2 See fatal case No. 78, p. 71. 37 AN TH RAX AS AN OCCUPATIONAL DISEASE. CASES OF ANTHRAX REPORTED TO THE NEW YORK STATE DEPARTMENT OF LABOR UNDER THE OCCUPATIONAL DISEASE REPORTING LAW, SEPTEMBER, 1911, TO MARCH, 1916. September 1912 tober,Decem 1913 1914 1915 toJanuary March, Total. 1911. 1916. Occupation. Cases Cases Cases Cases Cases Cases re Fatal re Fatal re cases. Fatal Cases re Fatal re Fatal re Fatal re Fatal port port port port port port cases. cases. port cases. cases. cases. ed. ed. ed. ed. ed. ed. cases. ed. T able 1 .— Hiand de,leather skin, workers...... Tran sportation workers. Farmers........ Veterinarians Miscellaneous. Not in indus try............. Total... 1 1 1 1 2 1 1 1 3 1 1 1 4 1 2 2 2 2 12 1 2 1 2 2 1 2 2 9 3 1 4 10 1 1 4 331 4 2 2 2 2 23 3 13 None of the cases is specified as having been internal. Eight of the lesions were on the face, four on the neck, three on the hand, two on the arm, two on the chest, two on the hip, one on the leg, and one not stated. In eight cases anthrax bacilli were actually found, either in cultures from blood serum or by post-mortem examination o f the organs, and six of the cases in which bacilli were found resulted fatally. On two patients antianthrax serum was used; one of these recovered.1 The result o f applications filed in certain of these cases for indem nity under the New Y o rk workmen’s compensation law is taken up on p. 92. CASES REPORTED UNDER NEW JERSEY OCCUPATIONAL DISEASE REPORTING LAW. The law requiring the reporting o f occupational diseases in New Jersey 2 w^as passed a year later than the New Y o rk statute, the re sults o f which have just been described, and went into effect on July 4, 1912. T he State board o f health, to whom reports are to be sent, states that from that date to M ay 1, 1916, it received 13 certificates regarding cases of anthrax, all but one o f which arose in the city of Camden, the seat o f extensive leather, kid, and morocco works. The remaining patient was a feed merchant in a small town, whose infec tion, his physician thinks, may have been “ due to carrying bags o f feed on shoulder.” 1 In addition to the 23 cases here discussed, reports of human anthrax in New York State have been obtained from reliable sources, as follow s: 1911— New York City, assorter and packer of ready-made clothing, aged 30, treated at hospital; recovered. 1915— New York City, Government weigher handling hides, aged 34, died; New York City, medical student, aged 25, died; Saratoga Springs, farmer, contracted disease by performing autopsy on cow, outcome not learned. 1916— New York City, hide handler, employed by importer, aged 39, treated at hospital, recovered; New York City, fruit company employee, aged 16, died; Endicott, tannery laborer, handling dry hides, recovered; Utica, cattle dealer and butcher, outcome not learned. Further details of the two fatalities in 1915 will be found on pp. 75 and 78. 2 New Jersey, Laws of 191.2, ch. 351. 38 BULLETIN OF THE BUREAU OF LABOR STATISTICS. O n ly one o f the 13 cases was fatal— that o f a receiver and checker o f Russian horsehides. A ll the patients were men ranging from 21 to 55 years of age; 7, or more than h alf of the total number, were between the ages o f 21 and 30. Four o f the lesions were on the neck, two were on the face, and two were on the arm. “ Infected part resembled a typical vaccination, except black,” says the physi cian o f one o f these. In another case the form o f the disease is stated as external, but the location is not given ; in the remaining four cases the form is not stated, but since the patients recovered it was probably external in these also. In only one case is the finding o f anthrax bacilli reported; 100 c. c. o f antianthrax serum were used, and recovery followed. Three other patients who recovered were also treated with serum, one being given 10 c. c. and another “ about eight injections,” while the third “ had 20 injections o f antianthrax serum, 200 c. c.” The occupations are known for nine o f the patients in addition to the feed merchant, and all but one o f these were in contact with hides and skins. Three were engaged at the same leather works, one as a “ checker and receiver o f incoming horsehides” imported from Russia, one as a “ stock assorter, exam ining hides and skins,” and the third at “ assorting and handling hides.” O f three men employed in a single kid shop two are designated only as kid or morocco work ers, while one was a wool washer. A patient from another kid plant handled wet raw skins, while a stationary fireman in still another factory o f this class contracted the disease after acting for the “ last few months as sorter o f raw hides from Mexico and Central A m erica.” The ninth man o f this group was a teamster, and had helped load trucks with Russian sheepskin. Thus, at least six o f these men were infected by raw skins during their transportation to and receiving and sorting at the tanneries.1 CASES REPORTED UNDER PENNSYLVANIA INFECTIOUS DISEASE REPORTING LAW. In Pennsylvania under the infectious disease reporting law 49 cases o f anthrax were reported in the three years between January 1, 1913, and January 1 ,1 9 1 6 . E igh t o f the sufferers, including two hair sorters and a tannery hand, were females. Nearly one-half o f the cases, or 23, occurred in 1913, and 10 o f these were in the city o f Philadelphia, one of the centers of the glazed-kid industry. A ll o f the six cases reported in the first h a lf o f 1914 also came from P h ila delphia, thus m aking for that city a total o f 16 cases in 18 months. 1 Additional anthrax cases reported to the New Jersey department of health under the preventable disease notification law (Laws of 1911, ch. 381) are: 1912— Camden, occu pation not given, recovered; Camden, handler of imported hides, recovered; place and occupation not given, recovered; place and occupation not given, died. 1914— Cam den, occupation not given, recovered; two cases, place and occupation not given, died. 1915— Two cases, place and occupation not given, died. Record has also been secured of a tannery worker who recovered under serum treatment at a Newark hospital early in 1916. AN TH RAX AS AN OCCUPATIONAL DISEASE. 39 H ere, as in the two States whose experience with anthrax under occupational disease reporting laws has been described, the occu pational group most largely represented is hide and skin workers. F ive were given as tannery employees, two as leather workers, one as a raw hide sorter, and one as a skin washer. M ost o f the 12 classed as laborers were also, it is reported, employed by tanneries. There were eight hair workers, o f whom one was a haircloth examiner, two were sorters, and one a brush m aker; a ninth case is given as 44a car builder who m ight be included as a hair worker.” There were two longshoremen, and one from each o f the follow ing callings: W o o l handler, “ raw stock ” inspector (without designation o f the kind o f stock), liveryman, teamster, merchant, carpenter, and roofer. T w o were infants 1 year and 10 months old, respectively, the father o f one being a tanner and of the other a coal miner. In eight cases the occupation is not stated. A t least 7 o f the 27 cases reported during the first 18 months are known to have been fatal, and are discussed more in detail in the section on anthrax fatalities reported in the United States registra tion area. A number o f the nonf atal cases were treated in a Philadel phia hospital and are considered, together with other cases at the same hospital, in the next section. CASES ON RECORD IN A PHILADELPHIA HOSPITAL. One Philadelphia contagious-disease hospital reports a total o f 32 cases (6 fatal) from January 1, 1909, to A p r il 30, 1916. The great m ajority o f the patients in these cases were men, only three— a hair sorter, a hair twister, and one other hair worker— being w om en; all o f the six deaths occurred among men. T he patients were all residents o f Philadelphia. T heir prevailing age was markedly lower than that o f the cases reported in New Y o rk State, 12 o f them being between the ages o f 31 and 40, and 10 between 21 and 3 0 ; the youngest was a woman hair sorter aged 19, and the oldest a haircloth inspector o f 67. The distribution o f these cases by years and by occupations was as fo llo w s: .—CASES OF ANTHRAX RECORDED BY A PHILADELPHIA HOSPITAL, JAN. 1, 1909, TO APR. 30, 1916. 1 1913 1914 1915 toJan. Apr. 1909 to 1911 1912 191630, Total. Occupation. Cases Cases Cases Cases Cases Cases re cases. Fatal Cases re Fatal re Fatal re Fatal re Fatal re Fatal re Fatal port cases. port port cases. port cases. port port cases. cases. port ed. ed. ed. ed. ed. ed. ed. cases. Hide and 2 1 1 10 3 1 1 3 3 1 skinand workers Wool hair 3 1 2 3 2 17 3 4 5 workers...... 1 2 Longshoremen 11 1 2 Miscellaneous. Onot c c ureported. pation 1 1 4 Total... 8 7 1 6 1 4 1 3 3 32 6 T able 2 40 BU LLETIN OF THE BUREAU OF LABOR STATISTICS. I t w ill be noticed that the rate o f one case per month with which 1916 began is nearly double the next highest rate, that for 1912, during which year seven cases were recorded. The increase in fatal cases is still more striking, as many having occurred in the first four months o f 1916 as in all the preceding seven years.1 T he largest number o f patients were workers in wool or hair, due no doubt to the local prominence o f this industry. Seventeen, three o f whom died, were in this group, which covered a particularly wide range of processes. Thus there were four hair sorters,2 one wool sorter, one hair picker, one hair twister, three hair spinners, one wool teamster, and four laborers in wool or hair plants (duties not differ entiated) ; even men comparatively remote from danger contracted the infection, as witness a haircloth-loom fixer and a haircloth in spector. One o f the hair sorters worked in a horsehair fa cto ry ; the hair picker and at least one o f the hair spinners were employed in a single curled-hair plant. T he group next most largely repre sented is that o f the hide and skin workers, o f whom there were 10 (three o f whom d ied ). One was a hide sorter, one a hide washer, and one a sorter o f raw stock in a glazed-kid factory, while the precise process carried on by seven tannery workers is not given. T w o sufferers from the disease were longshoremen, and in both cases the hospital records state that fo r some days previous to the attack the men had been unloading hides. O f the two classified in the table as “ miscellaneous,” one was a shoddy worker who m ay easily have contracted anthrax from the dirty rags he h an d led ; the other was a glue-factory hand who m ay have got it from hoofs or other parts o f a diseased animal, although the hospital record further states that he “ occasionally handled leather.” In only one case among this valuable set o f records is the occupation not stated. Throughout, the connection between occupation and contagion is much closer than in the New Y o rk series. In all o f the cases recorded by this hospital the disease took the external form . T he pustule occurred in 19 cases on the face and in 10 cases the neck, the six deaths being distributed equally between these two groups. Three lesions were on the arm, and one on the h an d ; one case is noted— that o f a girl hair sorter— in which lesions ap peared both “ on jaw and wrist.” Due to the care with which these records were kept, valuable data regarding the duration o f anthrax attacks are available. The six cases with the shortest duration— ranging from three to eight days 1 O n Apr. 11, 1916, Chief Medical Inspector Cairns, of Philadelphia, stated that from 10 to 12 cases of anthrax developed in Philadelphia annually and that “ already, in 1916, four deaths have resulted from the malady.” 2 One of these, who contracted the disease in 1916, filed a claim for compensation, which was denied on the ground that infection had not taken place through a “ wound or other unusual incident.” (See p. 92.) A N TH RAX AS A N OCCUPATIONAL DISEASE. 41 after appearance of the first symptoms—were all fatal, and these were the only cases which so resulted. The next shortest case termi nated in recovery and discharge from the hospital on the seventeenth day o f the disease. The most protracted illness lasted for 51 days. The duration o f illness and number o f cases of death were as follow s: T a b l e 3 . — D U R A T IO N OF IL L N E S S , A N D D E A T H S A M ON G 32 CASES OF A N T H R A X IN A P H IL A D E L P H IA H O S P IT A L . Duration of illness. Under 1 w eek.................................................. 1 week and under 2 weeks.......................... 2 and under 3 weeks.................................... 3 and under 4 weeks.................................... 4 and under 5 weeks...................................... 5 and under 6 weeks...................... 6 and under 7 weeks................................. Over 7 weeks................................................. T otal...................................... Cases. Deaths. 5 5 1 1 5 8 4 5 3 1 32 6 In the overwhelming majority of cases, 22 out of 32, treatment was by excision and serum; of these, three died. In five cases ex cision alone was performed, and two deaths resulted. One man was brought to the hospital moribund and neither method was applied; he died eight hours later. In four cases the mode of treatment was not reported.1 CASES ON RECORD IN A MASSACHUSETTS HOSPITAL. The records of one Massachusetts hospital show 35 cases of an thrax between June 27, 1881, and April 26, 1916. O f these 6 were fatal, 26 were nonfatal, and 3 patients were still in the wards at the time of the investigation. The recent increase in prevalence revealed by the New York and Pennsylvania reporting laws is here paralleled. The number admitted during the first three months and 26 days of 1916 (9 out of the 35) is thrice that admitted in 1915, and equals the number treated during the whole period 1881-1904, inclusive.2 The largest number of cases from single cities came from Boston (5), Woburn (5), and Winchester (4) ; five other towns in the vicinity of Boston sent 2 cases each, and 11 towns 1 case each. Only 1 of the 35 patients was a woman. Fifteen were 1 The numerous instances of death from anthrax in Philadelphia was one of the rea sons given for the establishment during the summer of 1916 of the clinic for occupational diseases at the University of Pennsylvania Hospital in that city. 2 The total number of cases reported in the State during the first half of 1916 was 25. “ This was the severest outbreak of this disease ever recorded in Massachusetts.” Twenty oi: the cases occurred in three tanneries and were traced to* a common source, a single cargo of dried “ China ” hides from infected territory. (United States Public Health Reports, Dec. 15, 1916, p. 3401.) 42 BULLETIN OF THE BUREAU OF LABOR STATISTICS. between the ages of 21 and 30, 15 were between 31 and 5U, 2 were between 61 and 70, and the remaining 3 were between 11 and 20 years of age. Hide and skin workers made up nearly half of the total number o f patients— 16 out of 35. Thirteen o f these were tannery workers, one was a morocco worker, one a leather worker, and one a “ laborer handling raw hides.” The “ leather worker ” was in charge of men cutting fresh hides. O f the tannery employees two were “ beamers,” who scraped hides and put them through rollers; two split hides; two others took hides from the soaking pits; three of these six were re ported as handling wet hides. One man handled hides as a teamster for a tannery, one was a flesher, one is designated merely as “ la borer” in a tannery; one was engaged on sheep and goat skins; in the three remaining cases no information was given beyond the word “ tanner.” Transportation workers were represented by nine cases, two fatal. Four were dock laborers; two were freight handlers, one o f whom handled raw hides and w ool; two were weighers of skins and hides; and one was a teamster. Five patients were employed in the wool and hair industry. Two were employed in a wool factory, one of them as a carder; in the other case the infection was so serious that it necessitated amputation of the arm at the shoulder. One was an upholsterer’s helper and handled wool used for stuffing. Two days before coming to the hospital he cut his neck while shaving; infection developed on neck and chest, and four days later “ patient looked as if he weighed over 200 pounds.” One was a teamster cart ing wool, and one was employed in a hair factory. In addition to these workers, whose employment bears a welldefined relation to the disease, two patients were designated merely as laborers. One o f these, however, was employed in a soap factory. Three weeks before he was admitted to the hospital, it is reported, a box of skins was sent by mistake to the factory, where it was opened and a skin was kicked about by a fellow workman, striking the patient in the back of the neck. E-ag workers, factory girls, and machinists were also represented by one case, each. 43 AN TH RAX AS AN OCCUPATIONAL DISEASE. T a b l e 4 . — CASES O F A N T H R A X A D M IT T E D TO A M A SSA CH U SETTS H O S P IT A L , JU NE 27, 1881, TO A P R . 26, 1916, B Y O C C U P A T IO N S. June 27,1881, to Dec. 31, 1911 1912 1913 1914 Jan. 1 to Apr. 26, 1916 1915 Total. Occupation. Cases Cases Cases Cases Cases Cases Cases re Fatal re Fatal re Fatal re Fatal re Fatal re Fatal re Fatal port cases. port cases. port cases. port cases. port cases. port cases. port cases. ed. ed. ed. ed. ed. ed. ed. H ide and skin workers W ool and hair workers........ T ra n sp orta tion workers Miscellaneous. T otal. 5 2 3 1 4 5 1 2 17 4 2 1 1 2 3 1 7 10 1 2 1 3 1 1 5 1 2 1 5 9 2 2 9 1 35 6 The duration of illness was short in the 6 fatal cases. One such case lasted 3 days and another 5 days; 3 patients died after an illness o f 7 days each and 1 after 8 days. The shortest of the nonfatal cases lasted 10 days; in another the patient was ill 13 days; 6 lasted be tween 14 and 21 days; in 9*cases the duration was 21 days but under 28; 8 persons were ill 28 days or more. O f those remaining, 1 was an out-patient and 3 were still in the hospital wards at the time of investigation. The situation of the pustule is given in all but one fatal case, which, according to the symptoms, was probably internal. In a majority o f cases (20 out of 35) the lesion was on the neck, 9 lesions were on the face, and 5 were on the arm or hand. In 18 of the total number of cases and in 5 of the 6 which ended fatally, examination disclosed anthrax bacilli.1 CASES REPORTED BY TANN ERS AND LEATH ER M ANUFACTURERS. In the course of preparing this report the Bureau of Labor Sta tistics sent about 1,400 circular letters in regard to anthrax to tanners and leather manufacturers. To these, 592 replies were received. Nineteen establishments reported 70 cases of anthrax within the last two or three years, 6 of these cases being fatal.2 While these cases probably duplicate to some extent the cases else where discussed in the report, it is convenient to present them to gether. 1 For additional records of Massachusetts cases, see pp. 26, 27, 28, and 89-91. 2 At the same time, 1,600 similar inquiries were sent to wool dealers and wool manufac turers, but elicited a report of only one case, that of a Boston laborer trucking wool, who recovered under hospital treatment. 44 T BULLETIN OF THE BUREAU OF LABOR STATISTICS. able 5 .— A N T H R A X Location. Maine: Island F a lls. . Massachusetts: North W oburn. N orw ood . W ob u rn .. Michigan: C heboygan. CASES R E P O R T E D B Y N IN E T E E N T A N N IN G M A N U F A C T U R IN G E S T A B L IS H M E N T S . Firm. Occupation of victim . Treatment. Result. No. 1 .. Sweater in tannery. A t hom e—local p h y sician. Full recov ery. Tanner......... A t Massachusetts Gen ........d o ........... eral Hospital. Flesher......... A t h om e........................ .d o . .d o . Beam-house A t Massachusetts Gen hand. eral Hospital. N o. 3 .. N o informa Local physician........... ........d o ........... tion. No. 4 .. Beamster___ A t Massachusetts Gen R ecovery e x eral Hospital. pected. No. 5 .. 2 cases; oc ____d o ............................. Full recov ery. cupations not given. . . d o ......... 1 case........... A t h om e........................ No. 6 .. 5 cases; oc Some b y local p h y . .d o ......... sicians, and others cupations not given. at hospitals. No. 2 .. No. 7 .. 3 -yea r - old d a u g h ter o beamhouse em ployee. Beam ster. . . Antianthrax serum; ........d o ......... tincture iodine in jected hypoderm ic ally around area of infection. Antianthrax serum Full recov and early excision of ery (32 prim ary lesion. days). Sores washed w ith car Full recov bolic acid and io ery. dine; face and neck washed with iodine, vitriol ? and cam phor oil; gauze pack saturated with boric acid and epsom salts (hot water) applied to face for 5 days; ice-cold baths when fever over 103°. Munising. No. 8. B eam ster. . . N ew Hampshire: W hitefield___ N o. 9 .. -----d o .......... Hospital treatm ent__ ........d o . ___ d o ......... . ____d o ............................. ..d o . ___ d o ......... . ..d o . New Jersey: Cam den. N o. 10. ........d o ......... R aw - stock d ep a rt ment; dry horsehides .d o . .d o. Newark. A t hom e, b y com pany physician. Diagnosed as anthrax too late to be treated for same. Fatal. Antianthrax serum; in Full recov jecting 20 c. c. every e r y ^ weeks 4 to 6 hours; high fre 4 days). quency electricity and fulguration used over primary lesion; lachisis used inter nally. LEATH ER Precautions now taken. None. H ave discontinued use o f China hides. N o information. D aily exam ination of all em ployees. Use solution recom m ended b y State in spectors; stoppedtanning dry China hides. Carbolacitin used as wash b y m en, and in soak pits. China hides put into corrosive sublimate solution; employees wear wet sponges over m outh and nos trils when unloading these hides. Carbolic-acid wash kept on hand for use on cuts, etc. Disinfect hides in solu tion of bichloride of m ercury and com mon salt. Antianthrax serum; solution of bichloride of m ercury on hand for use b y employees. Breaks in skin of em ployees in raw-stock department cauter ized b y factory d o c tor. .d o. Full recov ery (5 weeks 2 days). Antianthrax serum ___ N o informa tion. No. 12. 3 or 4 cases in raw - skin d ep a rt ment or in beam house. No. 13 B e a m s t e r A t Newark City Hos engaged in pital. trim ming hides. ........d o ____ AND Full recov ery. Doctor in attendance every m orning for treatment of minor accidents. Rubber gloves. 45 ANTHRAX AS AN OCCUPATIONAL DISEASE. T a b le 5.—A N T H R A X CASES REPO RTE D B Y NINETEEN"* TANNING AND L E A T H E R , MANUFACTURING ESTABLISHMENTS—Concluded. Location. Firm. Occupation of victim. New Y ork: Endicott......... Treatment. No. 14. U nloadin g At Johnson City Hos hides. pital. Repairman.. At Mead's Hospital, Endicott, N .Y . H a n d l i n g .......do........................... hides. Beamster__ .......do........................... U nloadin g .......do........................... hides. Gloversville. . . No. 15. Beamster___ At home...................... Pennsylvania: Corry............... Result. Fatal Full recov ery. .......d o .......... ....... d o.......... ....... d o.......... Precautions now taken Hides whitewashed at shipping point; bales c o n t a i n in g hides whitewashed; hides soaked in solution of mercury at tannery. .......d o.......... Gloves to employees in beam house. No. 16. Raw - skin ___ d o ........................... ....... d o .......... Raw material naphthalened; solution of trimmer. weak lime liquor for Bagging hair .. ..d o .......................... Fatal........... washing hands. from raw material. No. 17. 2 cases; occu pation not given. Elkland........... No. 18. H a n d lin g hides in beam house. ....... d o .......... Various tanneries.. No. 19. 27 cases; occ u p ation not given. 3 cases; occ u p ation not given. At hospitals................. Full recov ery. Antiseptic solution for washing hands. At home...................... ....... d o .......... Antianthrax serum on hand. ....... d o .......................... ....... d o .......... Not given.................... ....... d o .......... Immediate care of all wounds; inquiry as to cause of illness if d o ______________ Fatal_______ absent. O f the 70 cases here reported, in 41, or more than half, no infor mation as to occupation is given. O f the remaining 29 victims, the majority (16) were beamsters or beam-house workers, while only 6 are reported to have been working on dry hides. This is apparently a reversal of the ordinary tannery situation, but may be partially accounted for by the unusually large proportion of cases in which the occupation is not given. Other workers affected were a sweater, a flesher, a raw-skin trimmer, one engaged in bagging hair from raw material, and a repair man. Particularly striking is the case of the 3-year old daughter of a beam-house employee, to whom the bacillus was probably carried on her father’s clothing. Information with regard to sanitary precautions, given by the 19 tanneries and leather plants which reported cases, is unusually full. Prophylactic measures ranged from the mere furnishing of a disin fecting wash for the men to daily examination of all employees and even discontinuance of the use of the more dangerous materials. In addition to these 19 plants, 54 which reported no cases indicated that they took precautions as follow s: Instruction to employees of danger__________________________ Immediate treatment of wounds_____________________________ Furnishing of gloves______,___________________________________ 10 21 23 46 BULLETIN OF THE BUREAU OF LABOB STATISTICS. Furnishing of respirators. Employ physician Employ nurse Disinfect hides before handling. 2 1 2 16 During the summer of 1916 the National Tanners’ Association took up the question of more thoroughly disinfecting their plants to guard against contagion from imported hides. Upon applying to the Bureau of Animal Industry for suggestions as to how to proceed with the work, the tannery owners were advised that “ next to fire, bichloride of mercury appears to be the most efficient agent in the sterilization of the anthrax spore.” The bureau therefore recommended that all parts of the premises be thoroughly sprayed with a 1 to 1,000 bichloride of mercury solution, then scraped and swept (the debris being carefully burned), next scrubbed with the same solution, and finally given another spraying with it, which should be allowed to dry in. Special warning was issued against continuous wetting of the hands or clothes with the solution, in order to avoid mercurial poisoning.2 FATAL CASES REPORTED IN REGISTRATION AREA OF THE UNITED STATES, 1910 TO 1915. During the six years from January 1, 1910, to December 31, 1915, no fewer than 132 deaths from anthrax were officially reported in the United States registration area, which covers less than two-thirds of the total population of the country.8 Were comparable informa tion available for the entire country there is no doubt that this total would be considerably augmented. In Texas, for instance, during the years 1912 to 1915 there were reported to the State board of health four deaths, none of which appears in the United States list 1 Of the 742 w ool dealers or w ool m anufacturers who replied to the circular letters previously mentioned, the replies o f eight indicated that precautions were taken to prevent anthrax. T w o establishments reported cautioning their employees to give immediate treat ment to cuts and scratches, besides using exhaust fans to carry off the d u s t ; one m ill posted notices w arning employees not to neglect w o u n d s; fou r concerns used exhaust f a n s ; and one m anufacturer o f w ool yarns stated that he disinfected hides before handling. 2 F or fu ll text o f the bureau’s com m unication, see Journal o f the Am erican Leather Chemists’ A ssociation, September, 1916, pp. 510, 511. 3 The registration area in 1913 included 24 States— California, Colorado, Connecticut, Indiana, Kentucky, Maine, M aryland, M assachusetts, M ichigan, M innesota, M ississippi, M ontana, New, Hampshire, New Jersey, New York, North Carolina (cities which had 1,000 or more inhabitants in 19 00), Ohio, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, W ashington, and W is co n sin ; and 41 additional cities— Birmingham , Mobile, and M ontgomery, A l a .; W ilm ington, D e l.; Jacksonville, Key W est, and Pensacola, F la .; A tlanta, Augusta, and Savannah, G a .; A urora, Belleville, Chicago, Decatur, Evanston, Jacksonville, Quincy, and Springfield, 111.; A tchison, Coffeyville, F ort Scott, Hutchinson, Independence, Kansas City, Lawrence, Leavenworth, Parsons, Pittsburg, Topeka, and W itchita, K a n s .; New Orleans, L a .; L incoln and Omaha, N eb r.; Portland, Oreg. ; Charles ton, S. C . ; Memphis and Nashville, T e n n .; E l Paso, Galveston, and San Antonio, T e x .; and W heeling, W. Va. The population covered at that date was 63,298,718, or 65.1 per cent o f the total. AN TH RAX AS AN OCCUPATIONAL DISEASE. 47 o f 132, presumably because they occurred in outlying districts not in cluded in the registration area. Although 12 Kansas cities are so included, a farmer reported to the State board of health as having died o f anthrax in 1915 is not among the cases known to the Census Bureau. Similarly a certificate of death from the pulmonary form of the disease filed with the Iowa health department did not get into the Federal statistics because Iowa is entirely outside the registration area. Since the close of 1915, also, at least 23 deaths from anthrax are already known to have occurred.1 In 15 out of the 23 cases the probable source o f the disease can be traced through the occupa tion or other facts given. Six of the persons worked with skins, hides, or hair, two handled cargoes, and one was a teamster in a seaport town where infected materials are known to have been re ceived. Three were farmers, one a “ sheepman,” and the death certificate of one, having no occupation, stated that she was infected from a sick cow. A Kansas child was apparently infected by a cat which, it is reported, had the disease. In the absence of specific information as to occupation or surroundings, the cause of the dis ease can not be traced in the cases o f five “ laborers,” a “ foreman in mill,” a “ housewife,” and a boy without stated occupation. This information is, however, scattering and incomplete, and while several o f these cases are discussed, as indicated, in the sections o f this report dealing with their respective localities, it has been thought best to confine this section of the study to those fatalities officially reported to the United States Bureau of the Census for the six years specified. Distribution by Industry, Place of Death, Etc. O f the 132 persons reported as dying of anthrax during this sixyear period, 27 were designated on the official death certificates merely as “ laborers,” a very unsatisfactory classification; 6 others were designated as “ laborer, clay,” “ laborer, paper mill,” “ laborer in tannery,” “ laborer, morocco works,” “ laborer, freight yard,” and “ laborer, longshore ” ; 12 as housewives or housekeepers; 9 as farm ers; 7 as morocco workers; 3 as stevedores or longshoremen; 2 as liverymen; 2 as barbers; 2 as carpenters; 2 as tailors; 2 as young single women “ at home,” and 2 as “ at school.” The following desig nations occur once each: Handling dry hides, paper-mill hand, tan nery worker, leather worker, stationary engineer in morocco works, mixing hair, hair-cloth maker, bristle comber, mill hand in carpet factory, freight agent, freight handler, weigher, ranch foreman, farm hand, veterinary surgeon, hairdresser, merchant, baker, cake baker, candy packer, cigar maker, retired cigar maker, chair maker, painter, molder, printer, mechanic, foreman, electrical supply sales 1 See footnote, p 55. 42806°—-Bull. 205— 17------ 4. 48 BULLETIN O F THE BUREAU OF LABOR STATISTICS. man, domestic, retired pilot, retired farmer, musician, lawyer, drug gist, physician, medical student, and undertaker. Eight of the de ceased were reported to have had no occupation, and in 10 cases no information on this point was given. Other data on the certificates, however, show that of these last 18 persons, one was a little girl aged 6 and five were infants of 1 year or younger. In a few cases in which the statement o f occupation given on the official death blank did not agree with more precise information subsequently obtained from other sources the real occupation was without significance as regards causation of the disease. Thus one woman who was reported as a cigar maker had left the bench at the time o f her marriage, 30 years before she died. One woman who was stated to have no occupation was acting as a housekeeper and nurse, and another was a teacher. A man reported as a lawyer had retired and had no active occupation except caring for his own country home. On the other hand, in other cases investigation brought out occu pational information o f great significance. Thus, the man reported as a weigher wTas employed by the Federal Government in the cus toms service and had been weighing hides and skins from South America. The one reported as freight handler worked on the wharves and was really a longshoreman. The man reported as a carpenter was employed around a tannery. The man reported as a molder was not engaged at his trade, but for six months previous to death had been a limer and general helper in a leather factory. The man reported as an undertaker had given up his business to become an employee in a tannery establishment, where he checked and received imported horsehides. One young woman who was reported as staying at home helped on her father’s dairy farm ; two more, designated as housewives, are believed to have contracted the disease from a sheep and from a cow, respectively, which had died of anthrax a few days before; a boy whose occupation was not stated did chores about home; so that all four o f these persons may appropriately be classed as farmers. Moreover, of the 30 reported as “ laborers,” it was found that 6 were tannery employees, 4 were farm or ranch hands, 4 were longshoremen, 1 was a freight handler, 1 a woolsorter, 1 a curled-hair worker, 1 a driver who had been unloading hides from a vessel, 1 a worker in a morocco factory, and 1 a paper-mill employee. In brief, then, although in about 50 cases the connection between occupation and disease is obscure or nonexistent, 77, or a majority of the persons under consideration, were in occupations where the menace o f anthrax is well recognized. Twenty-three were hide and skin workers or were otherwise employed about tanneries, 21 were farmers, ranchmen, or women living on farms, 13 were transporta AN TH RAX AS AN OCCUPATIONAL DISEASE. 49 tion workers, 6 worked with wool, hair, or bristles, 2 were rag han dlers in paper mills, 2 were liverymen, 1 was a veterinarian, and 9 were laborers, probably in one or another of the foregoing branches o f industry. T anning.— T he largest single occupational group among the 132 recorded persons who succumbed to anthrax in the United States registration area during the six years 1910 to 1915 is composed of tannery employees, o f whom there were 23. While the available information is too fragmentary to permit a positive statement, there is strong reason for believing that most o f these 23 workmen were engaged not in the late but in the earliest tannery processes. Thus No. 105, one of the cases given in detail on pages 60 to 78, was unloading at the factory dry South American and Chinese hides. Another (No. 80) was a checker and receiver, and dealt with Russian horse hides. A third (No. 35) had been employed for two years as an assorter of hides. Only with the next man (No. 58), who was a limer and general helper, do we come to an actual tanning process, and even he, at the time of his infection, had been helping store away raw sheepskins. A fifth (No. 87) was a skin washer, while a sixth (No. 50) was a “ lumper ” in the coloring room o f a morocco and calfskin tannery. This last operation, which occurs well along in the tanning process, is the latest one mentioned in any of these cases. Special note should be made of the circum stances that one tannery employee (No. 1) who died was a carpenter and that another (No. 54) was a stationary engineer.1 The remaining 15 tannery employees (Nos. 2, 3, 5,10, 20, 41, 49, 69, 74, 93, 94, 97,103, 126 and 128) are described merely as “ laborer in tannery,” “ morocco worker,” or by some similar indefinite term; but, judging from the experience in the groups of local cases previously examined,2 it is reasonable to believe that many of these were porters, warehouse men, and the like, who handled the hides in the earliest stages, be fore actual tanning had begun. Fourteen of the total number here grouped as working at “ tanning” are described as employed in tanneries or leather factories (i. e., establishments curing cow, horse, and similar large hides), while nine are described as employed in morocco works, where goat, sheep, and other light skins are tanned. F arming and R anching .—T wenty-one of the 132 fatal cases of anthrax under discussion occurred among farmers, ranchmen, or others engaged in similar pursuits. In half o f the cases (Nos.* 8, 18, 22, 48, 70, 71, 75, 104, 124, and 132) the source of infection remains unknown. One young woman (No. 120) in this group, however, assisted her father on his dairy farm. A boy of 16 (No. 65) helped % ___________________________________________________ _____ 1 F or the case o f a steam fitter who contracted the disease in a tannery, see p. 36. 2 See pp. 32 and 43. 50 BU LLETIN OF THE BUREAU OF LABOR STATISTICS. care for his father’s cow and horse. A California farm laborer (No. 99) at the time o f his attack handled cattle and cattle hides of local origin. A California woman (No. 33) who lived on a farm 16 miles from town is believed to have been infected indirectly from a dead sheep. In the case of another California housewife (No. 84), evidently the wife of a farmer, and in that of a Vermont farm hand (No. 24), the contagion was traced directly to sick cows, one of which died. Three men, in Louisiana, Kansas, and Pennsylvania, respectively (Nos. 26, 15, and 12), were infected by skinning cattle which had died of the disease. A Wisconsin farmer (No. 83) opened a cow to ascertain the cause o f its death, and even dissected the characteristic black spots he found in its abdomen. Particularly striking is the story o f a New York farmer (No. 78) who, according to the physician, “ was in the habit of buying up old and poorly nourished cattle, butchering them, and selling them where he could.” While awaiting trial on charges o f selling tuberculous meat this man apparently slaughtered for sale an animal suffering from anthrax, and died as a result. The possibility of acquiring the disease by eating the meat of anthrax-infected animals seems to be well recog nized.1 L ongshore W ork.— A t least 9 of the 13 transportation workers re ported as dying from anthrax were longshoremen at the ports of Boston (Nos. 43, 76, 108, 110, and .127), Philadelphia (Nos. 56, 82, and 89), and New York (No. 131). Probably the Boston 64freight handler ” (No. 4) and the New York “ laborer and driver” (No. 116), elsewhere discussed, also belong in this group. Six o f the nine men unloaded hides, specified in one instance as coming from South America and from “ America ” ; one unloaded hides and w ool; one hair from China; and the nature and source of the materials handled by the other are not stated. The death-bearing hides in two cases are known to have been dry. These hides arrive sometimes in large burlap-wrapped bales, sometimes loose. In either case the labor of fastening tackle upon them, hauling them from the hold, and lugging them onto the pier offers manifold opportunities for abrasions and scratches o f the skin, which readily become infected by the spore laden hides or the dust therefrom. (See cut facing this page.) Five of the lesions in this group appeared on the face, three on the neck, and the position o f one is not given. In one of these cases application for indemnity was made under the Massachusetts work1 T hat the business methods o f this man are not unprecedented is shown by the state ment o f R avenal that he had “ known an animal in the last stages o f anthrax to be slaughtered and dressed fo r market by a th rifty farm er who saw his cow about to die and wished to avoid loss. E xam ination o f the blood o f this animal proved it to be swarm ing w ith anthrax.” (A rticle on A nthrax in M odern M edicine, 1907, Vol. I l l , pp. 4 2 -5 1 .) PLATE 6.— U N L O A D I N G A CARGO OF HIDES FROM SOUTH AMERICA. PLATE 7.— W E I G H I N G DRIED CATTLE H ID E S I M P O R T E D F R O M SOUTH AMERICA. A N TH RAX AS A N OCCUPATIONAL DISEASE. 51 men’s compensation law, but was denied on the ground that the infec tion occurred while the workman wa's in the employ o f a -steamship line other than the one named in the application.1 C ustoms W eighing.— A case (No. I l l ) which brought into striking relief the inadequacies of the Federal Employees’ Compensa tion Act o f May 30, 1908, was that of a Government weigher in the customs service. This man’s duties included tearing open the bales of hides, examining their contents, and weighing them. (See cut facing this page.) Just before falling ill he had worked on hides and skins from South America. His widow, though left with three small children, was unable to secure indemnity from the United States Government because customs weighers were not covered by the act. T ruck D riving.—A nother transportation worker (No. 116) whose attack o f anthrax proved fatal is reported as laborer and driver; he had, however, for the week preceding illness, been “ unloading hides from a vessel,” so that, as previously stated, he probably be longs among the longshoremen. In his case the anthrax papule appeared on the chest. F reight H andling.— T he two remaining fatal cases occurring in transportation work were those of freight men— one designated as an agent and the other as a handler (Nos. 61 and 4, respectively), The latter, however, was most likely a Boston longshoreman. His infection was on the right arm. The freight agent worked in a small Pennsylvania town, but nevertheless contracted anthrax from handling foreign hides. H air W orking and W eaving.— F our of those who died of anthrax were engaged in different processes of hair working and hair weav ing. One (No. 55) had been employed for only eight months as a laborer in a curled-hair factory using large quantities of imported material. Another (No. 17) mixed animal hair in machines, pre paratory to spinning; a third (No. 63) was a haircloth maker and was taken fatally ill after working over a bale of Siberian hair; and the fourth of this group (No. 106) was employed in a carpet factory where the coarser grades of hair are woven. W oolsorting.— One man (No. 7) who succumbed to anthrax came in contact with raw American sheep wool, and according to the physician’s statement, was probably a woolsorter. In this work the bales o f wool are first placed on racks over steam pipes, which heat the wool and soften the natural grease it contains so that the fleeces can easily be opened out. The workbench has a top of wire screen, through which the dirt and impurities drop, and within easy reach 1 See pp. 89 and 91. 52 BU LLETIN OF THE BUREAU OF LABOR STATISTICS. are a number of baskets or crates, one for each grade of wool which is to be separated. (See cut facing p. 53.) Usually the only tool is a pair of woolsorter’s scissors, for clipping off tar and other matter which may be found adhering to the fleece. The whole process is very simple, but gives rise to large quantities o f dust, the fine parti cles o f which form convenient vehicles for the anthrax spores. B ristle C ombing.— One fatal case (No. 38) was that of a man employed as a bristle comber and hair dyer. The materials he worked with came from Siberia. P aper M aking .—T wo of those who died with anthrax symptoms handled rags in paper mills. One (No. 11) unloaded baled rags from cars, and trucked them into the storage sheds and to the cutting rooms, where the rag cutters would open the bales and feed the rags into the cutting machines. The other (No. 14) was engaged as a bleach boy in the rag room. Both workers handled large quantities of imported rags from such countries as England, Ireland, Germany, France, Italy, and Spain. L iverymen.—T wo of the deaths (Nos. 67 and 95) were among liverymen. The former had a pustule on the lower lip, which at his request was opened with a penknife by a relative. The penknife, however, had previously been used by the patient to incise what he considered an “ abscess ” on one of his horses, so that the physician is not certain whether the case was anthrax from the start or whether inoculation occurred through the knife. The knife had disappeared and could not be examined for anthrax bacilli. V eterinary S urgery.— One of the most interesting cases of fatal anthrax (No. 47), from the clinical point of view, which was disclosed in this study was that of a veterinary surgeon. Some 12 days be fore becoming alarmed over his condition he had performed an autopsy on some cows, in the course of which he scratched his fore finger. He cauterized the scratch and nothing developed there, but he probably scratched himself at the same time on the other wrist, for a week later there developed in that location the pustule which caused his death. B arbers and H airdressers.— T wo of the 132 persons dying of anthrax (Nos. 21 and 77) were barbers and one (No. 40) was a hair dresser. A ll were men. In none of these cases were details ob tainable, but a possible source of infection is indicated by the evidence presented on page 23 regarding infection through shaving brushes. Early in March, 1916, also, the New York city bureau of public health education received a communication from Dr. A. K. Chalmers, health officer o f Glasgow, Scotland, stating that two shipments of London-made shaving brushes had been received in Glasgow and that each brush had been found to contain anthrax germs. The New PLATE 8.— A “ D R U M ” IN W H I C H S K I N S A R E C H U R N E D , IN O R D E R T O S O F T E N AND REMOVE WASTE MATTER. PLATE 9.— W O O L SORTING. In wool manuf ac t ur i ng centers occupational ant hr ax is c o m m o n l y known as “ wool sor t er s ’ di sease. ' AN TH RAX AS AN OCCUPATIONAL DISEASE. 53 York health department thereupon announced that all future im portations o f shaving brushes would be thoroughly examined for the presence o f the germs. “ L aborers.”—I n nine fatal cases the occupation of the deceased workman is obscured under the vague designation “ laborer.” Two o f these deaths (Nos. 101 and 102) occurred within two and one-half weeks of each other in Pennsylvania tannery towns, a third (No. 29) occurred in a Massachusetts city with large shoe works as well as tan neries; and a fourth (No. 34) took place in Philadelphia, where in both hair works and tanneries the risk o f occupational anthrax is great. In these cases wnat the victims worked at can be surmised with approximate accuracy, but in the remaining five cases (Nos. 25, 31, 42, 91, and 109) there is no clue whatever. From the standpoint both o f accurate morbidity statistics and of efficient prevention of occupational disease, such loose reporting should be discouraged. . M usician.— One man (No. 30) was a traveling musician, and at the time o f his death is believed to have been with a circus. As he was fond o f horses it is suggested that he may have contracted the disease from one of the circus animals. H ousekeeping.— F ourteen of the fatalities reported as from anthrax occurred among women who were acting as housewives (Nos. 6, 9, 39, 53, 57, 68, 85, 96, and 119), housekeepers (Nos. 28 and 52), housekeepers and nurses (No. 66), domestics (No. 62), or (No. 92) simply living “ at home ” with no definite occupation. In no case is the source o f infection indicated. I nfants.— F ive o f the reported victims of anthrax were infants 1 year old or less. In three of these cases (Nos. 16, 73, and 88) the mode o f infection is unknown. A girl baby of 4 months (No. 64) was struck on the mouth with a fly swatter in the hands of an older child who was tending her, breaking the skin and perhaps intro ducing the fatal bacillus or spore from a fly which had previously been killed with the implement. The physician^ history in the remaining case (No. 98) is most convincing. This little boy, aged 1, lived on a farm. He was scratched on the leg by the teeth o f a pet dog with which he was playing. The dog had been feeding on the unburied carcass of a calf that had died of anthrax. A pure culture o f anthrax was taken from the child’s leg. No O ccupation.— Of the eight persons who, according to the official death blanks, had no occupation, six are elsewhere considered. The seventh (No. 32) was a man of 38, and the last (No. 79) a girl o f 14. In none o f these cases could additional information o f importance be secured. O ccupation N ot S tated.—I n seven cases the occupation was not stated on the official death certificates and could not be determined 54 B U LLETIN OF TH E BUREAU OF LABOR STATISTICS. from other sources. Three of these (Nos. 81, 86, and 117) were men, aged 52, 54, and 52 years, respectively. One (No. 107) was a girl 6 years old, the discharges from whose nose, contained a bacillus “ having all the characteristics of the bacillus anthracis.” The other three were women. One (No. 113) was on a visit to New York when she pricked a pimple on her lip with a needle. The records for the remaining two (Nos. 13 and 37) are brief and afford no clue to the cause o f the disease. M iscellaneous Cases, O ccupation N ot S ignificant.— T here re main 23 recorded victims of fatal anthrax attacks whose occupations, as given by the official death certificates, checked up from other sources, bear no visible relation to the disease and are too scattered to be considered in groups. The cause of infection in a few o f these cases has been roughly surmised. A tailor (No. 90) and a young woman school-teacher (No. 44) are believed by their physicians to have been infected by insect bites. Two girls, one (No. 115) a postoffice clerk, and the other (No. 121) a candy packer, are supposed by some physicians to have contracted the disease from fur neck pieces, but this theory is opposed by medical men of high standing. In the 19 cases still remaining no explanation for the onset of the disease has been offered. P lace and D ate of D eath .—J ust half o f the total number of deaths, or 66 in all, occurred in the three States of Pennsylvania, New York, and Massachusetts. The distribution by States in detail was— Pennsylvania, 31; New York, 23; Massachusetts, 12; California and Ohio, 9 each; Connecticut, 8; Delaware, 7; Louisiana, Minne sota, and New Jersey, 4 each; Indiana and Kentucky, 3 each; Colo rado, Missouri, Wisconsin, Virginia, and Maine, 2 each; Washing ton, Montana, Utah, Nebraska, Maryland, and Vermont, 1 each. Grouped by years, the deaths took place as follows: Nineteen hun dred and ten, 22; 1911, 14; 1912, 17; 1913, 25; 1914, 19; 1915, 35; total, 132. Considered by months, there seemed to be a period of high fre quency during March, April, and May, followed by a lull in the summer and early autumn, and another high-frequency period, even higher than the first, toward the close of the year. In half of the six years, the largest number o f deaths in any single month occurred in March or M ay; in two years it occurred in November and Decem ber; and in the remaining year the three months which had the same high number of fatalities were March, April, and December. Whether this apparently regular fluctuation is accidental only or indicates a real variation in the risk of infection can not yet be decided. N ativity, A ge, Sex, and C onjugal C ondition.— Seventy-nine, or not quite three-fifths, of 'the persons who died of anthrax in these AN TH RAX AS AN OCCUPATIONAL DISEASE. 55 six years were born in America, and 51 of them died in the States where they were born. There were also 8 Russians, 7 Poles, 6 Irishmen, 5 Germans, 5 Austrians, 5 Italians, 5 Canadians, 3 Eng lishmen, 3 Scotchmen, 1 Frenchman, 1 Greek, 1 Bohemian, 1 Hun garian, 1 Swede, and 1 native of the Azores Islands. Their ages ranged from 3 months to 81 years, but more died between the ages o f 31 and 40 and 51 and 60 than in any other age decade. One hundred three were males, and 29 were females. Seventy-nine were married, 46 single, 6 widowed, and 1 was divorced.® STATISTICAL SUMMARY. The following table presents in chronological order the 132 deaths recorded as from anthrax in the United States during the six years 1910 to 1915, inclusive, showing the place of death, birthplace, con jugal condition, date of death, age, occupation, and recorded cause o f death: T able 6 .—D E A T H S F R O M A N T H R A X R E P O R T E D IN T H E U N IT E D S T A T E S , 1910 TO 1915. [Data drawn from official certificates of death.] Case No. Place of death. Birth place. Con jugal Date of condi death. tion. Age. Occupation. Elmira, N. Y . P a ... M. 1910 Jan. 2 Carpenter 1......... W ilm ington, D e l. . . San Francisco, Cal.. Boston, Mass........... Philadelphia, P a . . . Jackson, O h io.......... Germany G reece.. Ireland . England O h io___ M. S. S. M. M. Jan. 10 Jan. 11 Jan. 29 Feb. 15 Mar. 8 Morocco w orker. Laborer 2............. ........do a................ ........d o 3................ Housewife.......... W illiamsport, Pa. Pierceton, In d ____ Ita ly ----I n d ........ M. M. Mar. 28 Apr. 1 Laborer 4............... Law and farming. Reading, Pa.......... W ilm ington, D el. P a .. D el. S. Apr. 22 June 4 Cigar maker 6___ Morocco worker.. Cause of death. Anthrax (external); tetanus. Anthrax. E xhaustion;anthrax. Anthrax. Do. Septicemia; anthrax and Bright’s. Anthrax. Anthrax; heart fail ure. Anthrax. Do. Special inquiry disclosed that the actual occupation just prior to death was as— 1 Carpenter at tannery. 2 Laborer in tannery. 3 Freight handler. * W orker with raw sheep w ool; probably a woolsorter. e Housewiie. a B etw een th e b e g in n in g o f 1 916 a n d th e final p r o o f r e a d in g o f th is re p o r t (D e c . 2 4 , 1 9 1 6 ), 18 a d d itio n a l ca ses o f d ea th fro m a n th ra x h a d been d is c o v e re d by cle rk s in th e C ensus Office in th e co u rse o f th e ir r o u tin e c o m p ila tio n o f d e a th ce r tifica te s f o r t h a t ye a r. T h e v ic tim s w ere, in c h r o n o lo g ic a l o r d e r : “ S h eep m a n ,” C o lu m b ia C o u n ty , W a s h .; O c cu p a tio n n o t giv en , H o d g e n sv ille , K y ., a n th ra x in fe c t io n fr o m sick c o w ; W o o l w a sh er, J o h n s to w n , N. Y . ; T a n n er, C h ic a g o ; B o y , o c c u p a tio n n o t g iv e n , N ew Y o r k c i t y ; “ L a b o r e r ,” B o s to n ; F o re m a n in m ill, P h ila d e lp h ia ; “ L a b o r e r ,” P h ila d e lp h ia ; F a rm e r, G o ld s b o r o , N. C . ; T ea m s ter, B o sto n ; “ L a b o r e r ,” P h ila d e lp h ia ; L o n g sh o re m a n , B o sto n ; “ L a b o r e r ,” S t. J a m es, M o . ; F a rm er, G len d a le S p rin gs, N. C . ; C u rrie r, B o s to n ; “ L a b o re r,” P h ila d e lp h ia ; F a rm e r, B ea u m on t, T e x . ; H o u s e w ife , San A n to n io , T e x . In a n a c c o u n t o f th e ou tb rea k in M a s sa ch u se tts, 191 6 , in th e U n ite d S ta te s P u b lic H e a lth R e p o rts fo r D ec. 15, 1916, th e t w o a d d itio n a l fa ta litie s w e re re c o rd e d o f a ta n n e ry w o r k e r (b eam h o u s e ), W in ch e s te r, a n d a d ock la b o r e r, C h elsea . T w o o t h e r ca ses o f d e a th tra ce d th ro u g h th e U n ited S ta tes P u b lic H e a lth R e p o rts a n d th ro u g h n e w sp a p e r a cco u n ts , res p e ctiv e ly , w ere th a t o f a cu rled -h a ir w o r k e r in D e tro it, M ich ., o n A u g . 12, 1 916, a fte r an illn ess o f 24 h ou rs, a n d o f a ta n n e ry w o r k e r in A r r o y o , P a ., on N ov. 19, 1916. T h e r e w a s lik e w ise o n r e c o rd th e fa ta l ca se o f a K a n s a s ch ild w h o w a s a p p a r e n tly in fe c te d b y a ca t. S ev era l o f th e s e cases h a v e a lre a d y been d iscu sse d in th e s e c tio n s d ea lin g w ith the ex p erien ce o f p a r tic u la r S ta tes o r h o s p ita ls. 56 B U LLETIN OF THE BUREAU OF LABOR STATISTICS. T able 6 .—DEATHS FROM ANTHRAX REPORTED IN THE UNITED STATES, 1910 TO 1915— Continued. Place of death. No. Birth place. Con jugal Date of condi death. tion. Greensburg, Pa.. A ustria. M. 1910 June 29 Howe, P a ........... Canada. M. July 19 Philadelphia, P a . Holyoke, Mass___ England W. S. Aug. 8 Aug. 20 L a Junta, Colo. Fairport, O hio. Scotland O h io .... Baltimore, M d. Germany Pom ona, C a l... Newcastle, P a . 111.. 20 E lm ira, N . Y . 21 17 Age. 60 15 Occupation. Cause o f death. Laborer, paper mill. ....... d o ..................... A nthrax; septic in toxication. Anthrax; skinning cow dead with the disease. Anthrax; bronchitis. General sepsis; an thrax. A nthrax. Cramps—disease o f bowel; anthrax. T oxem ia; anthrax. N ot reported. Paper m illJ. . O ct. 2 Oct. 13 Ranch forem an.... N on e..................... . Dec. 46 4 mos 62 2 M. W. D ec. 8 D ec. 19 Mixing hair (ani mal) in ma chines, prepar ing for spinning. Farmer (retired). . Baker...................... N. Y .... M. Dec. 22 M echanic2. Fresno, Cal. Germany M. Dec. 28 Barber. K ittery, M e.............. M e ... M. Dec. 29 Farm er. Pa. M. Canastota, N . Y ........... N. Y .... M. 1911 Jan. 27 W aterford, V t. Harrison, I n d .. V t.. In d . M. S. Feb. 28 A p r. 28 M. S. M. A p r. 28 M^y 7 May 16 N ew Orleans, L a .......... L a . . . W indham Co., C on n ... C onn___ N ew Britain, C onn___ Ireland.. Cigar maker (re tired). L a b orer3 ........d o . . . F arm er.......... Tailor * .......... H ousekeeper. L yn n, Mass.................... .. d o ....... S. May 30 Cleveland, O h io............ Bohemia M. June 21 M usician5. Monterey, C al............... D. July 10 Laborer___ C al... Dubois, P a ..................... Hungary M. July 28 N one........... Bakersfield. Cal. . Philadelphia, P a . F rance.. A u stria . M. M. Oct. 16 N ov. 7 H ousewife. Laborer___ W ilm ington, D el. Pa. M. N ov. 20 New Orleans, L a . La. Assorter of hides, morocco works... Salesman, electric supplies. 37 Logan County, K y ___ K y .. 39 Philadelphia, P a .......... Mesopotamia, O hio___ P a .... O h io .. Philadelphia, P a . W ilm ington, D el. M d......... Russian Poland Dec. 27 M. M. S. 1912 Feb. 3 Not reported____ Feb. 6 Feb. 13 Bristle comber «.. H ousewife.......... . Mar. Mar. Hairdresser.......... Morocco worker *. 2 6 Special inquiry disclosed that the actual occupation just prior to death was as— i Bleach Doy in rag room of paper mill, a Handler of hides in leather com pany. * Farm laborer. * Tailor and presser. 6 Musician traveling with circus. 6 Bristle comber and hair dyer. 1 Morocco worker; probably in the beam house. A nthrax; senility. A nthrax; exhaus tion following dis ease. A nthrax, external, and general tox emia. A nthrax, followed b y septic abscesses and pyem ia. Septicemia w ith ma lignant pustule. Anemia; malignant pustule, r ig h t cheek. A nthrax. A nthrax; septice mia. A nthrax. D o. A nthrax (malignant pustule); septice mia. A nthrax; pulm onary tuberculosis. Malignant pustule; edema of glottis. A nthrax; acute ure mia. A n t h r a x ; a n th ra x edema. A nthrax. A nthrax; due to ba cillus anthracis. Anthrax. A nthrax (carbuncle); malignant pustule. M alignant pustule; heart paralysis. A nthrax. M alignant p ustu le on right side of face; abscess of right kid ney. A nthrax. Do. AN TH RAX AS A N OCCUPATIONAL DISEASE. 57 Table 6.—DEATHS FROM ANTHRAX REPORTED IN THE UNITED STATES, 1910 TO 1915— Continued. No. Place of death. 42 Toledo, O h io___ 43 Boston, Mass New Y ork, N. Y Cincinnati, Ohio Birth place. O h io .... Con jugal Date of condi death. tion. M. 1912 Mar. 7 Mar. N . Y .. O h io.. W. Allegheny County, Pa. Ireland Orange, N . J.................. N . J ... . Age, 57 9 Occupation. Laborer. L a b o re r—lo n g shore.! Not reported 2___ Retired p ilot........ Aug. 6 Sept. 13 I n d .... Russia. . . d o ... M inn ... Oct. N ov. N ov. N ov. Graves County, K y ___ Ballard County, K y . . . K y ....... T en n ... Dec. 4 Dec. 23 W ilm ington, D el. M d ... M. 1913 Jan. 19 Philadelphia, P a . P oland.. M. Jan. 23 ....... d o............................. S n o h o m i s h County, Wash Gloversville, N. Y ___ D e l.. W is. M. M. Feb. 13 Feb. 15 Ireland. M. Mar. Molder Italy ----- M. Apr. Druggist. 14 14 18 20 30 Morocco, station ary engineer. Laborer 6............... ....... d o.6 ___ Housewife.. . Gardner, Mass.. Mass___ M. Apr. 12 Chair m aker... Cascade, P a ___ P a ... M. May 2 Freight agent 8 Racine, W is ___ R u ssia .. M. May 5 Dom estic......... Philadelphia, P a .. Wilkes-Barre, P a . Poland.. P a ........ . Hennepin County .Minn M in n ... North Attleboro, Mass. Canada . W indsor Locks, C on n .. C o n n .... W. M. 25 4 mos, 16 L a b orer» . . . July 17 76 None 10......... July 20 A ug. 5 49 L iverym an. Brighton, P a ........ W ilm ington, D el. Lincoln, M o.......... P a ........ Ireland Mo.......... M. S. S. Aug. 13 Aug. 23 Sept. 8 34 54 28 H ousewife........... Morocco worker. Farmer.......... Gates, N . Y ................... N. Y . .. . Sept. 29 16 N ot reported11. . . Malignant pustule. Anthrax carbuncle of neck. Anthrax. Anthrax of right hand. Anthrax; edema of glottis. Anthrax of the neck; fatty degeneration of heart. Anthrax infection of face. Anthrax. Malignant pustule on face, also internal in m outh; edema of glottis. Haircloth m ak er.. Anthrax. Malignant pustule. May 9 May 28 Elyria, Ohio., O h io___ M. Oct. Physician............. U nity, P a ___ P a ... S. Oct. N on e...................... Special inquiry disclosed that the actual occupation just prior to death was £ 1 Longshoreman handling hides. 2 School-teacher. * Laborer in tannery. < Lum per in coloring room of morocco and calfskin factory. 5 Laborer in curled-hair factory. • Longshoreman loading hides and wool. 7 Limer and general helper in leather-dressing establishment. 8 Freight agent handling foreign hides. 9 General helper on small-fruit farm. Housekeeper and nurse. “ Chore-boy around home. E x h a u s t io n fro m c h ro n ic cy stitis , b lo o d p oison in g; a n t h r a x — malig nant pustules on leg ana hand. Septicemia; anthrax. Malignant pustule. A nthrax or carbun c l e ; s e p t ic e m ia and asthenia. Forem an................. Anthrax. Veterinary surgeon Inoculation b y an thrax bacilli, caus ing general sys temic poisoning. F a r m e r ... Anthrax. L aborer3. . D o. Morocco 4. Do. A t school.. Malignant pustule; blood poisoning. Housekeeper. Anthrax. Housewife___ Do. June 2 July 23 Richland, M o....... Philadelphia, P a . P eabody, Mass. . . St. Paul, M in n .. . Brooklyn, N. Y . Cause o f death. Anthrax. M alignantpustule. Malignant pustule; septicemia. Anthrax. Do. Anthrax; metastatic pneumonia. Splenic fever; malign a n t facial an thrax. Anthrax; c h r o n i c nephritis. Cholera i n f a n t u m and anthrax. 58 BU LLETIN OF THE BUREAU OF LABOR STATISTICS. T able 6.—DEATHS FROM ANTHRAX REPORTED IN THE UNITED STATES, 1910 TO 1915— Continued. Case No. Con jugal Date of condi death. tion. Place of death. Birth place. Lycom ing C ounty,P a. N. Y .... M. 1918 Oct. 23 Hanford, Cal................. S. Boston, 1 W inchester, V a . A zores Islands. Mass___ M d......... U nion, N . Y .................. N . J....... Age. Occupation. Cause of death. N ov. 11 H a n d l i n g dry hides.1 Laborer2............... . A nthrax; infection upon the neck. Anthrax. S. M. Dec. 13 Dec. 20 Longshorem an3. . Barber................... S. Dec. 24 Farmer Anthrax; toxem ia. B lood poisoning, the result of anthrax. A n t h r a x infection. South W indsor, Conn.. Conn___ S. 1914 Jan. 16 Camden, N . J. N . J.. M. Jan. 29 Fremont, O h io. O h io .... M. Mar. Philadelphia, P a ........ Pleasant Prairie, W is. N .C .... Ill........... S. M. Mar. 15 Mar. 20 Calexico, Cal................ Scotland M. A pr. 85 86 Philadelphia, P a . Norfolk, V a .......... P oland.. V a ......... M. M. . .d o ....... A pr. 11 88 87 Philadelphia, P a . N ew Orleans, L a . Germany L a ___ M. May 6 May 29 89 90 Philadelphia, P a . Cincinnati, O hio.. M d......... O h io___ S. M. June 17 Aug. 8 mos. 35 41 91 Lewiston, Me.. Canada . M. Aug. 19 45 92 93 Hollidaysburg. P Pa.. W ilm ington, Del P a ......... R ussia. . Sept. 10 Oct. 10 94 Brooklyn, N . Y . Germany N ov. 25 95 96 McKeesport, P a . Lincoln, N e b r ... V a ......... Iow a___ Dec. 8 . . . d o ___ 97 Camden, N . J.. P oland.. 98 99 Fort Morgan, C olo. Fresno, Cal............. C an ad a. Ita ly— 1915 Mar. 29 Apr. 3 N one......... L a b orer10. 100 101 Hartford City, Ind.. W illiamsport, P a . . . O h io___ A u stria . Apr. 4 Apr. 25 Merchant.. L aborer... 102 Coudersport, P a ........... . . . d o ....... May 12 -----d o........ 103 .d o . .do.. M. M. 9 6 Dec. 31 May 18 Anthrax or malig nant pustule; tox emia. U ndertaker5. Anthrax (malignant pustule); infected from h a n d l i n g hides in a local leather factory. R heum atism and an N ot reported. thrax; pericarditis. Anthrax. Stevedore6.. Anthrax; general in Farm er........ fection. Septicemia, almost Housewife.. certainly due to an thrax in a cow . Anthrax. ........d o ............. Anthrax (malignant Not reported. edem a); toxem ia. Leather worker7.. A nthrax. None....................... Anthrax at base of spine; scrofula. Laborer 8................ Anthrax. Tailor and presser. Anthrax infection of face; nephritis, acute. Laborer.................. Endocarditis; chron ic rheumatism; an thrax. A t hom e............... . Malignant pustule. Anthrax; edema of Morocco w orker. . larynx. Anthrax; infection Laborer 9.. bacillus anthracis. L iverym an ., Anthrax. Septic infection due H ousew ife... to anthrax bacillus. Laborer, m orocco Anthrax. works. N one____ 29 . .d o .9............. Farmer and stu dent.1! Special inquiry disclosed that the actual occupation just prior to death was as-r1 Handler of dry hides in tannery. 2 Ranch laborer. 8 Longshoreman handling hides. <Farmer who made a practice of butchering cattle. 6 Checker and receiver of horsehides in leather factory. 6 Stevedore unloading hair. * Skin washer in leather factory. « Longshoreman unloading hides. ®Laborer in tannery. io Farm laborer handling cattle and cattle hides, u Schoolboy who also did chores around home. 104 Nunda, N. Y . N. Y . . . . S. May 24 14 Anthrax; measles. Anthrax; due to ba cillus anthracis. Malignant anthrax. A nthrax c a u s i n g edema of larynx, facial anthrax. A nthrax, internal; typical case o f true anthrax. Septic i n f e c t i o n ; typical case of true anthrax. Septicemia; anthrax of back. 59 AN TH RAX AS AN OCCUPATIONAL DISEASE. T able 6.—DEATHS FROM ANTHRAX REPORTED IN THE UNITED STATES, 1910 TO 1915— Concluded. Case No. Place of death. Birth place. Con jugal Date of condi death. tion. Occupation. 1915 Cause of death. 105 E ndicott, N . Y ........ Russia.. June 1 Tannery worker i.. Bacillus 106 Hartford, Conn........ Poland.. June 7 107 Brooklyn, N . Y ....... N. J.. June 29 108 Boston, Mass........... July 4 109 New Orleans, L a ___ New Bruns wick. La....... anthrax; septicemia; an thrax. Mill hand, carpet Anthrax infection; factory. genuine anthrax; from initial ulcera tion of neck. Not reported......... General astheni a from anthrax in fection of nose. Stevedore2............. Anthrax. July 8 Laborer................... Acute nephri t i s; 110 Boston, Mass............ Russia.. ...do...... 111 112 Manhattan, N. Y .......... N. Y .... July 29 Weigher 4............... 113 Salt Lake City, U ta h .. N. Y .... Manhattan, N. Y .......... Md........ Aug. 24 Aug. 30 Carpenter............ Not reported......... Laborer, yard.3 freight 114 N ew London, C o n n ... N. Y .... Sept. 3 Printer................. 115 Brentwood, N. Y ......... N. Y .... S. Sept. 29 None5.................... 116 117 Manhattan, N. Y .......... U. S .. .. Madison, N. Y .............. N .J .... s. Oct. 7 Oct. 12 Laborer 6............... Not reported......... 118 119 Manhattan, N. Y .......... U. S .... Blue Earth Co., M in n .. Minn.... Oct. 15 Oct. 22 Lawyer 7................ Housewife............. 120 121 122 N. Y .... Nov. 12 At home8.............. Manhattan, N. Y .......... Russia.. Philadelphia, P a .......... Scotland Nov. 18 Nov. 20 Candv packer....... Cake Daker............ 123 124 Johnson City, N. Y . . . Lewis tow n, M ont........ Pa........ England M. S. ...d o .... Nov. 21 Laborer in tannery Farm hand. . . . 125 Kings County, C al. . . . Ohio.... M. Nov. 26 126 New Brunswick, N. J . . Italy---- M. .. .do...... Bainbridge, N. Y ......... Poland.. M. Nov. 27 128 129 Boston, Mass................. Italy— Manhattan, N. Y .......... N. Y . . . . M. S. ...do...... Nov. 28 Chelsea, Mass................. 56 Painter 9.......... Laborer, clay 10, 40 Freight handler Laborer 11......... Medical student, 130 W illington, Conn........ N. Y .... S. Dec. 131 Brooklyn, N. Y ............ Russia.. M. Dec. 18 Laborer12........ . 132 St. Paul, M inn.............. Sweden. W. Dec. 27 Farmer............ 5 At school........ Special inquiry disclosed that the actual occupation just prior to death was as— 1 Worker in leather factory, unloading dry hides. 2 Longshoreman working in hold of vessel and unloading dried hides. * Laborer unloading dry hides at wharves. 4 Weigher in United States customhouse. * Clerk in post office. * Laborer and driver, and unloading hides from vessel. 7 Retired lawyer, caring for his own home. 8 Helper on father’s dairy farm, doing housework and milking, sLaborer with no particular kind of work. 10 Laborer working in clay pit. * Worker in tannery. 12 Laborer handling'hides at docks. edema of lungs; bacillus anthracis; septicemia. Anthrax; neck in fection with bacil lus anthracis. Anthrax inlection of neck. Anthrax. Pustula maligna on under lip; pyemia; anthrax. Malignant pustule; convulsions. Malignant anthrax edema. Anthrax. Poisonfromanthrax; cardiacparalysis. Anthrax. External and inter nal anthrax. Septicemia; probably anthrax bacillus. Anthrax. Septicemia due to malignant pustule on hip; cirrhosis of liver. Anthrax. Anthrax infection; septicemia. Anthrax on back of neck; exhaustion. Cellulitis of neck; sepsis; anthrax; valvular heart disease. Anthrax; malignant pustule. Anthrax. Malignant anthrax; edema. Malignant pustule; general septicemia. Anthrax; edema of glottis; acute cardiac dilatation. Malignant anthrax (carbuncle) on back of neck. 60 BULLETIN OF THE BTJBEATT OF LABOR STATISTICS. Individual Histories of Fatal Cases. In this section a more detailed account is given of each of the foregoing 132 cases of death from anthrax. The facts were secured by correspondence and interviews with hospital authorities and with attending physicians, supplemented in some cases by visits to the family and friends of the deceased. By such inquiries many addi tional particulars were obtained which were important as throwing light on the relation between occupation and cause of death. No. 1, of Elkland, Pa., died at the age of 39 on January 2, 1910, of “ an thrax (external) ; tetanus.” He was a carpenter at a tannery, and upon contracting the infection from hides was sent to Elmira, N. Y., to be treated by a physician who had previously practiced near Elkland and had had much experience with anthrax. “ I think,” says the physician, “ he would have recovered from anthrax if tetanus had not developed about two weeks after the appearance of anthrax symptoms; he lived only 24 hours from the time tetanus developed. Of course he probably would not have developed tetanus if he had not suffered from anthrax first.” As near as the physician could find out the diseased hides “ were imported from South American countries, and from cattle that had died o f anthrax.” The physician further states that in five years’ practice near Elkland he treated “ quite a number o f cases suffering from anthrax contracted by employees handling hides ” at the tanneries of three neighboring towns, and that this was his “ first case that succumbed to the disease.” No. 2, of Wilmington, Del., died at the age of 50 on January 10, 1910, o f “ anthrax.” He was a morocco worker by trade. No. 3, of San Francisco, Cal., died at the age of 24 on January 11* 1910, of “ exhaustion; anthrax.” He was a laborer in a tannery, where, according to the physician, he became infected by hides. The illness lasted only three days, and death occurred in a hospital. No. 4, of Boston, Mass., died *at the age of 34 on January 29, 1910, o f “ an thrax.” He was a freight handler. His right arm was affected. Upon admis sion to the hospital an excision o f the affected area was made. Serum was not used. A pure growth of anthrax bacilli was obtained from the blood. He had been in the hospital about a day when death occurred. No. 5, of Philadelphia, Pa., died at the age of 32 on February 15, 1910, of “ anthrax.” For six weeks preceding his illness he had worked as a laborer in a tannery. According to the hospital physician, the disease began three weeks prior to his admission to the hospital “ with a small pustular eruption on the face. Next day the neck became edematous, until on admission the whole neck was purplish in color and doughy to the feel.” He died on the day he was admitted to the hospital. No. 6, o f Jackson, Ohio, died at the age of 68 on March 8, 1910, o f “ septi cem ia; anthrax and Bright’s.” She was a housewife. No. 7, of Williamsport, Pa., died at the age of 51 on March 28, 1910, of “ anthrax.” The physician states that the man came in contact with raw sheep wool o f American origin, and that he probably was a wool sorter. The disease took the form of “ malignant pustule— external anthrax,” according to the physician, who goes on to sa y : “ He had all the classic symptoms, especially a marked edema o f shoulder which spread to face and breast. He lived about five days. Crucial incisions were made about shoulder and breast. No relief was derived from this treatment.” Anthrax bacilli were found. Antianthrax serum was not available at the hospital where the patient was treated. PLATE 10.— A "BEAM H O U S E ” IN A T A N N E R Y . Scrapi ng hi des t aken f r om l i me vats in whi ch t he y have been s u b me r g e d until t he hair is l oos e ne d. PLATE 11.— “ F L E S H I N G ” HIDES BY M A C H I N E . AN TH RAX AS A N OCCUPATIONAL DISEASE. 61 No. 8, of Pierceton, Ind., died at the age of 52 on April 1, 1910, of “ anthrax ; heart failure.” His occupation was law and farming, and death followed within five days, the physician states, after “ bite of fly.” A carbuncle ap peared on the cheek, with “ papules, pustule, vesicles, great induration.” Phenol (carbolic acid) was injected and stimulants were given. When asked whether antianthrax serum was injected the physician replied: “ N o; none to be had.” No. 9, of Reading, Pa., died at the age o f 49 on April 22, 1910, of “ anthrax.” According to the physician the patient “ was the mother o f a large family, and a hard-working housewife. She claimed to become infected through an abra sion of the skin of the back. She was treated in the beginning by domestic remedies. When I saw the case the patient was so weak and the slough so large that I made no attempt at excision.” Her husband states that the de ceased had been a cigarmaker for a few years before her marriage. No. 10, of Wilmington, Del., died at the age of 17 on June 4, 1910, of “ anthrax.” He was employed at $1.75 a day by a large morocco firm and came in contact with goat skins imported from South America and from China. The skins, according to the physician, were washed, but not disinfected, before the boy handled them; hot water, gloves, nailbrushes, and disinfectants were provided for the workers. Bloodstained materials were eliminated “ as far as possible,” but there was no special ventilation. The illness lasted four days. “ When he sent for me,” declares the physician, “ I found the pustule on his right chest, which, with the history o f his working in the morocco factory, I decided was probably anthrax. A slide confirmed it.” That is, anthrax bacilli were found by microscopic examination. “ The course was very rapid,” con tinues the medical man, “ the people poor and could not afford serum treat ment, and he died. I cut out the pustule, but it did him no good.” No in demnity was received by the family for the boy’s death. No. 11, o f Latrobe, Pa., died at the age o f 84 on June 29, 1910, of “ anthrax ; septic intoxication.” He was a laborer in a paper mill, his duties, according to one who was connected with the mill at the time, being to unload baled rags from cars and to truck them into the storage sheds and to the cutting room, where the rag cutters would cut the bales open and feed the rags into the cutting ma chines. The rags were principally cotton, coming in the main from “ all parts of the United States and Canada,” but occasionally as many as “ 50 cars of foreign rags ” would arrive at one time from England, Germany, France, Ireland, and Spain. The rags were “ never treated with any disinfectant ” or cleaned. This man’s work was done in the open air, on a platform which was “ cleaned as often as needed.” No hot water, gloves, nailbrushes, or disinfectants were pro vided ; in fact, says the informant, “ there has never been any precaution taken in regard to the prevention of disease.” The man went for treatment to a hos pital in Greensburg, Pa. The physician in charge of the case states that the clinical symptoms were so typical that he holds the case was one o f anthrax. “ Two o f my colleagues who saw the case with me are o f the same opinion. The man had a virulent infection above the ankle. There was at this point a circular area, probably 2 inches in diameter, much reddened and elevated, with a rather clear serous and somewhat depressed center. There was a marked lymphangitis extending up the leg and thigh. The man was profoundly toxic and had a high temperature range. When the diagnosis was made, which was very soon after his admission to the hospital, he was removed to a tent which I had erected in the yard, and there he died during the night following admission.” The duration of the illness was 10 days. Antianthrax serum was not available for injection. 62 BU LLETIN OF TH E BUREAU OF LABOR STATISTICS. No. 12, of Howe, Pa., died at the age of 52 on July 19, 1910, of “ anthrax; skinning a cow dead with the disease.” The man’s occupation is given merely as “ laborer.” Illness lasted five days. No. 13, o f Philadelphia, Pa., died at the age of 60 on August 8, 1910, of “ anthrax; bronchitis.” The disease lasted eight days. The patient was a widow. No occupation is given on the death certificate. No. 14, o f South Hadley, Mass., died at the age of 15, on August 20, 1910, o f “ general sepsis; anthrax.” According to the physician, he was employed at $1.35 a day as bleach boy in the rag room o f a paper mill, but some time after the occurrence the superintendent of the mill is reported to have asserted that, while the boy “ had access to the rag room and was probably there, he was not supposed to be there.” The physician states that, although the rags used were imported from France and Italy, they were “ all new clippings.” The physician’s story indicates infection through a scratched arm. “ On Saturday night, August 13,” he says, “ patient slept out o f doors in a tent.” The next morning he “ noticed an ‘ insect bite ’ on middle o f left forearm which was swollen and extremely itchy.” On Monday he returned from work “ in the middle of the forenoon, feeling sick. Had a chill, nausea, and vomiting.” The physician saw the patient first on Wednesday afternoon. He “ had some fever and increased pulse rate.” On the left forearm was a small localized swelling that looked like a b o il; “ rest of arm was normal, but left axillary glands and the whole left chest wall was swollen. Patient had an extremely septic look.” Under local treatment and catharsis the patient apparently improved for one day, but Friday morning he was worse. The swelling was opened, and a very small amount of pus obtained. “ Friday night patient was very restless and looked very sick. Temperature and pulse were both high, and patient was vomiting. Saturday morning patient was in a state of collapse— subnormal temperature, and radial pulse absent until stimulated with strychnia and camphor. Skin was a dark livid red, cold, and covered with sweat. Was still vomiting and passing black urine. It was not until now that I suspected anthrax.” The patient was removed to a hospital in Holyoke, Mass., and a consultant called. “ Excised localized area (about 2 inches in diameter) and swabbed surface with pure carbolic acid followed with alcohol. Swelling involved only the skin and sub cutaneous tissue. Patient died Saturday night.” The excised specimen was sent to Harvard for diagnosis, and the report was anthrax. No. 15, o f Maple Hill, Kans., died at the age of 46 on October 2, 1910, of “ anthrax.” He was a ranch foreman, and according to the physician’s state ment “ infection was through the skin in the forearm,” where the man “ had a little abrasion.” Three or four days before the disease broke out he “ helped to skin and take care o f a dead cow,” and it is supposed that he “ got the infection at that time.” Death occurred in a hospital at La Junta, Colo., after five days’ illness, the disease taking the form of “ malignant anthrax edema.” No. 16, o f Fairport, Ohio, died at the age of 4 months 11 days on October 13, 1910, of “ cramps— disease of bow el; anthrax.” How this infant girl con tracted the disease the physician was unable to state. No. 17, of Baltimore, Md., died at the age of 62 on December 2, 1910, of “ toxem ia; anthrax.” He was employed at mixing animal hair in machines, preparatory to spinning. Illness was fatal after two days. No. 18, o f Pomona, Cal., a retired farmer, died at the age of 72 on December 8, 1910, of “ anthrax; senility,” according to the official death certificate. No. 19, of Newcastle, Pa., died at the age of 78 on December 19, 1910, of “ anthrax; exhaustion following the disease.” The deceased was a baker, and death occurred in a hospital after an illness of one month’s duration. AN TH EAX AS AN OCCUPATIONAL DISEASE. 63 No. 20, of Breesport, N. Y., died at the age of 46 on December 22, 1910, o f “ anthrax, external, and general toxemia.” He was employed by a leather company and handled hides, which the physician thinks were imported from Australia. For the purpose o f treatment he was taken to Elmira, N. Y. “ The local lesion,” says the doctor, “ was single and situated under the lower jaw, about over the submaxillary gland. Undoubtedly infection gained access through abrasion o f the skin at that point. He rapidly became toxic and unconscious and died within a few days from onset o f constitutional symptoms. The local symptoms were first papular, then rapidly vesicular, with an area of cellulitis, and soon local gangrene.” No. 21, of Fresno, Cal., died at the age o f 52, on December 28, 1910, of “ anthrax followed by septic abscesses and pyemia.” His occupation is given as barber. No. 22, of Kittery, Me., died at the age of 24, on December 29, 1910, of “ septi cemia with malignant pustule.” He was a farmer, but the mode of infection could not be ascertained. The physician states that he displayed “ all the typical clinical symptoms.” Death occurred after three days’ illness. No. 23, of Canastota, N. Y., died at the age o f 75, on January 27, 1911, of * anemia; malignant pustule, right cheek.” For much o f his life he had worked as a cigar maker, but at the time of his death had retired. Anti anthrax serum was not available. No. 24, o f Waterford, Vt., died at the age o f 29, on February 28, 1911, of “ anthrax.” He did farm work about the neighborhood. According to the phy sician, eight days before the man’s death “ malignant pustule ” appeared in the form of “ pimple on face,” contracted by “ contagion from a sick cow.” Curative serum was not available. There were no dependents. No. 25, o f Harrison, Ind., died at the age of 62, on April 28,1911, of “ anthrax; septicemia.” His occupation is given as “ laborer.” Illness lasted, according to the official death certificate, 21 days. No. 26, of Youngsville, La., died at the age o f 34, on April 28, 1911, of “ anthrax.” Deceased was a farmer. The record at the New Orleans hospital to which he was sent furnishes these d a ta : “ Patient admitted to ward in delirious state. Was unable to give coherent account o f illness. Friend, who accompanied him to hospital, said that eight days prior to admission a small sore like a boil appeared on bridge of nose (this told him by patient’s w ife). The inflammation process spread rapidly and involved the skin o f forehead and both eyelids, together with some o f the skin covering cheeks, in a gangrenous process with necrosis and sloughing pustules here and there. Patient gradu ally grew worse and died.” The eyes were “ closed by exudate from skin lesion,” and “ punched-out ulcers with undermined edges ” were found on nose and forehead. Anthrax bacilli were found. The patient had skinned a dead cow some time before he became ill. No. 27, o f Windham County, Conn., died at the age of 72, on May 7, 1911, of “ anthrax.” He was a self-employing tailor, and was partially supported by an Army pension of about $12 a month. His work consisted of “ mending and pressing old clothes,” states the physician. No antianthrax serum was avail able. No. 28, of New Britain, Conn., died at the age of 52, on May 16, 1911,, of “ anthrax (malignant pustule) ; septicemia.” Her occupation is given as housekeeper. No. 29, of Lynn, Mass., died at the age of 38, on May 30, 1911, of “ anthrax; pulmonary tuberculosis.” His occupation is given only as laborer. From the hospital record it is learned that the patient went to the accident room “ with 42806°—Bull. 205—17------ 5 64 BULLETIN OF THE BUREAU OF LABOR STATISTICS. a small red spot on right cheek which he had had for two days.” There was also small swelling and redness around the spot. A “ slide was taken and anthrax bacilli found.” The patient, however, refused treatment and went home, saying he would return in an hour. He did not go back until the follow ing morning, when the spot had “ increased in size, swelling greatly in creased, and some edema.” Excision was then performed under ether, the wound cauterized with carbolic acid, and corrosive poultices applied. The man died on the fourth day after first applying at the hospital. No. 30, of Cleveland, Ohio, died at the age o f 40, on June 21, 1911, o f “ malignant pustule; edema o f glottis.” He was a traveling musician, “ with a circus ” at the time of infection, the physician is sure. While in a Pennsyl vania city he “ had a small infection on upper lip which he squeezed; following this the infection rapidly involved the whole upper lip, and he was advised to hurry home.” When called the physician “ recognized a very severe infection with rapidly extending edema involving cheek and eye, temperature 105°, with extremely rapid pulse.” Treatment consisted in local injections o f car bolic acid, ichthyol applications to his face, which was edematous, with tem perature baths and supportive treatment; medication mostly by hypodermic in jection. “ A strong attempt was made to get anthrax vaccine, locally and by telegraph.” One firm sent a supply through a local representative, “ but patient died before application could be made.” The history of the patient’s “ traveling with the circus, his fondness for horses (by his own statement), the initial lesion with extremely rapid progress o f disease, characteristic pustule, gangrenous, vicious appearing ulcer, high temperature, and rapid disinte gration,” are considered by the physician convincing evidence o f anthrax. No. 31, o f Monterey, Cal., died at the age o f 38, on July 10, 1911, o f “ an thrax ; acute uremia.” The statement of occupation is merely “ laborer.” No. 32, o f Dubois, Pa., died at the age of 38, on July 28, 1911, of “ anthrax; anthrax edema.” Under the head o f occupation the death certificate says, “ None.” No. 33, of Bakersfield, Cal., died at the age o f 42, on October 16, 1911, o f “ anthrax.” The woman lived on a farm 16 miles from town. A pustule broke out on her neck, but she paid little attention to it for 10 days, when she called a physician, who pronounced it anthrax. “ It seems,” says the medical man, “ a sheep had died in the neighborhood, and as there was an abundance o f flies in the house there is no doubt that the infection was carried by the flies.” Death occurred on the fifth day o f treatment. There were two dependents. No. 34, o f Philadelphia, Pa., died at the age of 38, on November 7, 1911, o f “ anthrax; due to bacillus anthracis.” His occupation is given as laborer. No. 35, of Wilmington, Del., died at the age o f 48, on November 20, 1911, o f “ anthrax.” For two years previously he had been employed as an assorter o f hides in a morocco works, at $1.20 a day. The hides were imported in a raw state, and, according to the physician, were domestic cleaned, but the cleanli ness of the workroom was “ not what it should be ” and no gloves or nail brushes were provided. The patient “ showed all the symptoms o f anthrax ” ; no test for bacteria was made. Antianthrax serum was injected, but “ too late.” The wife and four dependent children received no indemnity beyond funeral expenses. No. 36, of New Orleans, La., died at the age of 25, on December 27, 1911, o f “ anthrax (carbuncle) ; malignant pustule.” He was a salesman for an elec trical supply house. The attack lasted 10 days, appearing first, the hospital physician says, as “ infection on upper lip, right side.” It then “ spread to nose and face o f same sid e; subsided after drainage and cauterization, followed by AN TH R AX AS AN OCCUPATIONAL DISEASE. 65 ichthyol dressing.” The final symptoms were “ rapid invasion o f other side of faee, neck, chest, pharynx, etc.” Serum treatment was not utilized. No. 37, of Logan County, Ky., died at the age o f 51, on February 3, 1912, of “ malignant pustule; heart paralysis.” The woman’s occupation is not given on the official death blank. No. 38, of Philadelphia, Pa., died at the age of 52, on February 6, 1912, of, “ anthrax.” He was a bristle comber and hair dyer, earning $1.50 a day, and the materials he worked with came from Siberia. The illness lasted seven days, but the doctor in the case states that the man “ had no physician until the day before his death, when I was called in to attend him.” Six days before he had noticed a pimple on the back o f his neck, but “ thought it of little consequence, working every day and using antiphlogistine, and in fact intended to work the day before hi$ death, but feeling very sick he sent for me.” On examination the physician found on the back of the patient’s neck what at first seemed to be a carbuncle, but closer observation proved it was not one. It was probably anthrax. The man was “ suffering severe pain and had every evidence o f septic infection.” A few hours later excision was per formed, which the patient said gave him great relief, “ as if a bar o f iron had been removed from his neck.” The following morning the physician “ was called early and found him in extremis.” Examination o f the specimen re moved showed anthrax. No. 39, o f Mesopotamia, Ohio, died at the age o f 30, on February 13, 1912, o f “ malignant pustule on right side of fa ce; abscess of right kidney.” She was a housewife, and the physician’s history shows a long period o f neglect o f initial symptoms, “ as her people were strong Christian Scientists.” When a medical man was finally summoned he found a temperature o f “ about 103$°, pulse 110; patient went from bad to worse, until death finally ended the scene.” No. 40, o f Philadelphia, Pa., died at the age o f 47, on March 2, 1912, o f “ an thrax.” Death occurred in a hospital. The man’s occupation is given as hairdresser. No. 41, of Wilmington, Del., died at the age of 19, on March 6, 1912, of “ anthrax.” He was a morocco worker, probably in the beam house. The pustule appeared at the angle o f the jaw, and caused death by strangulation in 48 hours. No. 42, o f Toledo, Ohio, died at the age o f 57, on March 7, 1912, o f “ ex haustion from chronic cystitis; blood poisoning; anthrax, malignant pustules on leg and hand.” Nothing more definite than “ laborer ” is given as his occupation. Death occurred in a hospital. No. 43, of Boston, Mass., died at the age o f 26, on March 9, 1912, o f “ sep ticemia; anthrax.” He was a longshoreman, and for some time preceding the date o f infection had been handling hides. The assistant superintendent o f the hospital where he died on the day after admission and three days after the beginning o f the attack states that the disease took the form of a “ small pimple, increasing until sides o f face became swollen.” Examination disclosed “ very numerous, very large bacilli—bacillus anthracis.” Treatment was by excision o f a “ wide area about pustule.” No. 44, o f New York, N. Y., died at the age of 18 on June 2, 1912, o f “ malig nant pustule.” As far as the physician can recollect she was a school-teacher, “ well developed, and in good physical condition, with a previous good history.” She had been “ bit by a mosquito on the left cheek immediately below the mouth.” On the following day there was observed a “ hard, tense swelling,” which in three or four days became “ much worse, much bigger, and exceedingly 66 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. painful.” The mass was opened, but as there was no improvement a second and more extensive operation was performed the next morning. “ The patient was given appropriate vaccine treatment and everything was done for her, but she died on the following day.” No. 45, o f Cincinnati, Ohio, died at the age o f 81 on July 23, 1912, of “ anthrax or carbuncle; septicemia and asthenia.” He was. a retired pilot. No. 46, o f Allegheny County, Pa., died at the age of 55 on August 6, 1912, of “ anthrax.” The physician who made out the death certificate gave the occupa tion as foreman, but did not state in what kind of an establishment he worked. No. 47, of Orange, N. J., died at the age of 52, .on September 13, 1912, of “ inoculation by anthrax bacilli, causing general systemic poisoning.” He was a veterinary surgeon, and the medical record of the case is so clear and striking that it deserves to be quoted at length. When the patient first went to secure medical advice he had, reports the physician, “ a brownish spot at his left wrist about the size o f a wart, and his left forearm was swollen and edematous up to the elbow. He gave a history of performing an autopsy on some cows about 12 days or more previous to seeing me, at which time he scratched his right forefinger, but at once cauterized it. Nothing developed at this spot, but it seems probable that he must have scratched himself on the left wrist at the same time without knowing it.” However, “ no symptoms o f any kind developed for at least a week or more after the autopsy, and I think it was nearly two weeks afterwards that he first saw me. That morning (September 9) he walked into my office not looking sick and with a normal temperature and pulse, and his forearm, though swollen and tense, was not angry looking.” The physician did not know what to make o f his condition and immediately consulted two other surgeons, who agreed with him that “ there was evidently some form of infec tion, but none of us knew what it was.” The patient was consequently taken to a local hospital, where the pathologist took a culture from the “ wartlike brownish spot at the wrist ” and reported next morning that the culture “ showed anthrax bacilli.” By this time the swelling had “ extended 2 inches above the elbow, and the spot at the wrist was as big as a quarter.” A physi cian from a large New York hospital was called in consultation, who advised that a few drops o f blood from the patient’s right ear be taken for examination. This was done, “ and the slide showed anthrax bacilli, which indicated that the bacilli were then in the general circulation.” The patient was again taken to the local hospital, where that afternoon the New York practitioner operated, cutting out the original focus at the left wrist and making long incisions in the arm and forearm. No pus was found, but the incisions were made to relieve the tension and promote drainage. Though this operation was performed within 30 hours after the patient first presented himself for treatment, there was little hope that it would save him, as the bacilli were all through the system, as evidenced by the blood taken from the lobe o f the right ear. “ A Philadelphia firm supplied through special messenger some anthrax serum made in Italy (I believe), and this was injected subcutaneously in large doses and repeated at intervals. No instructions were given at first as to the method of injection, but latterly the serum was injected directly into the veins as advised. In spite o f all that was done, the patient gradually grew weaker and died quietly in bed September 13, 1912.” The infected spot, adds the physician first consulted, “ was unlike anything I have ever seen, and its extraordinary development within 24 hours was a sight not likely to be forgotten.” No. 48, of Stoddard County, Mo., died in Richland, Mo., at the age of 59, on October 14, 1912, o f “ anthrax.” Deceased was a farmer. No. 49, of Philadelphia, Pa., died at the age of 34 on November 14, 1912, of “ anthrax.” The man was a laborer in a tannery and was admitted to a AN TH EAX AS AN OCCUPATIONAL DISEASE. 67 hospital on the fourth day o f the attack with “ anthrax lesion on neck.” He died the following day, leaving a widow. No. 50, of Peabody, Mass., died at the age of 20, on November 18, 1912, of “ anthrax.” He had worked for about a year as a “ lumper ” in the color ing room in a morocco and calfskin tannery, at $1.50 a day. According to the hospital physician there was no special ventilation, but the workroom was cleaned daily and hot water was provided, also bichloride of mercury as a disinfectant. The disease took the form of “ pustule, immense swelling.” The pustule was cut out under local anesthetic, but death resulted suddenly from “ embolism; blood vessels obstructed at site of swelling.” From the indus trial accident board which administers the workmen’s compensation act in his State it was learned that the pustule appeared on the right breast. On No vember 18 the man “ told the foreman when he went home at night that he felt sick.” Two days later he called a physician, and he was removed to the hospital, where he died next morning. The man was married, and his dependents were entitled to compensation, but lived in Europe and the accident board was unable to locate them. No. 51, of St. Paul, Minn., died at the age o f 7, on November 20, 1912, of “ malignant pustule; blood poisoning.” The patient was a schoolgirl, and the hospital authorities “ do not know how the disease was acquired.” Illness lasted 14 days; antianthrax serum was not available. No. 52, of Graves County, Ky., died at the age o f 17, on December 4, 1912, o f “ anthrax.” She was a housekeeper. No. 53, of Ballard County, Ky., died at the age o f 28, on December 23, 1912, of “ anthrax.” Her occupation is given as housewife. No. 54, of Wilmington, Del., died at the age o f 39, on January 19, 1913, of “ malignant pustule.” He was a stationary engineer in a large morocco works. No. 55, of Philadelphia, Pa., died at the age o f 30, on January 23, 1913, of “ anthrax carbuncle of neck.” He had worked for only eight months at the establishment where he contracted the fatal infection. The uncle with whom he lived states that he complained of having a painful neck two days before he called a physician, death occurring within the succeeding 24 hours. The coroner’s inquest developed the following information: Deceased earned $9 a week working as a laborer about a factory where “ curled hair was handled.” Most of the hair was imported from Russia, South America, and England. The firm stated that “ the usual precaution, by sterilizing the hair, had been taken.” According to the coroner the firm “ supplies freely serum imported from Italy,” but the man and his uncle “ apparently neglected avail able means of treatment until too late.” No. 56, of Philadelphia, Pa., died at the age of 55, on February 13, 1913, of “ anthrax.” He was a longshoreman, and seven days before death had loaded hides and wool. First symptoms appeared seven days before death, in the form of “ pimple on right cheek.” On the day of his death the patient was ordered removed to a hospital, but died before the arrival o f the ambulance. No. 57, of Snohomish County, Wash., died at the age of 58, on February 15, 1912, of “ anthrax of right hand.” She was a housewife. No. 58, of Gloversviiie, N. Y., died at the age of 37, on March 1, 1913, o f “ anthrax; edema of glottis.” Deceased was by trade a molder in a foundry, but at the time o f contracting the disease had been employed about six months in a leather-dressing establishment, liming skins and as general helper. Here, according to the official occupational disease certificate, he “ had been helping store away raw sheepskins, and picked small pimple on side of neck.” The chief symptoms were “ papilla (small) on left side o f neck over tonsil, chills. 68 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. moderate fever, 101°-102£°; rapid pulse, 120-140; edematous swelling about head, neck, and chest.” The swelling was “ extremely rapid,” and the physician elsewhere states that “ within 24 hours it involved all the lymphatics of the neck and axilla.” Anthrax bacilli were found, but protective serum was not available. Death occurred in four days. The sheepskins the man handled were imported from South America and from Africa, and were frequently blood stained. Bloodstained materials were not eliminated, and were disinfected only by the “ tanning solutions, lime, naphthalin, etc.” The cleanliness of the workroom is described as “ generally good ” by the physician, who further states that hot water and disinfectants were furnished to the men, but no gloves or nailbrushes. The wife received a small indemnity. No. 59, of Brooklyn, N. Y., died at the age of 46, on April 6, 1913, o f “ anthrax of the n eck; fatty degeneration o f the heart.” Deceased was a druggist, and the physician who attended him was unable to determine the manner of con tagion, but found anthrax bacilli and a true anthrax pustule. Treatment was by “ antiseptic solution and antiseptic dressing.” No. 60, of Gardner, Mass., died at the age of 33, on April 12,1913, of “ anthrax infection of face.” The man was a chair maker, and the physician states that he “ could find no history of contact with hides, leather, wool, or animal mat ter.” Nevertheless, anthrax bacilli were found. April 5 he squeezed a small pimple on the right side o f his lip, and it immediately began to pain and swell. He was seen by a physician on April 7, when he had a “ congested pimple on upper lip ” and “ temperature 104°.” Two days later he returned to the phy sician, with “ extreme inflammation of side of face, hardened area with car buncle appearance.” The following day he was taken to a hospital, where he died within 48 hours. Antianthrax serum was not available. No. 61, o f Cascade, Pa., died at the age of 34, on May 2, 1913, o f “ anthrax.” He was a freight agent, and the physician states that “ infection was caused by handling foreign hides.” No. 62, o f Racine, Wis., died at the age of 33, on May 5, 1913, o f “ malignant pustule on face, also internal in mouth; edema of glottis.” The woman was a domestic servant. No. 63, of Philadelphia, Pa., died at the age o f 25, on May 9, 1913, o f “ an thrax.” The man was a haircloth maker. According to a local newspaper he felt ill after working over “ a bale of hair from Siberia,” and went home. “ Shortly afterwards, apparently slightly better, he went for a walk with his wife. Then came a sudden seizure which laid him unconscious in the street.” A physician had him sent to a hospital, but “ he died on the way.” The paper further states that the home was placed under quarantine. The hospital physician describes the symptoms as “ anthrax lesion o f left cheek.” No. 64, of Wilkes-Barre, Pa., died at the age of 4 months, on May 28, 1913, o f “ malignant pustule.” The physician states that he was called in on May 24 and found the baby girl with a “ brawny swelling about 1 inch in diameter on the left side of the face just above the lip.” Thinking it was an insect bite or an ordinary boil, he gave an antiseptic wash, but on calling the next day he found the swelling “ had extended up to and was closing the eye, and skin was of a dark purple co lo r; fever quite pronounced.” The mother then stated that she suspected the infant had been struck in the mouth with a fly swatter by an older child. The abscess grew until it involved the whole left side of the face, and then opened spontaneously. Large quantities o f pus were dis charged. The physician states positively that, “ while no microscopic exami nation was made, the clinical symptoms clearly pointed to infection by anthrax bacillus.” AN TH RAX AS A N OCCUPATIONAL DISEASE. 69 No. 65, o f Hennepin County, Minn., died at the age o f 16, on July 17, 1913, o f anthrax. The boy was the son o f a small berry farmer, and helped to cultivate the berries and also to care for the cow and horse. The boy first complained of pain between the shoulder blades, and believed an insect had bitten him. When he consulted a physician two or three days later the latter “ told him it was a big carbuncle, as it had all that appearance,” and ordered 24 hours’ poulticing. “ When he came back,” says the doctor, “ I opened it, making a cross incision to the bottom o f it, then with iodized phenol thoroughly cauter ized it out and dressed it with antiseptic gauze.” Three days afterwards the boy came back, “ having considerable temperature ” and “ more pain.” The lesion was curetted out, cauterized again, and then dressed twice daily, but “ the malignancy kept spreading, delirium developed, as well as all the marked symptoms o f blood poisoning.” A consultant was called, who pronounced the case anthrax. “ No matter how thoroughly the gangrenous parts were cleaned out and strong antiseptics used, it kept extending. Temperature kept going up until it reached 107°.” No laboratory examination was made, but the attending practitioner states that the case “ was pronounced anthrax by two physicians.” No. 66, o f North Attleboro, Mass., died at the age of 76, on July 20, 1913, of “ malignant pustule.” She had been acting as housekeeper and nurse for one o f her daughters in a neighboring town who, according to her own family physician, died of puerperal sepsis. While so engaged the woman “ scratched her finger on a nail in cellar stairway,” and was seized with “ chills ” and “ high fever.” Two days after returning to her own home the woman called a physician, who found her arm swollen and “ of dark purple,” fever 104°. “ Next morning small pustules appeared on the whole extent o f limb, and glands of axilla appeared to be a whole solid mass.” General treatment was administered to reduce the fever, three incisions were made the entire length o f the arm, and a wet bichloride o f mercury dressing (1 to 3,000) was applied. Death occurred on the fourth day o f treatment. The physician states that in his opinion “ infection was due to inoculation with bacillus anthracis.” No. 67, o f Windsor Locks, Conn., died at the age o f 49, on August 5, 1913, of “ malignant pustule; septicemia.” He was a liveryman and the physician states that “ it has never been cleared whether the case was anthrax from the start, or if the patient was inoculated with the disease subsequently when, at his request, the small pustule was opened with a penknife in the hands o f a relative.” The knife had previously been used by the patient in incising what he thought was an “ abscess ” on one o f his horses, but had disappeared before the reporting physician took charge o f the case. The disease lasted five days, appearing as “ pustule on upper lip, profound toxemia from start.” Bac teriological examination was not complete, but antianthrax serum was injected. Local treatment was by incision, drainage, and antiseptic applications. No. 68, o f Brighton, Pa., died at the age o f 34, on August 13, 1913, o f “ an thrax.” She was a housewife, and the physician states that the “ symptoms convinced him as to bacillus anthracis.” No. 69, of Wilmington, Del., died at the age o f 54, on August 23, 1913, o f “ anthrax.” He was employed by a large morocco plant. No. 70, of Lincoln, Mo., died at the age o f 28 on September 8, 1913, of “ an thrax ; metastatic pneumonia.” Deceased was “ a robust, rugged young farmer.” On September 3 the physician who was called to examine him found “ a large vesicle at the seat o f infection ” on the septum of the nose, and “ several small vesicles on the external part of the nose.” The disease had then been progress-, ing two or three days, and the whole nose was “ o f a very dark color and badly 70 BULLETIN OF THE BUREAU OF LABOR STATISTICS. swollen ” and one eye was “ swelled shut.” The nose was gangrenous in appear ance, “ and also in fact, as when I cut the nose with my knife he did not have any painful sensations.” Temperature at the first visit was 99°, pulse 90, “ and not a great deal of constitutional disturbance.” On September 4 there was little change, “ except that the gangrenous condition had extended to the left cheek.” The following day, however, “ he had a severe pain in the left side, temperature 101°, dullness on percussion over the lower lobe o f left lung, bloody expectora tion, crepitant r&les on auscultation, and a further extension of the gangrenous condition o f the face.” On the 6th there was less pain in the side, but the gangrenous condition on the face was “ still spreading.” By the 7th the right lung had become involved, there was “ considerable difficulty o f breathing, pulse rate greatly increased in frequency; gangrenous condition at this time extended below the angle o f the jaw .” On September 8 all the symptoms had become more severe, and when last seen by the physician he was “ going into a state o f collapse and died in a short time. Anything I did for him did not check the progress of the disease in the least, and had he not been of a very robust consti tution would have died sooner than he did.” None of the pathological specimens were examined microscopically, but from the clinical symptoms the doctor has no doubt that he had “ to deal with a very severe case o f anthrax.” No. 71, o f Gates, N. Y., died at the age o f 16, on September 29, 1913, o f “ splenic fe v e r; malignant facial anthrax.” The physician states that the boy “ chored around home,” and that the source o f the infection is unknown. “ Pustule appeared on lower lip, spread rapidly over whole left side o f fa c e ; chills, enlarge ment of spleen, high fever, gastroenteric hemorrhages and meningitis; died in coma.” No. 72, o f Elyria, Ohio, died at the age o f 67, on October 7, 1913, of “ anthrax; chronic nephritis.” He was a physician. No. 73, of Unity, Pa., died at the age o f 1, on October 22, 1913, of “ cholera infantum and anthrax.” The physician states that the child, a girl, was ill about three weeks. He did not think it necessary to make a microscopic examination, but is certain case “ was due to inoculation with bacillus anthracis.” Protective serum was not available. The family, he declares, was “ very unclean, and child could have contracted the disease by toying with a diseased dog or cat, or from partaking o f milk or butter, or through the agency o f flies or insects, or by inhaling dust containing the virus.” No. 74, o f Elkland, Pa., died at the age o f 52, on October 23, 1913, o f “ anthrax; infection upon the neck.” He handled hides in a tannery, re ceiving $2 a day. The hides were imported from South America and China. Bloodstained materials were not eliminated at the plant, the physician says, and he does not think disinfection was carried on or that gloves or nail brushes were furnished. The man sought medical assistance only when it was “ too late for human aid.” He was taken to Lycoming County. Anti anthrax serum was obtained in Philadelphia and freely used, but the disease had already progressed too far, and he died on the sixth day of the attack. The company paid the funeral expenses and offered the widow $500 in settle ment, which she refused. The lawyer in whose hands she put the case secured a judgment for $300, out o f which he charged a $90 fee. Apparently the suit dragged until the beginning o f 1916, for the widow states that “ they are now paying me $10 per month ” since January 1 o f that year. No. 75, of Hanford, Cal., died at the age o f 33, on November 11, 1913, of “ anthrax.” He was a ranch laborer, earning $2 a day. First symptoms •appeared on November 6, but a physician was not called until the 9th. At that time, says the - latter, “ the face was swollen on right side over antrum AN TH RAX AS AN OCCUPATIONAL DISEASE. 71 and was quite tender to pressure. Tenderness on canine and biscuspid teeth was shown when pressure was made. Eyelid edematous and red. Diagnosis at that time was made as abscess o f antrum, and operation for draining was advised.” The same evening the floor of the antrum was perforated under ether “ and a dark, bloody discharge escaped.” The patient regained con sciousness, but the next morning the swelling had greatly increased on right side, closing the eye and assuming a dark purplish hue. The left side o f the face became involved. Bloody secretions drained from nose on right side and from opening draining the antrum. “ A peculiar odor from the patient caused me to associate it with the odor I had noted in a cow dying from anthrax. Specimens taken from secretions o f nose and antrum each showed the anthrax bacillus in large numbers. At noon on the 10th the patient became uncon scious. Patient died at 3 o’clock on the afternoon o f the 11th.” Death oc curred in a sanatorium. No. 76, o f Boston, Mass., died at the age of 23, on December 13, 1913, of “ anthrax; toxemia.” Deceased was a longshoreman. From the hospital record it is learned that two weeks before admission he “ handled South Ameri can hides,” and three days before admission he “ handled American hides.” Four days before he entered the hospital a “ pimple appeared on his right neck below the angle of the jaw. Several blebs appeared later around the pimple which broke down. Pain and swelling with redness and induration followed.” At the time of admission the patient presented “ a small brown ulcer on right side of neck one-third inch in diameter, surrounded by a circle o f white blebs near by. Considerable edema o f whole right side o f neck extending as far forward as point o f ja w ; temperature, 102° ; white blood count, 32,400.” A circular excision was made and swabbed out with iodine; forced nourishment and stimulants were given; corrosive 1/5,000 dressing every four hours. Blood culture was positive for anthrax bacillus. “ Edema soon extended down whole right side of chest, turning a dusky red. Patient failed gradually since operation,” though suffering little pain. Finally he “ became delirious and in a few hours sank into coma and died.” The deceased left a dependent mother, but indemnity, which under the Massachusetts workmen’s compensation law is paid for cases of anthrax, was refused in this case, because the insurance com pany contended that the disease was not contracted while the deceased was in the employ of their policyholder, but while working for another company. No. 77, of Winchester, Va., died at the age o f 46, on December 20, 1913, of “ blood poisoning, the result o f anthrax.” He was a barber. . No. 78, of Union, N. Y., died at the age o f 56, on December 24, 1913, of “ anthrax infection.” The disease took the form o f “ anthrax edema ” ; it “ developed on the fa c e ; advance was very rapid to extensive involvement of face, head, and neck ” ; diagnosis was made on the third day and was con firmed by the State laboratories. The deceased was a farmer, and, according to the physician, “ was in the habit o f buying up old and poorly nourished cat tle, butchering them, and selling them where he could. He certainly handled diseased meat.” At the time of his death he was awaiting trial for selling tuberculous meat. “ The hired man,” continues the doctor, “ says he has gone home at night leaving a very sick cow in the stable and found in the morning a beef dressed and the sick animal missing. No questions were asked or answered in regard to it.” It therefore seems to the physician “ likely that infection took place during, or as a result of, his occupation as a handler of domestic beef, and that often diseased.” . No. 79, of South Windsor, Conn., died at the age o f 14, on January 16, 1914, of “ anthrax or malignant pustule; toxemia.” The girl had no occupation. The illness lasted 10 days. 72 B U LLETIN OF THE BUREAU OF LABOR STATISTICS. No. 80, of Camden, N. J., died at the age o f 47, on January 29, 1914, o f “ anthrax (malignant pustule).” He had been employed for eight months as a checker and receiver of horse hides imported from Russia in an estab lishment where leather was tanned and finished. Diagnosis was made on the second day of the illness. The pustule was located under the right ear. The physician also found edema o f upper chest, rapid pulse, cold extremities, no pain, and no complicating conditions. Serum treatment was used, but with no improvement. The illness lasted four days. Previous to entering the occu pation which caused his death he had been an undertaker. No. 81, o f Fremont, Ohio, died at the age of 52, on March 9, 1914, of “ rheu matism and anthrax; pericarditis.” According to the official death certificate the illness lasted three months. The occupation of the patient is not stated. No. 82, o f Philadelphia, Pa., died at the age of 30, on March 15, 1914, o f “ anthrax.” “ Anthrax bacillus was proved by finding the organism in the discharge from his cervical lesion.” The man was colored and worked as a stevedore, and three days before his death he had been “ unloading a cargo o f hair from China.” The physician who examined him at the hospital “ found a diffuse swelling of the right cervical region, with evidence o f a small pustule which had ruptured and was rather inconspicuous because o f the dark surface of the skin. The case was not diagnosed at the time as one o f malignant pustule, and an incision for the purpose o f drainage was made in the neck.” The patient came to the hospital next day, and a number o f incisions were made on his neck for the purpose of relieving his respiratory difficulty. “ He grew progressively worse, and died in the hospital ward 60 hours from the time he applied for treatment. Our cultures showed the anthrax bacillus in both cultures.” No. 83, o f Pleasant Prairie, Wis., died at the age of 55, on March 20, 1914, of “ anthrax, general infection.” He was a farmer. Physician states that the man opened a cow to ascertain the cause of its death and found in its abdomen black spots, which he dissected. The “ pubic region and limbs ” were affected. Examination showed “ various necrotic areas which rapidly broke down. Scrotum very much enlarged and necrotic.” Patient was de lirious for two days. The illness lasted seven days. No. 84, of Calexico, Cal., died at the age of 70, on April 6, 1914, o f “ sep ticemia, almost certainly due to anthrax in a cow ; died of it a few days ago.” The illness lasted five days. The patient was a housewife. No. 85, of Philadelphia, Pa., died at the age of 38, on April 6, 1914, o f “ an thrax.” She was a housewife. No. 86, o f Norfolk, Va., died at the age of 54, on April 11, 1914, o f “ anthrax (malignant edema) ; toxemia.” Illness lasted five days. No. 87, of Philadelphia, Pa., died at the age o f 60, on May 6, 1914, of “ anthrax.” He was a skin washer in a leather factory. Illness lasted four days. The physician at the hospital where he was admitted on the third day o f the disease describes the attack as “ anthrax lesion on left side of face.” No. 88, o f New Orleans, La., died at the age of 3 months, on May 29,. 1914, of “ anthrax at base of spine; scrofula.” He was ill one month. No. 89, o f Philadelphia, Pa., died at the age of 35, on June 17, 1914, o f “ anthrax.” The patient was colored; he worked as a longshoreman, and three days previous to admission to the hospital where he died he was unloading hides. “ Two days after that,” writes the physician, “ a pimple on the face began to swell rapidly, causing little pain. The swelling progressed and involved all the tissues of the neck. Anthrax serum was not used in the treatment.” AN TH RAX AS A N OCCUPATIONAL DISEASE. 73 No. 90, of Cincinnati, Ohio, died at the age of 41, on August 8, 1914, of “ anthrax infection of fa c e ; acute nephritis.” He was a tailor and presser. He became sick on August 2; the first symptom “ appeared on the upper lip, where a horsefly bit him while out in the country. Entire face swelled up and was somewhat red and edematous. Both eyes were closed from extensive swelling.” No. 91, of Lewiston, Me., died at the age of 45 years, on August 19, 1914, of “ endocarditis, with chronic rheumatism and anthrax.” His occupation was given by the official certificate as laborer, and the physician states that his average earnings were $1.75 a day. The attack is described as “ cauliflower on the back of the neck.” The treatment given was “ cruciform opening and burning with cautery.” Serum was not used. No. 92, of Hollidaysburg, Pa., died at the age of 18 years, on September 10, 1914, of “ malignant pustule.” She had no occupation. No. 98, of Wilmington, Del., died at the age o f 29, on October 10, 1914, of “ anthrax; edema of larynx.” He was a morocco worker. No. 94, o f Brooklyn, N. Y., died at the age o f 56, on November 25, 1914, of “ anthrax; infection bacillus anthracis.” The official death certificate desig nated him merely as “ laborer,” but from other sources it was learned that he worked in a tannery. “ Two days before admission to the hospital patient noticed a small pimple on neck; he said he pinched it; from that time on the neck became more and more swollen. At first there was little pain, but a diffi culty in breathing developed just before admission.” In the hospital “ excision of pustule and incisions of indurated area ” were made. The patient died four days later. Anthrax bacilli were “ recovered from all organs.” No. 95, of Smithson, Pa., died at the age of 42, on December 8, 1914, of “ anthrax.” He was a liveryman. He was two days at a hospital in McKeesport, Pa. No. 96, of Lincoln, Nebr., died at the age o f 39, on December 8, 1914, of “ septic infection due to anthrax bacillus.” Her occupation was given as house wife. She was ill one month. No. 97, o f Camden, N. J., died at the age o f 53, on December 31, 1914, of “ anthrax.” He was a laborer in a morocco factory. The physician, when called in, found the patient dying. Examination disclosed “ external anthrax, malignant pustule, high fever, edema o f glands and surrounding parts.” The illness lasted five days. No. 98, of Fort Morgan, Colo., died at the age of 1, on March 29, 1915, of “ an thrax ; measles.” The child, according to the physician, was scratched on the leg by the teeth of a small dog with which he was playing. The parents attached no importance to the incident, and did not even wash or cauterize the scratch. Two or three days later, the child was taken, with a badly swollen leg, to the phy sician, who discovered that a calf had died o f anthrax on the farm and that the dog had been getting his meals from the carcass, which had not been burned or buried. “ The child was very ill when I saw it first. No serum was available when I recognized the cause of infection. The temperature was high. The secretion from the limb was bloody. No pus. The swelling con tinued to increase and extended upward to the abdomen. The leg was kept in a wet dressing of bichloride, while stimulants were given internally.” A cul ture in blood serum was made and “ a pure culture o f anthrax ” resulted. The child was ill two weeks. No. 99, of Dos Palos, Cal., died at the age of 25, on April 3, 1915, of “ anthrax; due to bacillus anthracis.” He was a farm laborer, and at the time o f the at tack he handled cattle and cattle hides of local origin. “ Patient was taken sick 74 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. about March 21, 1915,” writes the physician of a hospital in Fresno where the man was taken for treatment. “At this time he was treated by a doctor who made the diagnosis of pleurisy with rheumatism. At the onset he had severe pain in the left side with several chills. This was shortly followed by a swelling of the right ankle, which was quite tender and painful. Patient came under our care on March 28, 1915.” In the hospital his case was diagnosed as “ pulmonary anthrax, with general blood infection.” Local treatment was applied to the pustules, which were situated on the lower eyelid and on the anterior surface o f the thigh, and smears from both lesions showed anthrax bacilli. On April 1, 40 cubic centimeters of antianthrax serum were injected intravenously; on the following day a dose of 60 cubic centimeters was given. “ This is all the antianthrax serum we were able to secure on the coast,” writes the hospital physician. The patient died on the thirteenth day of his illness. No. 100, o f Hartford City, Ind., died at the age o f 69, on April 4, 1915, o f “ malignant anthrax.” He was a merchant. The physician in charge stated that this was a case o f “ infectious febrile disease due to the inoculation into the hand o f the anthrax bacillus. Death being due to obstruction o f circula tion by these bacilli; much subcutaneous edema near the inoculation wound, and also metastatic lesions.” No. 101, o f Williamsport, Pa., died at the age o f 53, on April 25, 1915, o f “ anthrax causing edema of la ryn x; facial anthrax.” Occupation is given merely as “ laborer.” No. 102, of Coudersport, Pa., died at the age o f 31, on May 12, 1915, of “ in ternal anthrax; typical case true anthrax.” His occupation is given as laborer. No. 103, of Coudersport, Pa., died at the age of 29, on May 18, 1915, of “ septic infection; typical case true anthrax.” For several years he had been em ployed at about $1.60 per day as a laborer in a tannery, where sole leather was made. He came in contact with imported dried hides. According to the physician in charge o f the case, no sanitary precautions were taken. Not all the hides were disinfected; there was no special ventilation; the workrooms were very dirty. The disease took the form of a pustule on the neck. At the hospital, where the patient was taken, excision was performed and carbolic acid was injected around the affected area. Serum was not available; the illness lasted six days. No. 104, of Nunda, N. Y., died at the age o f 14, on May 24, 1915, o f “ septi cemia ; anthrax o f back.” Physician says “ all symptoms point to true an thrax.” The disease was not suspected until three days before the boy’s death, when diagnosis was made. The patient had high fever and delirium, and the disease developed rapidly. The boy was attending school and choring about the house. No. 105, of Endicott, N. Y., died at the age of 22, on June 1, 1915, o f “ septi cemia ; anthrax.” The deceased was employed in a leather factory unloading dry South American and Chinese hides. They were said to have been disin fected. Examination showed “ infection on arm and neck, and swollen chest.” The hospital physician states that he “ injected with 12 per cent carbolic acid and removed infected area.” No serum was given. The illness lasted two days. “ Positive diagnosis was made after death by bacteriological test of blood and tissue of arm.” No. 106, o f Thompsonville, Conn., died at the age of 35, on June 7, 1915, of “ anthrax infection; genuine anthrax; from initial ulceration on neck.” The anthrax organism was “ diagnosed in smear and culture.” He was employed in a carpet factory. The physician at the Hartford hospital, where the patient A N TH R AX AS A N OCCUPATIONAL DISEASE. 75 was taken, states that there was a “ pustule on anterior neck, and edema and cyanosis of anterior chest.” Serum was not available. The illness lasted §ix days. No. 107, of Brooklyn, N. Y., died at the age o f 6, on June 29, 1915, o f “ general asthenia from anthrax infection of nose.” “ An infectious febrile disease with local symptoms,” says the physician, “ manifested itself in nose and its accessory and other sinuses; the discharge showed a bacillus having all the characteristics o f the bacillus anthracis.” The child’s illness lasted 15 days. No. 108, of Charlestown, Mass., died at the age o f 50, on July 4, 1915, o f “ anthrax.” Autopsy showed that “ he suffered from anthrax septicemia, with associated leptomeningitis and hydrothorax.” He was a longshoreman. “ In vestigation brought out,” states the physician of the Boston hospital where the man died, “ that on May 25, 1915, he worked in the hold o f a vessel laden with dried blood, ground bones, and phosphate, and subsequently to that date assisted in the discharging o f dried hides.” No. 109, o f New Orleans, La., died at the age o f 23, on July 8, 1915, o f “ acute nephritis; edema o f lungs; bacillus anthracis; septicemia.” He was a laborer. No. 110, o f Boston, Mass., died at the age o f 38, on July 8, 1915, o f “ anthrax; neck infection with bacillus anthracis.” He was unloading dry hides at the wharves. The physician at the hospital where the patient was admitted on the day before his death describes his disease as “ septicemia with brawny swelling of right face and neck and bulla formation. No local carbuncle. Blood cultures were positive.” No. I l l , of New York City, died at the age o f 34, on July 29,1915, o f “ anthrax infection of neck.” He was a weigher in the United States customhouse and handled skins and hides from South America. His duty was to tear open bales to inspect and weigh their contents. Not all the materials he handled were disinfected, and no care was taken to prevent danger. He had been in the work since 1908 and was earning on the average $4.50 a day. The physician to whom he applied for treatment performed “ excision o f lesion and drainage.” No serum was used. The illness lasted five days. A portion o f the excised tissue was sent for examination to the research laboratory of the New York City Department o f Health, which reported: “ Microscopic examination of gland removed from neck shows anthrax bacillus in culture and liver o f dead injected mice.” The physician considered the case particularly pathetic because the widow was “ left without means and with three small children,” and since the Federal Workmen’s Compensation Act o f 1908 does not cover the employees of the customhouse, the physician’s efforts to obtain a pension from the United States Government for the widow were unsuccessful, as “ there appears to be no provision for such cases. It would seem that the Government should make some provision for the ones left dependent through its employment o f workers at occupations likely to cause their death.” A special bill for the relief of this family was finally introduced in Congress, almost a year after the man’s death, but up to the time this report was written the House Committee on Claims, to which the bill was referred, had taken no action on it. No. 112, of Bountiful, Utah, died at the age o f 65, on August 24, 1915, of “ anthrax.” Death occurred in the farmers’ ward of the county hospital at Salt Lake City, after three days’ treatment. Tlfe man was a carpenter. No. 113, of Baltimore, Md., died at the age of 20, on August 30, 1915, of “ pug tula maligna on under lip ; pyem ia; anthrax.” The victim had no employment; she lived at home with her parents and at the time of her illness was visiting 76 BU LLETIN OF TH E BUREAU OF LABOR STATISTICS. New York. The first symptoms appeared about August 18. The young woman “ had a pimple on her lower lip and, as it annoyed her, she pricked it with a needle. It steadily grew worse,” and she went to a hospital across the street. There she was treated as an outpatient for a few days. The diagnosis o f an thrax was made on August 25, and then “ injections of iodine and other germi cides ” were made and “ constitutional treatment internally ” was given. Serum was “ not obtainable. The pus filtration was very rapid and spread to the right cheek and neck alarmingly.” The physician was unable to find out to what uses the needle had been put with which the patient pricked the pimple on her lip. No. 114, o f New London, Conn., died at the age o f 57, on September 3, 1915, o f “ malignant pustule; convulsions.” His occupation is given as printer. No. 115, o f Brentwood, N. Y., died at the age of 23, on September 29, 1915, o f “ malignant anthrax edema.” She Was a clerk in the post office. The hospital physician who attended the case diagnosed it as “ infection with bacillus anthracis, which bacillus was recovered from the excised papule at the New York City research laboratory. The source of this infection, which was on the side o f the neck, was not determined.” The physician states, however, that the young woman had “ tried on clothing trimmed with fur at various department stores in New York City.” The disease took the form o f malignant edema, “ without pustule except fleabitelike papule.” Curative serium was se cured from Philadelphia, after unsuccessful efforts to obtain it in New York, and injected both subcutaneously and intravenously. Supportive treatment was also given, but death occurred on the sixth day. No. 116, o f New York City, died at the age o f 52, on October 7, 1915, o f “ anthrax.” The first symptom was an “ itching sensation on chest.” Examina tion by the hospital physician disclosed “ papule on chest, with spreading in flammation over left side o f body. Fever and prostration. Both microscopical examination and autopsy proved case to be due to bacillus anthracis.” The patient had been working for five years as a laborer and driver and during the week before illness was unloading hides from a vessel. He was ill four days; diagnosis was made on the day preceding his death. No serum was available. No. 117, o f Madison, N. Y., died at the age o f 52, on October 12, 1915, o f “ poison from anthrax; cardiac paralysis.” His occupation is not given on the official certificate. The physician stated that death was due to “ true anthrax; fever and involvement of the glands.” No. 118, o f Riverhead, N. Y., died at the age o f 71, on October 15, 1915, o f “ anthrax.” The patient was a retired lawyer and did no work except caring for his own home. The manner o f infection was a puzzle to the physicians, as he came in contact neither with nondisinfected material nor with animals. The man was never ill before. On October 8 he first noticed on his face a small lump, which soon became a red itching spot. The disease spread rapidly over his face, it reached the chin and attacked the glands of the neck. On the fol lowing day he was taken to the hospital and the disease was diagnosed as anthrax; 130 c.c. o f Eichorn’s serum were injected during the period o f three days, but without avail. Anthrax bacilli were demonstrated. No. 119, o f Blue Earth County, Minn., died at the age o f 35, on October 22, 3915, of “ external and internal anthrax.” The physician’s statement gives “ diagnosis o f inoculation with bacillus anthracis.” The patient was a house wife. Her illness lasted 12 days. No. 120, o f Bainbridge, N. Y., died at the age of 24, on November 12, 1915, of “ septicemia; probably anthrax bacillus.” The deceased was helping on her AN TH RAX AS A N OCCUPATIONAL DISEASE. 77 father’s dairy farm doing housework and milking. The disease was diagnosed as anthrax by two physicians who had seen cases before. The illness lasted 10 days. Serum was not available. No. 121, of New York City, died at the age o f 17, on November 18, 1915, o f “ anthrax.” The cause o f the death is further described by the hospital super intendent as “ infectious febrile disease due to inoculation with bacillus anthracis.” The patient was a candy packer. On November 14 she was taken ill. A physician was called, and found a small gray spot on her chest, which, according to the patient, had appeared five days previously. Within the next three days the spot became red and inflamed and her condition grew so alarm ing that she was sent to the hospital, where 40 c.c. o f serum were injected. The patient died 12 hours later. The presence o f anthrax bacilli was proved. Some physicians believed that the patient became infected from a neck piece made of cat’s fur. As a result official medical inspectors examined a large num ber o f fur-making shops, mostly on the lower East Side, where the victim bought her fur. The theory was opposed, however, by another group o f official medical men, who maintained that infection from cat’s fur is exceptionally rare. No. 122, o f Philadelphia, Pa., died at the age o f 69, on November 20, 1915, o f “ septicemia due to malignant pustule on h ip ; cirrhosis o f liver.” The dura tion of the anthrax attack is given as 1 month and 10 days, and the man’s occupation is given on the death certificate as “ cake baker.” No. 123, of Johnson City, N. Y., died at the age of 49 on November 20, 1915, o f “ anthrax.” He was a laborer in* a large tannery. His widow made a claim for indemnity under the New York workmen’s compensation law, and from the decision o f the State industrial commission it appears that “ while being shaved on November 16 his neck was slightly cut with a razor. Shortly after commencing work the following morning his neck began to swell, anthrax germs having presumably entered the cut.” On that morning, the widow states, “ there was a little white spot in the middle o f the pimple which appeared to be festered and appeared as though there was pus in it. I took a needle and pricked it and lifted up the edge o f the white part, but no pus was discharged but it bled a little.” Next day the patient was removed to a hospital where he died two days later. Smears from the anthrax bacilli were found. The industrial commission agreed that the cause o f death was anthrax and that it was contracted from the hides among which the deceased was working. Indemnity was, however, denied on the ground that the cut on the neck through which infection took place was not received in the course of employ ment. No. 124, of Lewistown, Mont., died at the age of 16, on November 21, 1915, of “ anthrax infection; septicemia.” He was a farm hand. No. 125, of Kings County, Cal., died at the age o f 56, on November 26, 1915, from “ anthrax on back of neck; exhaustion.” He was first reported as a painter but later as a laborer, not having any particular kind o f work. His illness was stated by the hospital physician to be “ due to infection of bacillus anthracis producing carbuncle and general infection.” Stimulants were given but serum was not available. He was ill two days, and died an hour after arrival at the hospital. No. 126, ©f New Brunswick, N. J., died at the age o f 25, on November 26, 1915, of “ cellulitis of neck; sepsis; anthrax; valvular heart disease.” De ceased was a laborer and worked in a clay p it The malady took the form of a large pustule on the neck, which the physician reported was “ genuine anthrax.” Anthrax bacilli were found. Serum was not available; the illness lasted three days. 78 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. No. 127, o f Chelsea, Mass., died at the age of 40, on November 27, 1915, o f “ anthrax; malignant pustule.” He was a freight handler at the wharves. “ Autopsy showed that he died from anthrax septicemia, the principal ana tomical lesions being pustule o f the cheek, focal necrosis with hemorrhage o f the stomach, jejunum, and ileum; hemorrhage* of the cervical and mesenteric lymph nodes.” No. 128, o f Winchester, Mass., died at the age of 31, on November 27, 1915, o f “ anthrax.” He was employed in a tannery. According to the physician at the Boston hospital where the man died, it was a fairly typical lesion. A crucial incision was made on the day o f admission. “ Autopsy showed that he died from anthrax septicemia, the principal anatomical lesions being pustule of the upper arm (incised) ; enlargement with hemorrhage of the axillary, mesenteric, and aortic lymph nodes; enlargement and softening of the spleen; focal necrosis and hemorrhage o f the gastrointestinal tract.” No. 129, o f New York City, died at the age of 25, on November 28, 1915, o f “ malignant anthrax; edema.” He was a medical student. No. 130, o f Willington, Conn., died at the age o f 9, on December 5, 1915, o f “ malignant pustule; general septicemia.” No bacteriological culture was taken, but according to the physician the case presented a “ perfect clinical picture of true anthrax.” The girl’s occupation is given as “ at school.” No. 131, of Brooklyn, N. Y., died at the age of 45, on December 18, 1915, o f “ anthrax; edema of glottis; acute cardiac dilatation.” He was a laborer and handled hides at the docks. On admission to the hospital “ he showed two typical punched-out ulcers with escharotic bases, small vesicles surrounding each lesion with marked inflammatory areolae. There was intense swelling and edema of the whole right side of neck extending down to chest. Anxious face, sweating o f head, pulse barely perceptible, marked difficulty in respira tion and dilated heart. * * * Patient complained o f intense general ab dominal pain (for which no reason could be discovered on ante mortem ex amination).” “ Smears from lesions o f neck showed anthrax bacilli.” Serum “ could not be obtained in time.” He died in 15$ hours after admission to the hospital, the illness lasting altogether three days. No. 132, of St. Paul, Minn., died at the age of 60, on December 27, 1915, o f “ malignant anthrax (carbuncle) on back of neck.” He was a farmer, and also occasionally did carpentering. When the physician was called he found a “ carbuncle on the posterior region of neck.” The neck was badly sw ollen; an incision was made.” The wound was dressed every day. Food and remedies to sustain strength were given and the patient was kept in bed. He was under the doctor’s care only three days. PROBABLE RATIO OF DEATHS TO TOTAL NUMBER OF CASES. Because o f the variety and the incomplete nature o f the material, any attempt to estimate the probable ratio o f fatal to total cases o f anthrax is surrounded with difficulty. In the course o f this study, data givin g figures for both fatal and nonfatal cases were secured from a number o f different sources, including a company physician, the infectious-disease reports o f four States, occupational-disease reports in two States, four hospitals, and a State workmen’s com pensation commission. The proportion o f fatal to total cases varied widely, from 3 out o f 48, or 6 per cent, in the experience o f the AN TH RAX AS AN OCCUPATIONAL DISEASE. 79 company doctor, to 15 out o f 18, or 83 per cent, in the figures reported for two years to the New Y o rk State B oard o f H ealth. U pon closer examination, however, the discrepant figures seem to be susceptible o f considerable adjustment. The ratio o f fatalities experienced by the physician in question was probably extraordi narily low, due in part to his being employed directly by the tannery companies, so that he received the cases in the early stages, and in part to his considerable experience with the disease and the conse quent development o f a more successful treatment. The reports from the four State boards o f health all covered periods o f two years or less, and showed, respectively, a fatality rate o f 2 cases out o f 17, or 12 per cent (Massachusetts), 4 cases out o f 17, or 24 per cent (T e x a s ), 3 cases out o f 5, or 60 per cent (C a lifo rn ia ), or 15 cases out o f 18, or 83 per cent (N ew Y o r k ). T he wide range displayed by these fig ures from similar sources is remarkable. Perhaps the largest single factor o f error they contain is that deaths from anthrax are likely to be reported as a matter o f routine with all other deaths, but that reports o f nonfatal cases are more likely to be neglected. T his would tend toward a preponderance o f fatalities among the cases reported, a tendency the effect o f which is evidenced by the fact that three o f the ratios in this group are higher than the median ratio secured, and that tw o o f them are the highest obtained from any source. Moreover, the low ratio in this group, that from M assa chusetts, covers a period o f only two months and four days, while there was an epidemic o f the disease in that State, so that the figures are likely to be unusual. Another group o f figures, those secured through the occupationaldisease reports o f tw o States, shows a sim ilar diversity, the New Jersey ratio for nearly four years being 1 fatal case out o f 13, or 8 per cent, while the New Y o r k ratio fo r a slightly longer period was 13 fatal cases out o f 23, or 57 per cent. Occupational-disease reports, however, are likely to suffer from the defects already men tioned as affecting infectious-disease reports, and from the further circumstance that the occupational disease reporting laws are com paratively new, are not even yet known to all physicians to whom they apply, and for business reasons are not so likely to be lived up to or enforced. T he figures from the Massachusetts W orkm en ’s Compensation Commission showed 3 fatal cases out o f 30 in which claims fo r compensation were made in three years, or 10 per cent. D ata secured from such a source should be fa irly com plete; but, since the ratio is the third lowest in the series, it is probably best not to attach too much importance to it. T he figures which from the standpoint o f accuracy o f diagnosis and completeness o f recording are probably most valuable for the 42806°— Bull. 205— 17------ 6 80 BU LLETIN OF THE BUREAU OF LABOR STATISTICS. purpose in hand are those from hospitals. Returns from four o f these institutions fo r widely varying periods were secured, and it is interesting to note that the ratios they present group closely together near the middle o f the range o f ratios studied. T hus two M assa chusetts hospitals had, respectively, fatality rates o f 6 out o f 35, or 17 per cent, and 2 out o f 4, or 50 per cent. A Philadelphia hospital had 6 fatal cases out o f 32, or 19 per cent, while a New Orleans institution had 1 out o f 5, or 20 per cent. The first, third, and fourth o f these ratios are in substantial agreement; the variation shown by the second set o f figures is possibly due to their coming from a small hospital in the same city as the much larger institution from which the larger number o f cases was reported. I f the three sets o f hospital figures which are in closest agreement, and which incidentally include the largest numbers o f hospital cases reported, are taken as a reasonable gauge, the probable proportion o f fatal to total cases would seem to be.about 1 out o f 5, or 20 per cent.1 LEGISLATION. Am erican legislation regarding anthrax deals (1 ) with the re porting o f cases, (2 ) with measures for prevention, and (3 ) with compensation or insurance for those who contract the m alady in the course o f employment. In none o f these fields is the legislation as thoroughgoing, as widespread, or as vigorously enforced as the sit uation demands, but the beginnings have been made and further study o f the subject should result in its extension and substantial improvement. REPORTING. In the United States, as in most civilized countries, the value o f reporting or n otifyin g infectious diseases is generally recognized. M ortality statistics compiled from the official certificates o f death indicate roughly the geographical distribution o f a disease and its trend toward higher or lower frequency. A s has been seen, however, the m ortality statistics o f anthrax cover but about one-fifth o f the total number o f cases, and therefore fa il to give any adequate in fo r mation on its actual extent, occupational causation, and numerous other features o f social interest. S till more im portant, only by re p orting infectious diseases as soon as diagnosed can epidemics be recognized, checked, or prevented. R eporting o f human anthrax is, nevertheless, a comparatively re cent advance in this country, being required, even as late as July, 1 This figure is in substantial accord with that of the British authorities, Bell and Legge, who state that “ In Europe about 25 per cent of all cases prove fatal.” (Allbutt and Rolleston: System of Medicine, 1906, p. 252.) AN TH RAX AS AN OCCUPATIONAL DISEASE. 81 1911, in only seven States. B u t because o f the grow ing frequency o f anthrax, together with more lively interest in occupational as well as infectious diseases, reporting laws spread rapidly, and by January, 1916, anthrax had been made notifiable in the follow ing 24 States and in Porto R ic o : A labam a, California, Connecticut, Delaware, F lorida, Illinois, Kansas, Louisiana, M aine, M aryland, Massachusetts, M ichigan, M in nesota, New Ham pshire, New Jersey, New Y ork , Ohio, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Verm ont, and W ashington. In most of these anthrax is on the list o f notifiable infectious diseases, and reports must be sent to the local board o f health or health officer, by whom they are transmitted to the State board o f health. The obligation to report usually rests upon the p h y sician, and in some States, i f there is no physician in attendance, any other person knowing o f the case is required to report it. Some States provide for the payment o f a small fee to the physician or other person m aking the report. In New Y o rk , for instance, the fee is 25 cents in cities and 20 cents in villages and towns. In M ich igan and New Jersey, 10 cents is paid, whereas in some States, such as Connecticut and California, the person reporting is entitled to 50 cents. Failure to report is usually punished by a fine, varying from $5 in M aryland to $50 in New Jersey. In some States the provisions for enforcement are more stringent. Thus in W ashington the State board o f health m ay remove from office any health officer who refuses or neglects to make prompt and accurate reports.1 In addition to requirements for notification o f infectious diseases, 12 o f these S ta te s2 have adopted statutes or administrative orders requiring physicians to report, as an occupational disease, every case o f anthrax “ contracted as the result o f the nature o f the patient’s employment.” T he standard certificates used under these statutes are usually made returnable to the State board o f health, which often must transmit them to the State department o f labor; some times, however, the reports go directly to the labor department. The blanks are more detailed than the ordinary infectious-disease blank, asking, in addition to the name and address and nature o f the illness o f the employee, his occupation, length o f time therein, and the 1 According to the weekly United States Public Health Reports there were reported between the first of the year and Nov. 1, 1916, under the infectious disease reporting laws, 48 cases of anthrax, distributed as follow s: California 7, Louisiana 6 , Massachu setts 25, Michigan 1, New Jersey 3, New York 5, Ohio 1. For special discussion of anthrax reports received under the infectious disease reporting laws of Pennsylvania and Massachusetts, see pp. 31, 38, and 79. 2 California, Connecticut, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New York, Ohio, and Rhode Island. 82 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. employer’s name, address, and business. A careful study o f occupa tional hazards is thus facilitated. T w o o f these 12 States (C a li fornia and Connecticut) offer a 50-cent fee as an inducement toward more thorough reporting; penalties for failure to report range from $5 to $50, while Minnesota provides as alternative to a $10 fine, imprisonment for not more than 10 days.1 PREVENTION. The story told by such statistics o f anthrax as the present m or tality registration and disease-reporting laws have made available is one o f steadily and, o f late, even sharply increasing prevalence. T h e cause o f this condition must be sought in the incomplete and lax character o f existing efforts at prevention, both in agriculture and in trade and manufacture, especially in the latter. Agriculture. Since anthrax in man is practically always the result o f contagion in some manner from animals, one essential in eradicating the dis ease is to prevent it among animals. Law s and regulations for the suppression o f animal anthrax have been enacted in all civilized countries and in all the large stock-raising sections o f the U nited States. Congressional action covering this matter dates from 1865, when an act was passed prohibiting the importation o f cattle from any foreign country into the U nited States.2 The Secretary o f the Treas ury was, however, given power to suspend the prohibition whenever he determined that such importation would “ not tend to the intro duction or spread o f contagious or infectious diseases am ong the cattle o f the U nited States.” E xcept fo r an extension to be men tioned later, this provision has been embodied practically unchanged in successive tariff laws, and to-day form s subsection 1 o f Section I V - H o f the tariff act o f October 3, 1913. U nder its terms im porta tions o f neat cattle were permitted in the summer o f 1916 only from Great Britain, Ireland, the Channel Islands, New Zealand, and North Am erica. In 1884, with the organization o f the Bureau o f A n im al Industry- in the Department o f Agriculture, the formulation o f rules governing importations of live stock was taken over by that department. 1 For summaries of cases reported under the New York an# the New Jersey occupa tional disease reporting statutes, see pp. 35 and 37. In New Hampshire 2 cases were reported under this law in 1815. Both patients were laborers in a tannery, and both recovered. In Maryland the remarkable case was reported in 1914 of a 15-year-old boy who contracted the disease while working as a doffer in a woolen mill. 2 United States, Statutes at Large, Vol. X IV , p. 1. AN TH RAX AS AN OCCUPATIONAL DISEASE. 83 In most States, also, the regulations do not refer specially to anthrax, but apply to infectious cattle diseases in general. A lm ost all o f these States forbid the importation o f animals affected with contagious or infectious diseases. Cases o f such diseases must be re ported, and an official o f the veterinary department is required to in vestigate, to examine the stock, and to prescribe necessary measures for the protection o f healthy stock. Diseased animals or those which have been exposed to the disease must be quarantined. T o prevent further spread o f the disease many States prescribe the killing o f affected or exposed anim als; frequently in such cases an official or a committee appraises the animals and the owner is compensated for the loss. Complete and careful destruction o f carcasses o f animals dying o f the disease and disinfection o f their stalls are also required. Failure to comply with the regulations is punishable by a fine ranging, fo r ordinary offenses, from $5 to $500. Penalties as high as $5,000 may be levied in Tennessee fo r im porting diseased stock, and in V irginia for failure to disinfect freight cars. Several States, however, chiefly in the W est and South, where stock raising is an important industry and where anthrax is prev alent, have prescribed measures specifically fo r the prevention and eradication of this scourge. These measures are on the whole similar to the general regulations just described. Periodic vaccination o f herds, which is compulsory in a number of countries abroad and which has proved its effectiveness as a preventive measure, is strongly advocated by agricultural stations in this country but is required in only a few States. In Kentucky, vaccination is prescribed for all animals which have been exposed to the disease. T he vaccine must be approved by the U nited States Bureau o f A n im al Industry, by the Kentucky Agricultural Experim ent Station, or by the State live stock sanitary board. In Pennsylvania the State live stock sanitary board, according to one o f its officials, prepares and distributes to qualified veterinarians, free o f cost, anthrax vaccine for use on ex posed animals. E a rly each spring, for years, it is reported, the board has vaccinated the stock on all premises where anthrax is known recently to have existed. Form erly the vaccine was furnished free o f cost and the work carried on at the expense o f the State. Since 1916, however, the State merely supplies the vaccine and does not pay fo r its administration. Sim ilar precautions are being taken in other States.1 1 During June and July of 1916 serious anthrax outbreaks occurred among cattle in the neighborhood of Buffalo, N. Y., in Arkansas and Texas and in the Mississippi Delta region of Louisiana. Prompt work by State veterinary officers in killing infected cattle, securing their burning or deep burial in quicklime, vaccinating exposed herds, and estab lishing quarantines, succeeded in checking the plague. Several human cases were re ported in this connection, including the death of the State veterinarian of Texas. 84 B U LLETIN OP TH E BUBEATJ OP LABOB STATISTICS. Trade and Manufacture. T he question o f prevention o f anthrax among industrial workers, which is the subject o f extensive legislation in the leading countries o f Europe, has so fa r received little attention in the United States. N ot a single special factory or workshop regulation for the safe guarding o f employees against this disease has yet been enacted by any State. W h a t governmental precautions do exist refer only to the importation o f dangerous animal materials and until January 1, 1917, these were limited in application to hides and glue stock from “ neat cattle.” T he dangers lurking in imported hair, wool, and bristles, in horsehides, and in goat and sheep skins were com pletely ignored.® Imports for the six years ending June 30,1915, of animal materials liable to carry anthrax are shown in the following table, in which the figures represent thousands of pounds: T able 7.—IMPORTS OF ANIMAL PRODUCTS LIABLE TO BE INFECTED WITH ANTHRAX, 1910 TO 1915. (Compiled from reports of United States Bureau of Foreign and Domestic Commerce on imports of mer chandise into the United States. Figures represent thousands of pounds.] Materials and exported. the country from which Year ending June 30— 1910 1911 1912 1913 1914 1915 HIDES AND SKINS, RAW OB UNCURED. Dry:Total................................................ South America.................................. Asia.................................................. Africa............................................... Green or pickled: Total................................................ South America.................................. Asia.................................................. Africa............................................... i 608,615 177,746 234,914 1152,802 76,324 i 17,490 89,235 51,639 45,433 6,593 45,515 6,317 197,140 302,849 (2) 27,295 (2) 22,345 57,656 26,331 (2) 22 (2) 257,373 231,183 55,972 54,107 72,177 6,432 60,873 5,676 314,817 329,880 52,504 71,809 26,995 399 23,440 1,209 209,119 71,085 64,881 13,777 329,095 135,191 18,835 420 137,646 193,399 195,292 247,645 263,927 Total...................................................... 37,341 21,021 30,626 29,188 47,504 South America........................................ 59,921 38,987 50,679 Asia........................................................ 121 145 342 55,415 387 44,343 711 Africa..................................................... 308,081 95,734 40,959 25,068 WOOL, HAIR OF THE CAMEL, GOAT, ALPACA, AND OTHER LIKE ANIMALS, MANUFAC TURED. HORSE AND OTHER ANIMAL HAIR MANU FACTURED. Total...................................................... South America........................................ Asia....................................................... 18,759 2,941 130 7,534 2,426 75 16,176 2,625 343 16,495 2,313 451 14,245 1.573 200 11,689 1,872 416 BRISTLES. 4,029 1,722 3,553 1,491 3,461 1,565 3,578 1,483 3,436 1,592 4,061 2,482 Total...................................................... Asia........................................................ 1 Including dry, green, and picked hides and skins. 2 Included in dry hides and skins. * ° Certain regulations did exist regarding the disinfection of wool, horse, and other hair imported from South America, but these had reference only to foot-and-mouth disease. (Treasury decisions 30783, July 13, 1910, and 32027, Nov. 23, 1911.) It is said that in one State the board of health requires hair shipped into the State to be submitted to a temperature of 200° F., but this report could not be verified. AN TH RAX AS AN OCCUPATIONAL DISEASE. 85 Precautions for obviating the danger o f anthrax from imported animal materials were first taken by Congress in 1866. In that year the same Congress which had limited the importation o f cattle as already described amended the law to apply as well to the “ hides of neat cattle.” 1 Incorporated in the original statute which it extended, this amendment also has come down to the present time as part o f the tariff law. W h ile the Department o f Agriculture, as stated, has taken over the regulation o f live-stock importations, the Treasury Department still has charge o f the regulation o f hide imports, the actual administration o f both sets of rules, however, being performed by the Quarantine D ivision o f the Bureau o f A n im al Industry. The tariff clause under discussion, however, provides only fo r the unregulated entry or the absolute exclusion o f hides from suspected areas, and is therefore likely in application to be either too lax or too strict. M ore precise safeguards against anthrax were needed, and are now authorized by section 2 o f the act o f February 2, 1903.2 T h is section empowers the* Secretary o f Agriculture to take meas ures against the introduction o f contagious diseases o f animals from a foreign country into the United States or from one State o f the United States into another. In pursuance o f this act the Secretary o f Agriculture has at various times made recommendations for the disinfection o f imported hides, with special care against anthrax, and rules embodying these recommendations have been issued by the D ivision o f Customs o f the Treasury Department. The rules in force during 1916 were based on an order which went into effect June 1, 1910.3 I t required that untanned hides o f neat cattle (later interpreted to include bu ffalo4) , hide cuttings or par ings, and glue stock, shipped from districts where anthrax was known to the Am erican consul to be prevalent, undergo disinfection by im mersion fo r at least 30 minutes in a 1 to 1,000 solution o f bichloride o f mercury. Consuls in such districts were instructed to refuse the certification o f invoices covering the above products fo r shipment to this country unless they were disinfected by the prescribed method, and admission was refused to products requiring disinfection which lacked the proper certificate. Disinfection o f suspected products on the dock upon arrival in this country or their transportation across Am erican territory was not permitted, as it m ight tend to propa gate the disease in this country. Disinfection was also required for hides produced in North America if landed and transshipped in another country in the course o f importation. The rules did not 1 United States, Statutes at Large, Vol. X IV , p. 3. 2 United States, 32 Stat., 791. 8 Treasury decision 30583, May 2, 1910. Also known as Treasury Department Circular No. 23 (Division of Customs). 4 Treasury decision 31981, Nov. 2, 1911. 86 BULLETIN OF THE BUREAU OF LABOR STATISTICS. apply, however, to goatskins, sheepskins, or articles manufactured from the hides o f neat cattle. The delay and expense necessitated by even these mild regulations caused considerable opposition among American importers, which may have been increased by the cutting off, through the war, of hide importations from Europe, especially from Russia, and the consequent augmentation o f imports from more dangerous sources, such as China. Moreover, tests seemed to show that soaking in bichloride o f mercury solution o f the prescribed strength for so brief a period as half an hour was totally insufficient to exterminate anthrax spores.1 Accordingly, late in 1915, the regulations were modified2 to permit the substitution of either o f two methods of disinfection which ex periment had indicated were more efficacious. One of these was immersion for not less than 48 hours in a solution containing 10 per cent o f sodium chloride (common salt) and 2 per cent o f hydro chloric acid in water; the other was immersion for not less than 24 hours in a solution containing 2,500 parts o f a 1 per cent formic acid solution and 1 part of mercuric chloride.3 The Secretary of Agriculture, according to the order, stated that “ these methods of disinfection for anthrax hides or anthrax suspected hides will be acceptable to his department.” In a little over four months, however, another amendment to the regulations was issued which, as far as anthrax is concerned, almost completely frustrated their purpose. This remarkable amendment4 provided that “ in future when a shipment of hides which requires * * * a certificate of disinfection arrives without such certificate ” the importer might apply for permission to perform the disinfection at his tannery. I f the importer had “ proper facilities ” the Depart ment o f Agriculture was to permit the disinfection under supervision o f an inspector from the Bureau of Animal Industry, and the cus toms collector, upon being so advised, “ shall permit the hides to go forward from the port of entry to the tannery under customs seals,” notification o f his action being sent to the inspector who is to super vise the disinfection. It has been seen, however, that in almost every group o f cases studied most o f the tannery workers contracting anthrax did so in the early processes of trucking the hides to the tannery, receiving, checking, sorting, and storing them. Another striking revelation is the large proportion of cases among longshoremen, teamsters, and other baggage handlers, including even a Government weigher at 1 See p. 118. 2 Treasury decision 3 5761, Oct. 11, 1915. 3 The same as bichloride of mercury. 4 Treasury decision 36188, Feb. 25, 1916. ANTHRAX AS AN OCCUPATIONAL DISEASE. 87 tached to the customhouse.1 In view of these facts, it would seem that permitting suspected materials to arrive in America and to spread contagion in their wake from dock to railroad, from railroad to dray, and from dray to warehouse and tannery before they were finally disinfected was a violation of elemental principles of caution and sanitation. Nevertheless, the Agriculture and the Treasury Departments con tinued to weaken their requirements. Under date of April 20, 1916, still another modification 2 was promulgated, setting forth that there after even “ foreign hides which can not be certified by an American consul as coming from a district in which * * * anthrax is not prevalent” were to be allowed the right o f shipment. The only restriction was that the bales must “ have been whitewashed under consular supervision,” and that they were “ subject to disinfection after arrival at destination in this country.” The provisions for supervising the disinfection at destination remained the same as before, but the process was made more thorough, immersion in a 1 to 1,000 solution of bichloride o f mercury for at least 48 hours being now required. While this rule extended a measure of protec tion to tannery workers in the later processes which even the original requirement o f disinfection for 30 minutes did not afford, it still left transportation workers and those engaged in receiving the hides at the tanneries exposed to the full hazard of the disease. However, even the prescribed method o f disinfection was not always sufficient to destroy the anthrax spore. Moreover, there were serious difficulties in the way of enforcement, since the consuls, who were to require the whitewashing of hides coming from anthrax-infected districts, did not always possess sufficient information as to the loca tion of the outbreaks. This source of danger was pointed out as early as 1897. “ Some of these officers (consuls) have frankly stated that the regulations for the disinfection of hides were not and could not be enforced by them.” 3 Under these circumstances the increasing number of anthrax cases continued to force attention, and in the fall of 1916 a special commit tee o f the National Association of Tanners cooperated with the Federal authorities in the preparation of more effective provisions for the disinfection of imported hides.4 Under the new regulations the importation of hides, wool, glue stock, or other products from animals affected with anthrax is prohibited. For hides from anthrax-infested districts the 30 minutes’ immersion in 1 to 1,000 1 See fatal case No. I l l , p. 75. 2 Treasury decision 36332, Apr. 20, 1916. 3 Delaware College Agricultural Experiment Station : Anthrax, A Study of National and of State Legislation on This Subject, Bui. No. X X X V I I , 1898. 4 Now issued as United States Treasury Department and Department of Agriculture Joint Order No. 1, effective Jan. 1, 1917. (See Appendix A .) 88 BULLETIN OF THE BUREAU OF LABOR STATISTICS. bichloride of mercury solution allowed at the port of shipment is extended to 24 hours’ immersion. Materials shipped without disin fection and without a consular certificate showing nonprevalence of anthrax may still be received in this country and transported, under customs seals, to the tannery, where they are to be disinfected under supervision o f an agent o f the Bureau o f Animal Industry at the tannery’s expense.. The previous method o f disinfection at the tannery, namely, soaking for not less than 48 hours in a 1 to 1,000 bichloride o f mercury solution, is still accepted, but as a substitute hides may be immersed for not less than six days in a 1 to 5,000 bichloride o f mercury solution, followed by not less than 5 days in lime o f the usual strength for dehairing, which is believed by the bureau effectively to disinfect hides against anthrax.1 The new regulations also contain for the first time detailed requirements for the disinfection o f glue stock, bones, hoofs, wool, and hair, and of cars, boats, other vehicles, and certain premises.2 The growing frequency of anthrax among industrial workers in New York and Massachusetts during 1915 and the early part o f 1916 stimulated interest in the question among officials of these States. In New York the industrial commission investigated the reported cases which developed during the last 10 months o f 1915, and called a conference on the subject for March 27, 1916. Four State depart ments were represented— the conservation commission, the depart ment of agriculture, the department of health, and the industrial commission. The conservation commission reported that in response to a petition from the residents o f one county, who complained o f a leather factory as the polluting agent, it was studying the relation t)f stream pollution to anthrax. Appointment o f a committee o f one representative from each department was suggested for the purpose of studying the question thoroughly. Recommendations later issued by the division o f industrial hygiene of the industrial commission are reprinted in Appendix A. In Massachusetts the occurrence, early in 1916, o f 25 cases, at least four o f which were fatal, and which centered among the tannery workers at Woburn and Winchester, started an investigation by the State department of health, with the cooperation o f the board of labor and industries. Investigators were sent to near-by States to. trace the suspected shipments of hides to their source and to learn whether cases had been caused by them elsewhere. It was found that 20 o f the cases were infected from one source, a cargo of dried hides from China.3 Rules subsequently suggested by the State board o f labor and industries for the handling o f hides, skins, and wool are reprinted in Appendix A. 1 See p. 120. 2 See Appendix A . 3 United States Public H ealth Reports, Dec. 15, 1916, pp. 3 3 9 9 -3 4 0 2 . 89 ANTHRAX AS AN* OCCUPATIONAL DISEASE. COMPENSATION. Also, in the matter o f workmen’s compensation for victims of oc cupational anthrax the United States has made but little progress— much less than other leading countries. While Great Britain, Ger many, France, Holland, Italy, South Australia, and the Canadian Province o f Ontario have for years been awarding such compensa tion, in the United States only one State is as yet acting consistently on this principle. The Massachusetts workmen’s compensation law, when it was drafted, was made to cover “ personal injury,” instead of merely “ personal injury by accident” as did most of the other State laws. Occupational diseases were thus included, and during the first three years o f the operation of the act, closing June 30, 1915, there were filed with the industrial accident board 30 claims for compensation on account o f occupational anthrax, in 17 o f which awards were made. 8 .—CLAIM S F O R C O M P E N SA T IO N ON ACCOU N T OF A N T H R A X F IL E D U N D E R T H E M A SSA C H U SE TTS W O R K M E N ’ S C O M P E N SA T IO N L A W , 3 Y E A R S E N D IN G JU N E 30, 1915. T a b le Compensation. Occupation. Duration of disability. Indemnity for wage loss. Medical aid. HIDE AND SKIN WORKERS. Lumper in beam house...................... No disability___ None due.............................. . . . Not reported. 1 week................. ........do................................................ Beamster................................................ Do. Do. Machine operator in beam house___ If weeks.............. ........do................................................ Lumper.................................................. If weeks.............. ........do................................................ Do. Lumper in dry loft.............................. 2f weeks.............. $2.86.................................................. Do. Lumper in storehouse......................... 2f weeks.............. $2.57.................................................. Do. Do. Lumper in beam house...................... 2f weeks.............. $5.43.................................................. Do. Tanner ................................................ 3 weeks................ Not reported................................... Do. D o.................................................... 3f weeks.............. ........do................................................ Do .................................................. 4 weeks................ ........do................................................ Do. weeks.............. $14.28................................................ $5.00. Leather finisher doing “ seasoning” . Foreman in rough stock department. 6 weeks................ $18.00................................................ Not reported. Do. Laborer in leather factory.................. ........do................... $16.00................................................ Do. Tanner. ......................................... 6f weeks.............. Not reported................................... .. Do. Lumper ............................ ................... 7 weeks.............. $21.43................................... . weeks.............. $23.79................................................ Splitter of skins in leather factory... Do. Lumper in coloring room of a calf Fatal.................... Unable to locate dependents in Do. Europe. skin tannery. Do. Worker in soaks in beam house........ ........do.................. ........do................................................ 5f 7f : TRANSPORTATION WORKERS. Longshoreman...................................... D o.................................................... ................................. Do Do ......................................... D o.................................................... Do ................................. 1 week................. 3f weeks.............. 5? weeks.............. 6weeks................ 85- weeks.............. Fatal.................... Do. None due........................................ $11.42................................................ Do. $23.22................................................ $16.00. $24.00................................................ Not reported. Do. $58.04. .......................................... C1) 0 ) Laborer for private weigher............. 7 f weeks............ $34.46....................................._ ............. Not reported. Do............................................. 15 weeks.............. $78.00................................................ $56.00. Do ....................... 15? weeks............ $110.86................................................... $1.00. WOOL AND HAIR WORKERS. Foreman wool-pulling department.. 2weeks............. None due......................................... Picker hand in felt factory................. I l f weeks............ $83.84................................................ Over 2 years; $754.69.............................................. Brush drawer in brush factory . exact time not reported. i Compensation refused. $9.50. Not reported. $18.29. 90 BULLETIN OF THE BUREAU OF LABOR STATISTICS. Hide and skin workers made up over one-half of the claimants, or 18 out o f the 30. O f these, seven were “ lumpers ” in leather fac tories, six o f whom were employed in one establishment in Salem. One was a foreman in the “ rough stock ” department in a goat and sheepskin tannery; one was splitting skins in a leather factory; one was a leather finisher engaged in “ seasoning ”—he applied finish to skins with a sponge, and an “ eruption on both his hands and fore arms ” is reported. One tannery employee worked in “ soaks in beam house” ; there were also a “ machine operator in beam house,” a “ beamster,” and a laborer, all employed in leather factories. In four cases it was merely stated the “ men worked in tanneries.” Transportation workers were represented by nine claimants. Six o f these were longshoremen, of whom five were employed by one concern in Boston. One was, by his own testimony, on or about July 24, “ discharging buffalo hides from a steamship. I had been on this job four days when I got a scratch on my arm. The following day I noticed something like a Avart which was itchy. I finished the job and there was no work until August 5. I started to go to work on this day, but my arm was itchy and sore, and I went to the hospital instead, where they said I had anthrax, and was operated on right away.” Another of the longshoremen “ had been pushing behind truck unloading hidfcs for three days, and he stopped work at the end o f the third day, as his hands began to swell ” ; two were “ handling salt hides,” and one “ green ” hides, at the time they contracted an thrax; the sixth was unloading wool and hides, in addition to other cargo. The remaining three transportation workers were reported as “ laborers,” all employed by a firm of weighers in Boston. Two cases occurred among woolworkers; one was a foreman in the wool-pulling department o f an establishment where wool was pulled and scoured; the other was a “ picker hand ” in a felt factory. The report reads: “ Sliver ran into his leg. It was removed and leg was poisoned from wool. Anthrax and complications on left lower ex tremity.” One applicant for compensation was a brush drawer. She scratched her face over the left eye, and as a result anthrax developed. The periods o f disability ranged from one week to over two years. In one case no disability resulted and the employee remained at work; five workers were disabled from one to two weeks. In none of these six cases was compensation awarded, as the law requires a waiting period of two weeks. Medical aid is allowed by the Massa chusetts law from the day o f disability, but in only one of these six cases was it stated that such aid was given. In the remaining cases disability lasted beyond two weeks, and 17 awards for compensation, beginning with the third week and equal to two-thirds o f average weekly wages, were made. The amounts ranged from $2.57 for a ANTHRAX AS AN OCCUPATIONAL DISEASE. 91 disability of two and two-sevenths weeks to $754.69 for a disability o f over two years. This case was finally disposed of by a lump-sum payment toward the close of the second year of weekly payments. In addition to the weekly indemnity for loss of wages, medical attendance costing from $1 to $56 was paid for in at least six cases. Three o f the claims were filed in behalf of workers whose anthrax attacks ended fatally, the course of the disease being extremely rapid in all three instances. Two o f the victims were taken to a hospital two days after they began to feel i l l ; one died in five hours and the other in 17 hours after admission. In neither of these cases was compensation paid, as it was impossible to locate the dependents in Europe. In the third fatal case, in which death occurred three days after admission to the hospital, the claim for compensation filed by the victim’s mother was disallowed by the arbitration committee to which it was referred. While there was no question as to the cause o f death, the insurer contended that the disease was not contracted while the deceased was in the employ o f their policyholder, but while working for another company, which was not insured under the act. One-third (10) of the cases considered in this section occurred in Boston. Six were from Salem; Haverhill, Peabody, and Lynn fur nished each two cases; Worcester, Davenport, Millbury, and Woburn, one case each; in the remaining four cases the place o f employment could not be ascertained. Only one of those injured was a woman. The youngest was 17 years old; one-half, or 15, were between the ages o f 20 and 29, eight were between 30 and 39, five between 40 and 49, and one was 60 years o f age. Most frequently, or in nine cases, the lesions were on the face. In seven they were on the hand or arm ; five workers, of whom one died, had the pustule on the neck; one, who died, had it on the chest, and one on the leg. In the seven other cases the location o f the lesion was not stated; one o f these, however, ended fatally and, judging by the symptoms, it was probably a case of internal anthrax. The cause o f death was given as “ lobar pneumonia,” and for this reason the case was not listed among those reported in the United States registration area. Nevertheless, a blood smear sent to Harvard Medical School showed the presence o f anthrax bacilli. Another State which has taken the same enlightened position as Massachusetts is California. The compensation statute o f this western Commonwealth applied, as enacted, only to “ personal in jury sustained . . . by accident.” By amendment in 1915 the words “ by accident” were stricken out, so that the law is now as broad in scope as that o f Massachusetts. Up to May 1, 1916, however, no claim for anthrax had been presented to the industrial accident commission, so that the first California award for this trade illness had still to be made. In 1915, also, Pennsylvania amended its 92 BULLETIN OF THE BUREAU OF LABOR STATISTICS. constitution to allow the passage o f a law establishing compensa tion for occupational diseases, and the legislature o f 1917 will have an opportunity to enact the necessary legislation. The compensation laws of the remaining States do not cover dis eases o f occupation. Nevertheless in a certain number of cases indemnity for anthrax has been allowed when infection developed as a result o f an accidental injury sustained by the worker in the course o f employment. In New York, for instance, five such claims were filed during the first 22 months of the operation o f the act (July 1, 1914, to May 1, 1916). In three cases agreements were arrived at between the in jured workmen and the insurance carriers, and compensation for periods ranging from two to six and two-sixths weeks had already been paid at the time o f this writing. In another case, in which death occurred, it was recommended that the claim be disallowed as the scratch through which infection occurred was received while the man was being shaved, and was not due to an accident in the course o f employment.1 On the remaining claim, which was the first to be presented in New York, the commission awarded seven and fivesixths weeks’ compensation. The insurance company took an appeal, but later withdrew it and paid the claim. The workman concerned, an employee in a plant where raw skins are handled, was trimming sheepskins on the day o f the accident. He hit his jaw against the beam on which he was placing skins for the purpose of cutting off the head, tail, and legs. The accident occurred in the forenoon and caused an abrasion o f the skin, with pain and smarting, so that during the afternoon the claimant frequently rubbed the sore place with his hand. On the next day a doctor was called in, found a pustule at the seat o f the injury, and diagnosed the case as anthrax. The commission decided that the injury “ was an accidental injury, and arose out o f and in the course of his employment.” The in surance carrier appealed on the ground that anthrax is an occupa tional disease in tanning, and that therefore the compensation act does not require damages, but the court sustained the commission, thus establishing a favorable precedent for New York State.2 The situation in New Jersey is the same as that in New York. Records o f the employers’ liability commission in that State for the year 1915 reveal four cases in which “ there was previously a specific accident which later became infected (anthrax).” In three cases the employees were working on hides and skins; the occupation of the fourth worker is not given; it is merely stated that he was in jured on a shearing machine. One was a fatal case; the other em 1 For authentic cases of infection through shaving brushes, see p. 23. 2 The appeal was argued in the Appellate Division of the Supreme Court, a t Albany, during the M ay, 1916, term. ANTHRAX AS AN OCCUPATIONAL DISEASE. 93 ployees were out for three, five and two-sixths, and eight weeks, re spectively. The amounts awarded in the fatal case, where there were no dependents, were $100 for burial and $13 for medical aid. In the other cases compensation at half the average wages amounted to $29.17, $16.67, and $36, respectively, and for medical aid $33, $41.50, and $44 was allowed. In Pennsylvania the workmen’s compensation law of 1916, similar in intent to the laws o f New York and New Jersey, provides that “ the terms ‘ in ju ry ’ and ‘ personal in ju ry’ as used in this act shall be construed to mean only violence to the physical structure of the body, and, such disease or infection as naturally results therefrom.” When in April, 1916, a claim was filed with the workmen’s compensation board on the part o f a hair sorter1 who had contracted anthrax, the claim was disallowed, as the examination o f the physician u dis closed no evidence o f any wound or cut upon the person of the claimant nor did the investigation, made at this time, discover any unusual incident or occurrence that had happened to the employee in the course o f his employment. The claimant also admitted that there had been no wound or other unusual incident.” As far as can be learned no other State has yet been called upon to decide a compensation claim arising from anthrax, but probably the outcome would be the same as in New York and New Jersey. While this would permit indemnity for a limited number o f cases— those resulting from a definite physical wound—such a policy is far from just. In equity to sufferers from the disease, no less than from the standpoint o f enlisting the full interest o f employers in methods o f preventing infection, all cases of occupational anthrax should be compensated upon the same terms as industrial accidents. 1 W orking in a tannery. C H A P T E R V . ANTHRAX IN EUROPE. In Europe, where occupational, anthrax has been a matter of public moment for a much longer period than in the United States, the cam paign against it has been pressed with a consistency and vigor not yet displayed in this country. Among legislators and administrative officials, no less than among employers and physicians, there has been keen realization of the dangers o f the scourge and of the urgency o f measures for its eradication. PRIVATE ACTIVITY. The dramatic acuteness and high mortality of anthrax have led abroad to considerable private activity for its study, cure, and pre vention. In England, Germany, France, and Italy influential associ ations of manufacturers have interested themselves in the problem, while scientific societies o f international scope have cooperated in the campaign. ANTHRAX INVESTIGATION BOARD FOR BRADFORD AND DISTRICT. Since in England the manipulation of dangerous kinds of wool is practically confined to the West Riding of Yorkshire, the chamber o f commerce o f that district, at a joint meeting with representatives o f labor unions, organized in 1905 the now famous Anthrax Investiga tion Board for Bradford and District. The purposes of this organi zation are (1) the investigation of anthrax generally; (2) the more precise determination of the classes o f wool and hair in connection with which the danger of anthrax arises; and (3) the discovery of further means of prevention. The investigation is carried on through inquiries into cases of anthrax, and samples are collected of the material causing the infection. The data thus obtained are brought to the knowledge of the manufacturers. The board has en gaged the services of a bacteriologist, some of whose duties are (1) the examination of material which has caused outbreaks o f anthrax; (2) systematic examination of samples irrespective o f any such outbreaks; (3) studying o f the part played in infection by the sand, dirt, and organisms present in the material; (4) verification of doubtful cases and examination o f material submitted by physicians* Particularly careful study is given to the urgent question of disin fecting raw wool, and especially to the removal of blood clots and bloodstained fibers, which are frequent carriers o f spores. 42806°— Bull. 205—17------ 7 95 96 BULLETIN OF THE BUREAU OF LABOR STATISTICS. In order to secure effective results a large and representative mem bership was considered necessary. The board is therefore composed, in addition to the bacteriologist, the honorary consulting chemist, and the secretary, of 18 members, elected annually from among the manufacturers, the members of the Bradford Chamber of Commerce, and the health committee of the Bradford City Council; occasionally representatives of organized labor are included. The activity of the board is made possible chiefly by private contributions, the majority o f contributors being employers, although labor organizations and occasionally private individuals also subscribe. A point deserving special mention is the annual subvention of $250 granted for several years by the Home Office'^ which in 1913 was raised to $500. T o obtain the highest possible degree of efficiency the board is con stantly seeking the cooperation of the medical profession. Circulars are distributed inviting physicians to send in information of each case o f suspected anthrax, together with serum or blood for examina tion. The board emphasizes the necessity o f speedy action in sus pected cases and urges particular care with regard to bloodstained materials. Its statistics, which will be discussed later, are excellent, and the educational propaganda which it carries on is undoubtedly an important factor in the antianthrax campaign. GERMAN EMPLOYERS' MUTUAL TRADE ASSOCIATIONS. The activity of the German manufacturers has taken an entirely different form. In Germany preventive measures are introduced by the employers’ mutual trade associations ( Berufsgenossenschaften ) in those trades where the danger o f anthrax is present. These asso ciations are organized primarily for the purpose o f carrying mutual Workmen’s compensation insurance. Since it is to their financial ad vantage to have as few industrial accidents as possible, the activity of these associations is remarkably effective, aiming at the pre vention o f both industrial accidents and diseases. The employ ers o f practically all industries have combined into such associations and, as anthrax is compensated as an industrial injury, the associations for the leather, wool, hair, and brush industries have set forth carefully worked out rules based on the latest achieve ments o f technical and sanitary science. These rules when officially indorsed have the force of law. A considerable incentive to the ob servance o f these rules is provided in the cleverly arranged sliding scale o f premiums required from the employer and based on the number and effectiveness o f safeguards introduced in his factory; that is, the more attention is paid to disease and accident prevention, the lower are the insurance premiums charged the owner of .the establishment. ANTHRAX AS AN OCCUPATIONAL DISEASE. 97 The employers conduct the accident insurance activity of the trade associations, but in order to elicit the fullest cooperation of the workers they have given the latter a voice in framing the safety and sanitation rules; they have gone even further and have made the workers responsible for compliance with those rules which con cern them. The value o f personal appeal has also been appreciated by these associations; they have addressed warnings to the workers instructing them in the dangers and urging precaution. The remark able thoroughness with which these employers’ mutual associations have carried out their tasks has placed them in the foreground as powerful factors in the promotion o f industrial health and safety. ASSOCIATION OF FRENCH MANUFACTURERS FOR THE PREVENTION OF INDUS TRIAL ACCIDENTS. The idea o f employers’ mutual organization for the purpose of accident prevention has found application in other countries also. In France in 1883 the manufacturers combined into the “ Association des industrials de France contre les accidents du travail,” which by a Government order was recognized in 1891 as a public service or ganization ( Etablissem ent (Putilite publique ).1 This association pub lishes instructions to workers similar to those issued by the Home Office in England and by the German trade associations, and re quires that they be posted in work places* where the danger o f anthrax is present. MILAN LABOR CLINIC AND OTHER PRIVATE ACTIVITY IN ITALY. In 1910 the celebrated Labor Clinic at Milan, the first of its kind in the world, was established by a group of socially minded medical men “ for the scientific study and prevention of occupational dis eases.” In cooperation with the Permanent International Commis sion for the Study o f Occupational Diseases, which has its head quarters in the same city, the clinic has issued sanitary regulations and is carrying on an educational propaganda among workers and employers in the industries which involve exposure to anthrax. There exists in Italy also the Industrial Employers’ Association for the Prevention o f Industrial Accidents ( Associazione degli Ind us tria li per prevenire g li In fo rtu n i del Lavo ro ), an organization very similar to the French association which has already been described. This body issues instructions for workers, and also publishes occa sional studies on occupational anthrax. A notable instance of self-imposed but rigidly observed regula tions is found in the hair works o f Carlo Pachetti & Co., at Pavia. This is the largest establishment of its kind in Italy, and it re ceives practically all the hair imported. The firm is equipped with 1 Walter Abelsdorff: Gewerbliche Milzbrandvergiftungen in Deutschland, Frankreich, England, und Holland, 1915, p. 7. 98 BULLETIN OF THE BUREAU OF LABOR STATISTICS. all the requisites of modern industrial hygiene, and has adopted the most advanced measures for the prevention o f anthrax. Each process is carefully regulated. The hair is disinfected; great care is given to ventilation, cleanliness, and the elimination o f dust; and medical supervision o f the highest order is instituted, even a bac teriological laboratory being provided and a supply o f the Sclavo serum being kept. The proprietor states that cases of anthrax are detected in the earlier stages and promptly treated, and that the patients usually recover “ without cessation o f work for more than a day or two.” 1 INTERNATIONAL ORGANIZATIONS AND CONGRESSES. Anthrax has also been carefully studied outside o f industry. Besides the Permanent International Commission for the Study of Occupational Diseases, already mentioned, both international con gresses on occupational diseases which have so far taken place, one at Milan in 1906 and the other at Brussels in 1910, have discussed the subject. More prominence was given to it on the program o f the proposed third congress on occupational diseases, which was scheduled for Vienna in 1914 but was postponed on account of the war. In that congress, papers were to be read by such authorities as Dr. Legge o f England, Cavaille o f France, and Dr. Holtzmann of Germany. Keen interest is also taken in the subject by the International Asso ciation for Labor Legislation, o f which the American Association for Labor Legislation is an active branch. At the seventh delegates’ meeting o f the international body, which took place in Zurich Sep tember 10 to 12, 1912, a subcommittee was appointed for the study o f occupational anthrax, the recommendations o f which will be found in the concluding part o f this report. The subject was also on the program o f the eighth delegates’ meeting, which was expected to meet in Bern September 14 to 17, 1914. GOVERNMENTAL INVESTIGATIONS. Probably the first official investigation of anthrax was made in 1842 in France. In that country severe epidemics of the disease among animals in certain districts and its consequent frequency among human beings had led to these areas being called “ champs maudits,” or cursed fields. The investigation was undertaken at a time when medical science was rather primitive, and antedated by eight years the discovery o f the bacterium. Hence it did not bring forth any considerable results, but the interest of the Government is significant. In later years the question of anthrax was taken up by a commission on industrial hygiene organized under the Ministry o f Labor. 1 See C. H. W. Page : British Industrial Anthrax, in Journal of Hygiene, December, 1909, p. 373. ANTHRAX AS AN OCCUPATIONAL DISEASE. 99 In England the initiative against anthrax was taken by Parlia ment, where this subject was considered as early as 1878. In the year 1880 the Government, alarmed by the large number of cases among workers, appointed a commission to study the situation. In 1893 another official investigation was undertaken. These efforts, however, did not solve the problem, and in the year 1913 the Home Office considered it necessary to appoint a departmental committee for the purpose o f investigating anthrax in the textile industries. In Germany the Government was stirred by the alarming propor tions which the disease assumed in the hair factories of Nuremberg and in 1894 an investigation was ordered all over the Empire. Inquiries on a more limited scale had been made as early as 1875. In Belgium anthrax has been a familiar subject for many years, but it was not until 1900 that Government interest became active. A t that time several cases occurred in an important tannery and the Government ordered the medical factory inspectors to make an investigation, which, at first limited to skin and hair industries, was afterwards extended to all other occupations subject to the danger of anthrax. Moved to action by the number of anthrax cases reported in the tanning industry under the accident compensation law of 1901, the general director o f labor in Holland also ordered a painstaking investigation o f that industry, the report of which was published in 1913.1 SYSTEMATIC REPORTING AND RESULTANT DATA. Illuminating as are most of the studies just mentioned, they cover only limited periods, and emphasize the necessity for more thorough, continuous collection of data. This has been sought in various coun tries, usually through the enactment of compulsory reporting laws. GREAT BRITAIN. Apparently the earliest requirement concerning the reporting of anthrax as an occupational disease is found in section 29 of the Brit ish Factory and Workshop Act o f 1895,2 later superseded by the similar law of 1901.3 Section 73 of the latter act, referring to dan gerous and unhealthful industries, requires every medical practitioner called in to visit a patient suffering from lead, phosphorus, arsenic, or mercury poisoning, or anthrax, contracted in a factory or work shop, to report the case to the chief inspector of factories at the Home Office, London. For every notice sent, the physician receives a fee o f 2s. 6d. (61 cents), while failure to comply with the law makes 1 Directie van den Arbeid. 2 57 and 58 Viet., ch. 37. S i Edw. V II, ch. 22. De Looinijverheid in Nederland, The Hague. 1913. 100 BULLETIN OF THE BUREAU OF LABOR STATISTICS. him liable to a fine o f not over 40s. ($9.73). Similarly the manager or owner o f the factory must report every case o f any of the abovementioned diseases to the inspector and to the certifying surgeon for the district. Upon receipt of the report the latter must visit the patient and the place where the case occurred and report to the chief inspector. The report by the factory management must cover the following points: 1. Name o f establishment. 2. Name and address o f proprietor. 3. Kind o f work done. 4. Nature o f the disease. 5. Name and address o f the patient. 6. Age and sex. 7. Precise statement as to occupation. In the report of the factory inspector to the Home Office, which must be sent within seven days after receipt o f the report from the certifying surgeon, the sorts of suspected wool, hair, bristles, hides, or skins must be stated, as well as the country o f origin. For the first few years but a small number o f cases was reported— only 114, for instance, for the years 1896 to 1899, inclusive. Since that date reporting has been more complete, and larger numbers of cases have been brought to official attention. The following table is compiled from the annual reports of the chief factory inspector o f Great Britain and shows the number of cases o f anthrax reported to that official for the years 1900 to 1913 and the number o f these cases which were fatal: T a b le 9 . —CASES OF A N T H R A X AN D NU M BER OF D EATH S T H E R E F R O M R E P O R TE D TO CHIEF F A C T O R Y INSPECTOR OF G R EAT B R IT A IN , 1900 TO 1913, B Y IN D U ST R IE S A N D Y E A R S. [Source: Seventeenth Abstract of Labor Statistics of the United Kingdom, 1015, pp. 124,125.] Wool industry. Skins and hides. Horsehair. Other industries. Total. Year. Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths re re re re re re re re re re ported. ported. ported. ported. ported. ported. ported. ported. ported. ported. 1900.............................. 1901.............................. 1902.............................. 1903.............................. 1904.............................. 1905.............................. 1906.............................. 1907.............................. 1908.............................. 1909.............................. 1910.............................. 1911 ............................ 1912.............................. 1913.............................. 9 6 12 20 12 34 24 23 18 28 28 35 31 43 2 4 2 5 1 12 8 3 3 3 3 10 6 4 12 9 10 7 12 7 10 17 10 8 6 8 7 5 3 1 2 1 4 1 5 4 Total................ 323 66 128 1 5 5 1 3 4 5 2 1 6 3 1 9 20 11 12 18 17 18 12 13 18 14 20 8 19 26 209 2 1 1 2 7 4 5 8 8 1 14 6 6 2 3 1 1 3 38 69 1 5 2 1 3 2 3 1 2 37 39 38 47 50 59 66 58 47 56 51 64 47 70 7 10 9 12 10 18 21 11 7 12 9 11 6 7 20 729 150 AN TH RAX AS AN OCCUPATIONAL DISEASE. 101 These data show a marked though irregular increase in the number o f cases reported, which appears rather unexpected in view of the several preventive measures introduced during that period. The increase, however, may be due not to the lack or ineffectiveness of protective legislation, but to more extensive use o f dangerous mate rials or to a more satisfactory compliance with the notification law. Probably the fact that the "Workmen’s Compensation Act o f 19061 made anthrax a compensable disease has had much to do with securing fuller reports. As will be seen from the table, the frequency of anthrax varies considerably in the different industries. It is significant that in 11 o f the 14 years for which the data are given the largest number o f cases occurred in the wool industry, which is more developed in England than any o f the other industries subject to anthrax. In 6 o f these 11 years, also5 one-half or more of the total cases of anthrax reported each year occurred in that industry. Next in the prevalence o f anthrax is the leather industry. Practically all industrial cases o f the disease occur among workers in the wool and leather industries and in animal-hair works; in the remaining occupations anthrax is less frequent. Air important element in anthrax statistics is the death rate. A high rate may mean absence o f curative measures, or it may mean lack o f familiarity with the symptoms of the disease, which prevents early diagnosis and postpones treatment to a stage when cure is no Longer possible. The death rate for the seven years 1900 to 1906 was 25.9 per 100 cases; but a marked improvement took place in the subsequent similar period, when it was only 16 per cent. More detailed statistics are available for the wool industry o f the West Riding o f Yorkshire, which is under the supervision o f the anthrax investigation board organized for that district. The fol lowing table illustrates the situation in that industry: 10.—CASES OF ANTHRAX IN THE WOOL INDUSTRY REPORTED TO THE AN THRAX INVESTIGATION BOARD FOR BRADFORD AND DISTRICT, 1906 TO 1914. T a b le [Compiled from annual reports of the Anthrax Investigation Board for Bradford and District.! Cases reported. Year ending Oct. s i - External. Internal. igo?............ 1908............ 1909............ 1910............ 1911............ 1912............ 1913............ 1914............ 1915............ 14 15 Total. .. 129 1 6 Edw. 11 8 17 12 20 18 14 Total. 1 2 1 12 10 5 3 19 18 1 21 2 15 Deaths reported. 18 12 18 16 144 VII, ch. 47, third schedule. 3 *3 2 1 8 5 3 5 2 32 102 BULLETIN OF THE BUREAU OF LABOR STATISTICS. Comparison of these data with the data for the wool industry of the whole country for the almost exactly corresponding period of 1906 to 1913 shows that more than one-half of the anthrax cases in this industry occur in the district o f the West Kiding. The high fre quency o f anthrax in that district is caused by the use of wool im ported from such countries as Persia, Turkey, India, and Russia, where anthrax is endemic and where very little or no attention is given to the requirements of hygiene. GERMANY. In another leading European country, Germany, where consider able attention is being given to the subject of anthrax, fairly com plete data are obtainable, but only for the last few years. For the years 1894 to 1903 admittedly incomplete statistics are reported by Dr. Legge.1 He states that in that period there were 901 cases of anthrax, including those in agriculture as well as in manufacturing, o f which 128 were fatal. A great improvement in the collection of information was brought about in 1910, when an order of the Federal Council went into effect, extending to anthrax the notification and other provisions of the act o f 1900 relative to diseases constituting a public menace. Besides the usual data as to name, sex, age, address, and occupa tion, the following information, important from the medical point of view, must be given: 1. Date when taken ill. 2. Date o f first medical treatment. 3. Date o f admission to a hospital. 4. Date when the disease was diagnosed by the doctor as anthrax. 5. Was the disease bacteriologically recognized as anthrax ? When ? B y whom? 6. Nature o f the disease: Anthrax of the lungs, anthrax of the bowels, anthrax o f the skin? I f anthrax of the skin, what part of the body was affected? 7. Has the sick person recovered ? Has he died ? When ? Even more minutely are taken up the questions o f the patient’s occupation and o f the manner in which infection was transmitted. The method o f filling out the schedule calls for cooperation between several governmental agencies, namely, the police authorities, the district medical man or veterinary surgeon, and the factory inspec tor. A duplicate of the filled-in schedule is sent to the authority in trusted by the provincial government with its verification. Upon verification a copy is transmitted to the Imperial Health Office at Berlin, where it must be received within two weeks o f recovery or death o f the patient. 1 T. M. Legge, in The Lancet, Mar. 18, 1905, p. 692. 103 AN THE AX AS AN OCCUPATIONAL DISEASE, The statistics obtained under this law are published annually and are of more interest than the English figures because they include all cases, nonoccupational as well as occupational. Up to the present, figures are available only for the years 1910 to 1912. T a b le 11.—CASES OF ANTHRAX REPORTED TO THE IMPERIAL HEALTH OFFICE OF GERMANY, 1910 TO 1912. [Compiled from Reichs-Arbeitsblatt, July, 1914, p. 588.] 1910 Industry. Agriculture......................... Cattledealers, veterinarians, and fl£|yers....................... Tannery and other leather workers........................... Hair and brush workers... Wool combing................ . . Miscellaneous...................... 1911 1912 Cases Deaths Deaths Cases Deaths Deaths Cases Deaths Deaths report report per 100 report report per 100 report report per 100 ed. ed. ed. cases. ed. ed. cases. ed. cases. 121 142 12 14 103 15 19 3 1 9 Total occupational.., 263 Total anthrax............ 287 10 1 17 1 75 19 9 10 78 7 4 4 21 5 i6 6 36 13.7 261 36 13.8 246 28 11.4 40 13.9 281 40 14.2 274 36 13.1 2 - 114 16 16 1.......... 1 Taking the cases in the last four groups as those of anthrax in manufacturing pursuits, we obtain for the year 1910, 128 such cases; for 1911, 103 cases; and for 1912, 115. A comparison o f the individ ual occupations shows that agriculture, followed by the leather in dustry, heads the list in each o f the three years. The death rate is somewhat higher than that shown by the English figures (17.6, 17.2, and 12.8) for the corresponding years; it is also higher for the nonoccupational group than for the occupations, which is true in other countries also. This is explained by the comparative in frequency of nonoccupational. anthrax and consequent lack of fa miliarity with the symptoms on the part of the victims and their physicians. • Owing to the brief period covered by the data no conclusions can* be drawn as to fluctuations in the prevalence of the disease, but the situation in the leather industry is worth noting. The number of cases dropped from 103 in 1910 to 75 in 1911, and to 78 in 1912. This was probably due to the effective preventive regulations for that industry which went into effect in the latter part of 1910. The distribution by sex of all cases reported in the three years was as follows: Year. 1910......... 1911......... 1912......... Males. 257 264 254 Females. 30 17 20 Total. 287 281 274 104 BU LLETIN OF THE BUREAU OF LABOR STATISTICS, The small number o f eases among women is explained by their more limited employment in the occupations subject to anthrax. FRANCE. In France, also, anthrax statistics are of a very recent origin. They are now being collected as a result of the ministerial order of July 20, 1910, but, as in England, only cases of industrial anthrax are included. For the years 1910 to 1912 the cases reported were distributed among the industries as follow s: TABLE 1 2 .—CASES OF ANTHRAX REPORTED IN FRANCE, 1910 TO 1912. [Compiled from Reichs-Arbeitsblatt, July, 1914, p. 589.] Industry. 1910 1911 1912 Leather...................... Wool.......................... Hair.......................... Other......................... 36 23 7 3 9 22 6 4 4 Total................... 54 42 38 10 5 5 According to sex the cases were distributed as follows: Year. Males. 1910.......... 1911.......... 1912......... Females. 39 35 29 Total. 54 42 38 15 7 9 HOLLAND. Until 1905, when it was decided that workmen suffering from anthrax should receive indemnity in accordance with the workmen’s compensation act, there was no obligation upon either employers, patients, or physicians to report cases of the disease. Nevertheless, subsequent inquiry in North Brabant, the principal seat of the Dutch tanning industry, yielded the following data: T a b l e 1 3 . — CASES OF HUMAN ANTHRAX REPORTED IN HOLLAND, 1898 TO 1911. [Source: Direccie van den Arbeid. De Looinijverheid in Nederland, The Hague, 1913, p. 115.] Year. 1898 ........................ 1899 ............................ 1900............................... 1901 .............................. 1902............................... 1903 ............................ 1904 1905............................... 4_.- Total Cases cases among Fatal re cases. ported. tanners. 2 1 2 2 1 2 2 2 2 2 2 2 1 1 Year. Total Cases cases among Fatal re cases. ported. tanners. 1906............................... 1907............................... 1908............................... 1909............................... 1910............................... 1911............................... 5 9 5 9 5 3 5 9 4 8 1 Total.................... 47 45 4 1 5 3 105 AN TH RAX AS AN OCCUPATIONAL DISEASE. The influence of the compensation law in encouraging the report ing o f cases is clearly seen in the figures for the later years. The general director o f labor estimates that in the tanning industry there are annually, per 1,000 workmen, 4.7 cases of infection and 0.3 deaths. In 1911 a new labor code was enacted, section 21 o f which requires the reporting o f occupational diseases. The reports are to be sent to the general director of labor within eight days o f the diagnosis. For each report a fee of 22 cents is paid, and a fine of $20 is provided for failure to comply with the law. The report is made according to a prescribed form, giving name, sex, age, and residence of the patient, also the diagnosis, nature of establishment, kind and duration o f work, and other necessary data. An interesting educational section o f the law requires the doctor to have a manual describing the causes and symptoms of each disease to which the statute applies, as well as the occupations in which the disease may occur. For the year 1912, 16 cases of industrial anthrax were reported, 7 o f which occurred among brush workers.1 These figures are prob ably incomplete, as is usually the case with data obtained for the first year o f the operation of a law. ITALY. Data for Italy, where anthrax is reportable as an infectious dis ease, show tremeiidous prevalence of the disease. Sclavo gathered, from 1880 to 1890, records of 24,052 cases among human beings, of which 5,812 were fatal. These figures are carried down to the end of 1904 in the following table: T a b le 14.—RECORDED. CASES OF HUMAN A N T H R A X IN IT A L Y , 1890 TO 1904. [Source: C. H. W. Page, British Industrial Anthrax, in Journal of Hygiene, November, 1909, p. 291.| Year. 1890. 1891. 1892. 1893. 1894. 1895. 1896. 1897. Cases. 2,047 2,241 2,077 2,461 2,400 2,179 1,985 2,123 2,327 Deaths. 526 645 650 598 635 621 453 460 433 Deaths per 100 25.7 28.8 31.3 24.3 26.5 28.5 22.8 21.7 18.6 Year. 189 9 190 0 190 1 190 2 190 3 190 4 Cases. 2,672 1,867 1,992 3,528 3,423 3,104 Total 36,426 Deaths. 461 330 341 403 397 355 Deaths per 100 17.3 17.7 17.1 11.4 11.6 11.4 20.1 1 Walter Abelsdorff: Gewerbliche Milzbrandvergiftungen in Deutschland, Frankreich, England, und Holland, 1915, p. 9. 106 BULLETIN OF THE BUREAU OF LABOR STATISTICS. For later years the data have been published irregularly, but the following are obtainable: 1 Year. Cases. 1 9 0 5 _______________________________________________________________ 2, 893 August-December, 1908^____________________________________ 2,188 190 9 2, 736 191 0 2,252 364 January-M ay, 1911_______________________________________________ Most of these cases, it should be said, arise in the nonmanufac turing districts. RUSSIA. In Russia epidemics of the malady are common, under the name u Siberian pest,” 528 persons having died of it from 1867 to 1870 in the single Province of Novgorod. Javorsky is authority for the statement that in the whole country more than 10,000 cases are annu ally observed. Even this appalling figure would seem to be too low, for P op ov2 declares that in the years 1904 to 1908, inclusive, there were 80,498 cases, or more than 16,000 a year. As in Italy, however, it is believed that the majority of cases occur outside of the manu facturing industries. The data for other European countries are even less reliable. In Austria the law of April 14, 1913, made human anthrax, among several other infectious diseases, reportable. Earlier reports of the factory inspectors give the following data for the years 1903 to 1906: 1903, 15 cases; 1904, 5 cases; 1905, 13 cases; 1906, 4 cases. These fluctuations, however, seem improbable, and the figures as a whole appear to be too low, for in the report for 1907 a factory inspector stated that in the brush factories of his district alone 50 cases of anthrax had occurred in the preceding 10 years. P R O T E C T IV E L E G IS L A T IO N . Absolute prohibition of the importation of animal materials from countries where anthrax is known to exist, unless such materials are first thoroughly disinfected, would probably put an effective stop to the ravages of the malady among industrial workers. No country, however, has yet found such a step either commercially or adminis tratively possible. Many of them— France, Germany, Great Britain, Holland, Hungary, Italy, and Spain, for instance— do prohibit the employment of women or of children of different ages in dangerous processes, but the great mass of European legislation on occupational anthrax is confined to more or less careful general regulation of the hazardous trades and occupations. 1 Compiled from Rivista di Igiene e di Sanita Publica. aH. B. Popov: Russki Vratch [The Russian Physician], June 14, 1914, p. 848. AN TH RAX AS AN OCCUPATIONAL DISEASE. 107 WOOL, HAIR, AND BRISTLES. O f the industries in which there is danger of anthrax, those which involve the handling of wool, hair, and bristles have been most widely and thoroughly brought under Government regulation. In England the wool industry has reached a high degree of devel opment, and much of its raw material comes from Persia, East India, China, and other countries where anthrax is endemic and precau tionary measures are almost unknown. Its attention having been drawn by the frequency of anthrax among wool sorters, the English Government called in 1884 a conference of public health officials, representatives of the workers, and wool merchants. At this con ference the first tentative set of regulations for the wool industry was adopted. In 1897 instructions were published for wool-sorting and in 1900 for wool-dyeing establishments. In 1905 the Home Office issued regulations which codified and amplified the earlier rules. They refer1 to the work of sorting, “ w illeying” (willowing), washing, combing* and carding wool, goat hair, and camel hair, and the incidental processes. Only certain specified materials, imported chiefly from Asiatic countries, come under these regulations. Detailed instructions are given for the opening and handling o f wool or hair. Each bale may be opened only after it has been thoroughly steeped in water and only by men skilled in judging the condition of the material; screens, sorting boards, and willowing machines of specified construction are required. Several kinds of materials must not be sorted except in a damp state and after being washed. Goods must be stored only in places set apart for the purpose. Detailed regulations are set forth for ventilation, cleanliness, disposal of waste, working clothes, and requisites for treating scratches and slight wounds. Strict require ments apply to the places where unwashed wool or hair of the kinds named is handled or stored. For persons working in those rooms there must be sufficient washing accommodations, with soap, nail brushes, and towels, and proper places for keeping food and clothing. A worker having an open cut or sore must not be employed in any such room. The regulations prescribed for the employers are followed by instructions to the workers, who are also made responsible for com pliance with the rules. Attached to the regulations is a note describ ing the dangers o f anthrax and urging personal cleanliness. These regulations apply only to the more dangerous kinds o f wool, and therefore protect only part of the woolworkers of the United Kingdom; all other kinds of wool are disregarded, as, for instance, those coming from South Africa and South America, which 1 See pp. 137-140. 108 B ULLETIN OF THE BUREAU OF LABOR STATISTICS. are not classified as “ dangerous,” but which also cause anthrax, although less frequently than the materials mentioned by the regula tions. The insufficiency o f the regulations is, indeed, generally agreed upon, and revision is now being considered by the departmental committee on anthrax. Prevention o f anthrax in the trades using the coarser kinds of hair was not taken up by the British Government until several years later, probably because the danger was less conspicuous than in the wool industry. Processes involving the use of horsehair from China, Siberia, or Russia were made subject to regulation in 1908.1 These countries are specified because hair shipped from there is con sidered particularly dangerous. These rules contain for the first time the significant requirement o f disinfection, which may be car ried out by steam or by any other method certified by a Governmentrecognized laboratory. Rules are also set forth for the opening, sorting, and storing of nondisinfected material, exhaust drafts of a prescribed kind are required, and instructions are given for the disposal o f dust collected during the various processes. The require ments with regard to working clothes, respirators, supplies for treat ing wounds, cloak and lunch rooms, and lavatories are similar to those contained in the regulations for work on wool. As in those regulations, also, the workers are called upon to observe the pre scribed rules. An important factor in the success of these measures is the provision which imposes a penalty not only upon the recal citrant employer but also upon the worker who fails to observe the law. This provision is found in section 85 (2) o f the Factory and Workshop Act o f 1901: “ I f any person other than an occupier, owner, or manager, who is bound to observe any regulations under this act, acts in contravention of, or fails to comply with the regula tions, he shall be liable for each offense to a fine not exceeding £2 [$9.73].” 2 In Germany industrial anthrax appears to be particularly preva lent among hair and brush workers, and detailed legislation for that industry was secured fairly early. The question is taken up by an order o f the Federal Council o f October 22, 1902,3 which superseded a similar order of January 28, 1899. The German order agrees in its main points with the British regulations. Both require disinfec tion o f materials, isolation o f nondisinfected goods, special working clothes, and dressing rooms and lunch rooms for the workers who come in contact with raw products. Factory sanitation and personal hygiene are also prescribed along similar lines. But, contrary to the English law, the German decree applies not only to goods coming 1 Appendix B, p. 141, 2I Edw. VII, ch. 22. 8See Appendix B, p. 145. AN TH RAX AS AN OCCUPATIONAL DISEASE. 109 from certain countries but to all horse, cattle, and goat hair and pigs’ bristles o f foreign origin. It also differs from the English law in several other important points. For instance, public disinfection stations are established, indicating great interest on the part of the Government. The employer is required to furnish the workers facili ties for warm bathing twice a week and to see that each individual wears the working clothes assigned to him. Perhaps the most sig nificant provision is that allowing the employer to discharge without notice and without liability for breach o f contract any worker who, after repeated warning, persists in violating the rules. In addition to its salutary disciplinary effect upon the employee, this provision is o f considerable consequence in a country like Germany where anthrax is compensated as an industrial injury, as it safeguards the employer’s financial interests against the employee’s possible care lessness. French regulations for the prevention o f anthrax in the industries under discussion are contained mainly in the decree o f October 1, 1913,1 which superseded all earlier laws. This decree, like its prede cessors o f 1908 and 1910, does not follow the English or German method o f special regulations for each industry or allied group of industries, but applies to all establishments in which the employees are menaced by anthrax, including those “ where skins, fur, horsehair, hogs’ bristles, wool, horns, or bones, or. other animal products liable to be infected ” are handled. Special attention is given to the protection o f workers engaged on nondisinfected material or on the process of disinfection. The methods of disinfection used must, as in Eng land and Germany, be officially approved. The rules referring to sanitation in the work place, working clothes, dressing rooms, lava tories, and personal cleanliness are very similar to those prescribed by the two countries already discussed, but lack their minuteness and definiteness. Walls, floors, tables, and benches, for instance, must be washed, not at definitely stated intervals, but “ whenever neces sary,” or “ as often as may be necessary,” and must be “ frequently ” disinfected. The vital matter of dust prevention, which is taken up with considerable care in England and Germany, has received little thought from the French authorities. Instead o f requiring dustremoving devices the law simply states that wool, horsehair, other animal hair, and bristles must be handled, “ whenever possible/’ in closed vessels. I f this is impracticable, as for instance, in the case o f opening bales or beating, the operations must be carried out “ under such conditions as will allow the collection o f all offal and its subsequent destruction.” 1 See Appendix B, p. 143. 110 BU LLETIN OF TH E BUREAU OF LABOR STATISTICS. Another preventive dev’ ce which escaped the attention of the French lawmakers is that of imposing some responsibility upon the workers. Overalls and respirators provided by the firm can not serve their purpose unless they are worn, and the best equipped lavatories and dressing rooms are useless if the worker ignores them. Consequently, pressure must be exercised not only on the employer but on the worker also. French employees, however, are merely asked, through regulations posted in the workrooms5 to use the vari ous working articles provided for them, as well as the washstands and dressing rooms, to clean themselves before leaving the premises, and to bring no food into the workrooms. In Hungary workers in brush factories and in all establishments where horse and cattle hair and pigs’ bristles are manipulated are protected against anthrax by an order o f the minister o f commerce, issued on May 18, 1903. This order is practically the same as the order of the German Federal Council o f October 22, 1902. The majority of cases o f anthrax in Belgium have occurred among brush workers, and this circumstance prompted the royal order of August 20, 1908. In striking contrast to the previously discussed legislation, this order consists of only two short sections and merely prescribes, imperatively, the disinfection of hair in a manner “ suffi cient to kill the anthrax spore.” Medical inspectors are to test, through samples of disinfected hair, the effectiveness o f the method used. HIDES AND SKINS. Another large group of industries in which the need o f Govern ment activity against anthrax has been felt by several European countries is that connected with hides and skins, especially in the processes o f tanning. The problem of infection from imported hides and skins was taken up in Great Britain in 1899. In 1901 rules were published by the Home Office for establishments using dry and drysalted hides and skins imported from China or from the west coast o f India.1 It was required that provision be made for overalls and gloves, for the keeping o f food and clothing, for washing accom modations, and for the dressing of wounds. Notes are added to the rules, one calling the worker’s attention to the dangers of an thrax, and another reminding him of his obligation to observe the law: Prussian workers engaged on imported hides and skins are covered by a ministerial order issued on May 9, 1902. It briefly describes the nature o f anthrax and its danger to the worker and emphasizes the necessity of precautionary measures.2 1 See Appendix B, p. 136. 2 See Appendix B, p. 148. AN TH RAX AS AN OCCUPATIONAL DISEASE. Ill A later and more effective measure was the decree of the Prussian minister o f commerce dated December 20, 1910. This directs factory managers to adopt for the protection of tanners the regulations issued by the Leather Trade Association, which were based on the latest scientific investigations and were framed in conformity with the re quirements of the Imperial Health Office.1 The rules apply to raw sheep and goat skins and to all skins and hides imported in a dry, raw state. These materials must be kept in isolated storerooms. Detailed rules are prescribed for the sanitation o f the storerooms and for the transportation and handling o f the goods. The familiar instructions with regard to working clothes, lavatories and lunch rooms are also found, as well as an interesting rule forbidding the worker to enter the lunch room, to eat any food, or to leave the premises until he has changed his working clothes and has thoroughly washed the face, head, hair and beard, neck, hands, and arms. Each new worker receives a copy of regulations for the prevention of accidents, and instructions concerning anthrax. Other States of the German Empire have also accepted these regu lations. Stuttgart, the capital o f the Kingdom of Wurttemberg, for instance, is an important center of the glove industry. There were revealed in the first year o f the operation o f the compulsory notification law o f 1909 22 cases o f anthrax^ o f which 2 were fatal. This indicated a greater prevalence o f anthrax among tannery workers than was shown by earlier data, and as a result the regula tions for the leather industry were introduced by ministerial order.2 The French regulations for tanneries have been discussed in the preceding section. Incidentally it may be remarked that in Italy, the home of the Sclavo serum and the scene o f much intelligent private activity against anthrax, the Government remains practically inactive on the question. Despite the appalling prevalence of the disease no legis lation exists for its prevention among industrial workers.3 In 1911, in accordance with a decree of the minister of agriculture, industry, and commerce and a decision of the administrative council of the national workmen’s accident insurance fund, prizes were offered for the best essays on a number of topics connected with industrial safety and hygiene. One of the subjects was prevention of anthrax among workers employed in the transportation and treatment of skins, but none o f the essays submitted were deemed worthy of the prize. 1 See Appendix, p. 149. 2 Bulletin of the International Labor Office, Vol. V III, 1913, p. X V I. 3 L. Devoto and F. Massarelli: II Charbonchio Professional, II Lavoro, July 15, 1914, p. 194. 42806°— Bull. 205— 17------- 8 112 BULLETIN OF THE BUREAU OF LABOR STATISTICS. COMPENSATION FOR ANTHRAX AS AN INDUSTRIAL INJURY. Thorough as is much o f the administration of European factory law, the “ policing ” method alone has not been depended upon for the enforcement of regulations for the prevention of anthrax. The method o f cooperative pressure on employers through workmen’s compensation, which has proved so effective in reducing work acci dents, while at the same time it safeguards the economic position o f the injured or of their dependents, has already been applied to a number o f occupational diseases, but to none so early or so widely as to anthrax. A t least five European countries (Great Britain, Germany, France, Italy, and Holland), and two Provinces of one of these (South Australia and Ontario), already provide compensation for this disease.1 The British Workmen’s Compensation A ct o f 1897, the first o f its kind in any English-speaking country, established indemnity for personal injury “ by accident” arising out o f and in the course of employment. In 1905 the House of Lords was called upon to deter mine, on an appeal, whether the dependents o f a workman who had died o f anthrax were entitled to compensation under this act. The House decided in the affirmative, Lord Macnaghten saying: It is plain, I think, that the mischief which befell the workman in the present case was due to accident, or rather, I should say, to a chapter o f accidents. It was an accident that the noxious thing that settled on the man’s face happened to be present in the materials which he was engaged in sorting. It was an accident that this noxious thing escaped the down draft or suck of the fan which the Board o f Trade, as we were told, requires to be in use while work is going on in such a factory as that where the man was employed. It was an accident that the thing struck the man on a delicate and tender spot in the corner o f his eye. It must have been through some accident that the poison found entrance into the man’s system, for the judge finds that there was no abrasion about the eye, while the medical evidence seems to be that without some abrasion infection is hardly possible. The result was anthrax, and the end came very speedily. Speaking for myself, I can not doubt that the man’s death was attributable to personal injury by accident arising out of and in the course of his employment. The accidental character of the in jury is not, I think, removed or displaced by the fact that, like many other accidental injuries, it set up a well-known disease, which was immediately the cause of death, and would no doubt be certified as such in the usual death certificate.2 1 In addition it should be remembered that in most European countries, including Austria, Germany, Great Britain, Holland, Hungary, Luxemburg, Norway, Roumania, Russia, and Serbia, anthrax is covered by compulsory health-insurance laws, while in six countries, Belgium, Denmark, France, Iceland, Sweden, and Switzerland, a limited amount of protection is given by systems of subsidized health insurance. 2 Brin tons (Ltd.) v . Turvey, 92 L. T. R., 578 (1905). 113 AN TH RAX AS AN OCCUPATIONAL DISEASE. Other cases of occupational disease also arose which caused litiga tion under the law, so that when Parliament enacted the present British compensation statute in 1906 it included a list of six trade diseases (since expanded to 25) which were to be compensated on the same terms as accidents. One of these six was anthrax.1 Sec tion 8 o f the law states that if the certifying surgeon for the dis trict testifies that a workman is suffering from a disease to which the act applies and is thereby either unable to earn full wages or is sus pended from work, or if death is caused by any such disease and “ the disease is due to the nature of any employment in which the work man was employed at any time within the 12 months previous to the date o f the disablement or suspension, whether under one or more employers, he or his dependents shall be entitled to compensation under this act as if the disease or such suspension as aforesaid were a personal injury by accident arising out of and in the course of that employment.” In the seven years 1908 to 1914, the only years for which data are available, 233 cases of anthrax have been compensated under the law. The following table shows the distribution of the cases by year and by industry: T a b l e 1 5 . — CASES O F A N T H R A X C O M PE N SA TE D F O R T H E F IR S T T IM E D U R IN G T H E Y E A R U N D E R T H E B R IT IS H W O R K M E N 'S C O M P E N SA T IO N A CT, 1908 T O 1914. [Compiled from H om e Office annual reports on statistics of compensation and of proceedings under the W orkm en's Compensation A ct, 1906, and the Em ployers’ L iability A ct, 1880.!) Year. Cotton. 1908............ 1909............ 1910............ 1911............ 1912............ 1913............ 1914............ 1 Total___ 1 W ool, worsted, and shoddy. 6 19 20 26 24 16 111 Engi neering Other textiles. and ship building. Other metal work. 1 4 3 1 1 5 i 1 1 15 2 1 China and earthen ware. Miscella neous factories. 1 8 7 5 5 6 18 13 8 5 10 4 6 2 5 23 22 35 30 43 44 36 1 62 40 233 Docks. Total. 1 It is interesting to note, in connection with the British experience, that the example of the mother country has encouraged both South Australia2 and Ontario3 to write into their compensation laws the principle o f indemnity' for occupational diseases, each Province adopting the schedule of six compensable diseases, including anthrax, with which Great Britain began. The terms of the German workmen’s compensation code cover only injuries by “ accident,” but, as in Great Britain under the law o f 1 6 Edw. V II, ch. 47, third schedule. 2 South Australia, 2 Geo. V, No. 1053 (1911). * Ontario, 4 Geo. V, ch. 25 (1914). 114 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. 1897, anthrax is held to be an accident and is compensated as such.1 The same situation obtains in Holland by a decision of 1905,2 and in France.3 In the last-named country the question o f indemnity for trade diseases came up soon after the enactment o f the compensation law in 1898, and a committee on industrial hygiene was appointed under the Ministry o f Commerce to study it. The commission’s report, published in 1903, concluded with regard to anthrax: Anthrax has always an external origin and is due to infection by a microbe; this infection takes place at a given moment, and it cer tainly furnishes the element of suddenness required by the law of all accidents which come under the act of 1898.4 Since the publication of this report the French courts have reversed their previous opinion^ and in the years 1903 to 1909 they decided four contested cases which came before them in favor of the injured workers. The movement abroad in favor of compensation for occupational anthrax, as well as for other trade diseases, is not confined to these seven countries and parts of countries. Section 68 o f the Swiss industrial accident insurance law of 1912 empowers the Federal Council to “ prepare a list o f substances, the production or employ ment o f which occasions dangerous diseases. Every disease exclu sively or essentially due to the action of one o f those substances in an enterprise subject to insurance is deemed an accident within the meaning o f the present law.” It can hardly be doubted that anthrax would find a place on a list of this kind, but apparently the Federal Council has not yet exercised its power. 1 Pickenbach, Beitrag zur Milabranderkrankung in der Lederbranche, Aertztlicher Sachverstandigen Zeitung, 1914, No. 18, p. 365. 2 H. A. Van Ysselsteyn, General Director of Labor: Anthrax, 1912, p. 1. 3 J. CavaillS: Le Charbon Professionnel, Paris, 1911, p. 344. 4 France, Commission d’Hygi&ne Industrielle, Maladies professionnelles, Paris, 1903, p. 140. C H A P T E R V I. PRESENT STATUS OF THE PROBLEM OF DISINFECTION. It is obvious that the success of the extensive and energetic cam paign against occupational anthrax depends to a considerable degree on the effectiveness of methods of sterilizing industrial materials. The significance attached to the question of disinfection has stimu lated numerous investigations in the more advanced countries. The work is chiefly done in private laboratories, but important experi ments have also been made under the auspices of the United States Bureau o f Animal Industry and of the Imperial Health Office in Germany, while facilities for such work are furnished by the Home Office in England. The task of finding an adequate and practicable disinfectant is greatly complicated by several factors. For instance, various kinds o f materials require different modes of treatment. The cost of the disinfectant and the time of exposure necessary for destroying the bacilli and spores are also essential considerations, since an expensive disinfectant, or one acting only slowly, will be rejected by the manu facturers. Still more important is the effect of the disinfectant on the material, since it has been shown that a large number of disin fectants otherwise desirable can not be applied without injury to the goods. O f the materials liable to convey anthrax to the workers, bristles, horsehair, goat hair, and a few other kinds of hair have proved most susceptible to disinfection. A number of methods have been pro posed, three o f which are considered the most effective and the most acceptable for industrial purposes. These are: (1) Exposure to steam for a period varying according to temperature and atmospheric pressure; (2) boiling in water for two hours; and (3) boiling for at least 15 minutes in a 2 per cent solution of permanganate of potas sium with a subsequent bleaching in 3 to 4 per cent sulphuric acid. In the disinfection o f wool much less has been accomplished. Up to the present no disinfectant has been found entirely satisfactory for industrial purposes. In England constant and diligent study of various germicides is being made by the Bradford Anthrax Investi gation Board, which, after nine years o f work, reports:1 44 So far 1 Anthrax Investigation Board for Bradford and District, Ninth Annual Report, 1914, p. 6 . 115 116 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. formaldehyde, in the proportion of 1 per cent of neat or proof strength to 99 per cent of water, with a saturation of the opened material for seven hours, is the only germicide that has been found reliable, and even the effect o f this germicide must depend upon the absence of ammonia and of large blood clots. The effect of formalde hyde upon the spinning qualities o f the material is, however, very marked, and this germicide can only be recommended for extreme cases o f infected wool or hair.” Further experiments are being made. Steam disinfection of wool was also the subject of a series of experiments by the staff o f the board. The results have brought out the fact that while steam succeeds in destroying the germs its effect is to discolor light-colored material and to turn yellow white. The wool becomes brittle, its elasticity and luster are considerably affected, and the strength o f the fiber is also somewhat impaired. As a result a committee o f the board agreed that “ disinfection by steam can not be applied to ordinary wool or hair except under conditions that would stop any trade in the sorts so treated.” 1 However, even the officially approved methods of disinfection are not considered absolutely effective, and occasionally fail to prevent the occurrence o f anthrax. C. H. W. Page, an English authority, expresses himself with considerable pessimism. “ That steam is ever likely to be certainly effective in disinfecting horsehair is im probable,” he says, “ since the damper the steam the better chance o f destroying the spores, but the greater the damage to the hair; and the drier the steam the less chance of destroying the spores and the less damage to the hair. These antagonistic results produce a deadlock.” 2 He also criticizes the use o f steam on bristles because steam bursts or loosens the bundles, which necessitates an expendi ture o f time and money for putting them in order again; nor does he find boiling satisfactory, for in the time necessary to destroy the spores— two to three hours—the material would be considerably damaged. His stand on the question of disinfection in general he summarizes in the words: “ Great care and constant supervision are necessary to secure satisfactory results, and steam can not be regarded as absolutely certain in effect, though the great bulk of spores are destroyed and the vitality o f the rest is diminished.” Very similar is the opinion expressed by another English authority, Legge, who states that to secure certain destruction of all anthrax spores absolute reliance can not be placed on either steam disinfection or simple boiling in the absence of effective supervision; however, the adoption o f one or the other is a material safeguard. 1 Anthrax Investigation Board for Bradford and District, Eighth Annual Report, 1913, p. 23. 2 Journal of Hygiene, Industrial Anthrax, 1909, p. 369. AN TH RAX AS AN OCCUPATIONAL DISEASE. 117 This unreliability of disinfection has attracted official attention in the Grand Duchy of Baden, where, notwithstanding the practice of sterilization, the number of cases of anthrax has increased rather than diminished. Prompted by this circumstance the minister of the in terior, by an order which went into effect October 28,1909, instructed the proper authorities to make annual examinations of fresh disin fected samples o f materials used in manufacture.1 The examinations have shown that disinfection does not kill the spores. Some cases o f failure the author attributes either to the wrong construction of the apparatus or to the wrong use of it. The individual characteris tics of certain kinds of hair also sometimes impede disinfection. In this connection the author mentions goat hair, which comes in hydraulically pressed bales. Upon unpacking, the whole bale, which owing to the nature of the hair shows hardly any tendency to fall apart, is exposed to steam; naturally the steam can not penetrate very deeply, and after an exposure of one-half hour the temperature 8 inches below the surface is only 114.8° F., which is insufficient for sterilization. Still greater obstacles are in the way of disinfection of hides and skins. Numerous experiments with these materials have so far failed to discover a reliable and convenient germicide. Sterilization by steam, frequently applied in the hair industry, is impracticable for hides and skins, as it injures them for manufacture. Experiments have been conducted with low-temperature steam disinfection in a vacuum, which does not affect the skins, but the question of the ap plicability of this method for manufacturing purposes has not so far been settled. Researches, remarkable for their range and thoroughness, have been made under the auspices of the Imperial Health Office of Ger many. Hailer, one of the investigators, states2 that disinfection of skins is not an impossibility. Numerous methods have been sug gested, but so far they have not been applied outside the laboratory. The high cost o f the disinfectants, their poisonous properties, and their more or less deleterious effects on the skins, serve as ob stacles to their introduction into industry. O f the several layers of which the animal skiij. is composed the one used for leather is, ac cording to Hailer, sensitive to a temperature o f over 104° F., and also to whole classes o f chemical substances, such as the phenols, aldehyde acids, and heavy metal salts— in fact, to the strongest germicides. However, some of the substances contained in the skin, 1 Laubenheimer, Uber die Disinfection yon Tierhaaren zur Zerhiitung yon gewerblicher Milzbrand, Zeitschrift fiir Hygiene und Infections-Krankheiten, 1912, Vol. L X X , pp. 324, 325. 2 E. Hailer, Die Abtotung von Milzbrandsporen an H&uten und Fellen durch SalzsaureKochsalzlSsungen. Arbeiten aus dem Kaiserlichen Gesundheitsamte. Berlin, 1914, Vol. X L V II, p. 69. 118 BULLETIN OF THE BUREAU OF LABOR STATISTICS. chiefly the albuminoids, make insoluble compounds with these chemi cals, and as a result the skins change in appearance and become less valuable for manufacture. Numerous efforts for the removal of these difficulties have met with little success. A t present there are two methods of disinfection which give prom ise of meeting the necessary requirements; neither has yet been applied on a large scale, but one, recommended by Seymour-Jones o f England, chairman of the International Commission for the Preservation, Cure, and Disinfection of Hides and Skins, seems to be meeting with more approval than the other. This process con sists in soaking the dry skins for 24 hours in a 1 to 5^000 solution of bichloride o f mercury to which is added a 1 per cent solution of formic acid. After this treatment the skins are transferred for an hour or so to a saturated solution of common salt in water. The acid helps to render the bichloride effective because it prevents the forma tion o f the insoluble albuminate of mercury, and also because by its penetrating action the fluid is carried into the center o f the mass of any organic material that may serve as a protection for the spores. The process has been the subject o f an exhaustive investigation by Constant Ponder, who considers it simple, cheap, and effective, and “ believes that it holds out greater promise of success than any pro cess hitherto suggested.” 1 He suggests that the sterilization be car ried out in the port o f shipment. The other process was discovered by a German scientist, Schattenfroh. This investigator recommends that hides and skins be soaked for six hours at a temperature o f 104° F., or for two days at a temperature o f 68° F., in a 2 per cent solution o f hydrochloric acid to which a 10 per cent solution of ordinary salt is added. For practical reasons he considers the former method superior. He maintains that no injury is done to the skins by this process? In the United States numerous studies o f disinfection against anthrax have been made by the Federal Bureau of Animal Industry, as well as by the National Association of Tanners and by the Ameri can Leather Chemists’ Association, at whose meetings the problem is the subject of frequent reports and discussions. In 1910 John H. Yocum, of the leather chemists’ organization, pointed out that be cause of the action of the mercury salt in forming insoluble com pounds with albuminoids and thereby depriving itself of further power to act on bacteria, immersion in a simple 1 to 1,000 solution o f bichloride of mercury as then required by the Government could “ not possibly be effective.” He proposed m odifying the process by 1 Constant Ponder: A Report to the Worshipful Company of Leather Sellers, etc., 1911, p. VI. 2 E. H ailer: Die Abtotung von Milzbrandsporen an Hauten und Fellen durch SalzsaureKochsalzlosungen. Arbeiten aus dem Kaiserlichen Gesundheitsamte. Berlin, 1914, Vol. X L V II, p. 69. AN TH RAX AS AN OCCUPATIONAL DISEASE. 119 adding the bichloride to a saturated solution of common salt, which would prevent interference with the germicide. This method, how ever, he found efficacious only for wet salted hides. For dry hides he declared it impracticable because of the long time the fluid required for penetration, and recommended instead the Seymour-Jones proc ess, 1 to 5,000 bichloride of mercury with 1 per cent formic acid. This latter process, Yocum estimated, would entail an expense of about 7 cents a hide, which he held would be more than equalized by economies in the selection and tanning of hides which it would make possible. I f the process were carried on at the point of ship ment, it was further pointed out, shippers would not be likely to dry the hides out again, so that many of the hides now received in the “ flint dry ” state would be received as “ wet salts,” with a con sequent reduction of the danger of anthrax infection through flying dust. The paper was circulated for discussion at the following meeting of the tanners,1 who seemed to feel, however, that it should be subjected to important modification. Perhaps the most extensive series of American experiments on the subject are those undertaken by F. W. Tilley, of the United States Bureau o f Animal Industry.2 These experiments tend to show that the original Seymour-Jones process, immersion in 1 to 5,000 mercuric chloride solution with 1 per cent formic acid for 24 hours, is not efficient in killing anthrax spores, even if the germicide is not later neutralized as it would be by other substances in the regular course o f tanning. A modification of the Seymour-J ones method, however, by using a mercuric chloride solution of twice this strength (1 to 2,500), with 1 per cent of formic acid, is efficient in 24 hours if there is no neutralization. Hence this latter method, the investigator con cluded, seems usable “ provided the treated hides are not to be sub jected within a week or two to the action of any substances which will neutralize the disinfectant. This would be the case, for in stance, if the hides were disinfected at foreign ports before ship ment to this country.” Similar researches carried on with the Schattenfroh method, 2 per cent o f hydrochloric acid in a 10 per cent solution of sodium chloride, with 48 hours’ exposure, are reported to have “ proved efficient in every instance.” A European bacteriologist,3 however, is quoted as having found that this method works well for thin skins, but that if the skins were “ thick and heavily infected he was able, after iJohn H. Yocum: Disinfection of imported hides. National Association of Tanners, 1913. 2 F. W . Tilley : A bacteriological study of methods for the disinfection of hides infected with anthrax spores. Journal of Agricultural Research, Mar. 15, 1915, pp. 65—9 2 ; abridged in Journal of the American Leather Chemists’ Association, March, 1916. 3 Franz Sevcik : Zur Desinfection von Milzbrandhauten. In Weiner Aertaliche Monatschrift, Vol. I, No. 3, pp. 127-141. 120 BULLETIN OF THE BUREAU OF LABOR STATISTICS. very effective neutralization, to extract from pieces of the treated hides anthrax spores which were virulent.” In all his work Tilley has emphasized what he considers the ex tremely slow and superficial action of bichloride of mercury. “ Cer tainly for a short time,” he says, “ the combination between the bi chloride and the spores is what we might call a 4reversible ’ combina tion,” and the effect of a neutralizing agent, such as the lime used in later processes, “ will be to break the combination, and the spores will, so to speak, come to life again.” 1 For this reason he recom mends a long immersion in a relatively weak solution as preferable to a brief immersion in a stronger solution. On the whole he con siders the Schattenfroh method, though not perfect, “ far superior to other methods and well worth a trial as a standard method for the disinfection of hides.” On the other hand, a committee report submitted to the annual meeting o f the American Leather Chemists’ Association in June, 1916, stated that tanners who had tried the Schattenfroh method de clared it “ positively injurious” to hides, while at the same time bi chloride o f mercury solution o f the strength (1 to 1,000) then re quired by the Government was complained o f as “ burdensome in point o f cost.” 2 The committee therefore tentatively proposed a new method to supersede both of these. Stating that no cases of anthrax had occurred in glue or hair factories using by-products from Ameri can tanneries, the committee suggested that bichloride of mercury 1 to 5,000 or possibly 1 to 10,000, followed by the regular liming process, “ will prove effective in rendering the anthrax spores in nocuous. If, after further investigation, this proves to be a fact it will meet the situation and relieve the tanners from undue burden or cost.” This suggestion had already been conveyed to the Bureau of Animal Industry, and as has been seen a slight modification of the proposed process is embodied in the rules prepared by the Federal authorities, in cooperation with the tanners’ committee, later in the year.3 The other products liable to convey anthrax, chiefly bones and horns, are used to a more limited extent than hair, wool, or hides, and danger o f infection from them is also comparatively slight. For these reasons their sterilization is less urgent, and it has been almost disregarded in the spirited campaign for protection against the more common carriers of the disease. 1 Journal of the American Leather Chemists’ Association, July, 1916, p. 350. 2 C. R. Oberfell: Cure and Disinfection of Hides. Committee report, 1916. Journal of the American Leather Chemists’ Association, July, 1916, pp. 333-339. 3 See Appendix A. C H A P T E R V II. RECOMMENDATIONS FOR CONTROL AND PREVENTION OF ANTHRAX, The serious difficulties in the way o f a satisfactory solution of the occupational anthrax problem have been the subject o f considerable expert study. Since it has not yet proved possible to eradicate anthrax even in the countries where the most advanced legislation on the subject is combined with enlightened private activity, addi tional measures of protection are necessary. After careful study of the problem several authorities of world wide reputation have set forth recommendations in which they take up not only the question o f anthrax in manufacturing centers, but also in the stock-raising countries of export, and in which the neces sity of international action is emphasized. O f the recommendations published in recent years three sets are conspicuous for their thoroughness and for the extensiveness of the ground covered, and are here given entire. RECOMMENDATIONS OF SUBCOMMITTEE OF INTERNATIONAL ASSOCIATION FOR LABOR LEGISLATION, 1914.1 A. It is important (in order to be in a position to know the extent of the risk of anthrax infection in industries and the preventive measures necessary to combat it) that in each country full statistics should be kept o f cases which arise. Such statistics should always supply the following inform ation: Age and sex of the patient; precise occupation; the kyid and source of the materials handled at the time of the attack; situation and clinical form o f the disease; result. It is desirable that these statistics should be as wide as 'possible and cover all cases of anthrax— agricultural as well as industrial. B. In all premises where the products (wool, hair, bristles, hides, and skins) of animals susceptible of anthrax are stored and handled in the raw state the occupier should post up a notice containing— ( a ) An illustration showing the commonest and most characteristic form of external anthrax (malignant pustule) ; (&) A brief account of its origin and the typical forms of infection; ( c ) A warning to the persons employed as to the importance of personal cleanliness and the necessity of prompt treatment for every lesion, however slight. 1 Appointed to consider the question of anthrax, in accordance with the decision of the seventh delegates’ meeting of the association, 1912. 121 122 B ULLETIN OF THE BUREAU OF LABOR STATISTICS. C. In all premises where wool, hair, bristles, hides, and skins coming from suspected countries are stored and handled in the raw state, the occupier should adopt the following measures. (It will fall to the Government of each coun try to decide on and classify in one or more schedules, according to the degree of risk and quantity of material imported, the countries to be declared “ sus pected.” ) 1. Inspectors of factories should b e permitted by the occupier to inspect either the stock book in which is entered the purchase of material for the factory or workshop or a special register with entries as follow s: Nature and quantity of material introduced; date of receipt; country of origin; state ( whether raw or disinfected) of the products; name of the vendor. And in the case of material said to have been disinfected before introduction into the fac tory, an approved certificate to that effect. 2. All scheduled raw materials which can be subjected to the operation with out damage should be disinfected. 3. Opening of bales of wool, hair, bristles, hides, and skins should always be intrusted to persons skilled in judging the portions which are damaged. 4. Preliminary operations regarded as particularly dangerous should always be carried out in a room, or portion o f a room, set apart for the purpose. (It will fall to the Government of each country, having regard to the different processes of manufacture and manipulation customary in each country and in each industry under regulation, to define what are the preliminary operations to be regarded as dangerous.) 5. Wool and hair sorting should always be carried on so as to permit of the removal of blood clots adhering to the fleece, and of bloodstained portions. These fragments should either be burned or sterilized by a process recognized as efficient. 6. The preliminary ,manipulations as defined above, which are carried out on dusty material treated in a dry state, should be carried on under an efficient exhaust draft preferably in a downward direction. The dust should never be allowed to escape into the open air. The dust collected in a special receptacle should either be burned (unless coming from material that has previously been washed) or rendered harmless by treatment, chemical or otherwise. 7. The workrooms in which the preliminary processes are carried on should be kept in a constant state of cleanliness; the floors should be impermeable, and the walls treated in such a way. as to permit o f thorough washing, or limewashed at least once a year. The floor, wall§, tables, benches, tools, and machines should be frequently cleaned. 8. The occupier should provide for the persons employed in the preliminary manipulations means for securing personal cleanliness; a cloakroom (with arrangements for keeping separate the ordinary clothes from clothing worn while at work) and a lavatory with an abundant supply o f water (hot and cold whenever possible), soap, nailbrushes, and towels. Every person employed in handling raw material should be provided with his own overalls and head covering. Persons employed in cleaning dust-extracting machines and receptacles for dust should be provided with respirators. No food or drink should be deposited or partaken of in rooms where danger ous processes are carried on. AN TH RAX AS AN OCCUPATIONAL DISEASE. 123 9. Medical treatment should be organized on the following lines: Every person employed having a pustule or pimple resembling anthrax should report the fact without delay at the manager’s office, whereupon the occupier, on his part, should cause him to be examined by a surgeon appointed for the purpose. The name and address of the surgeon should be entered on the notice provided under B, above. 10. Every factory and workshop should be provided with an ambulance box kept in good condition and in a place easily accessible. 11. No person under 18 years of age should be employed in the preliminary operations defined above. D. It is desirable that in all countries where stock is raised, sanitary regula tions drawn up on the same lines should be seriously applied with a view to bring about diminution in the epizootic spread of anthrax, and destruction by efficiently organized methods of all the products or offal of animals that have died of anthrax. The members of the subcommittee: D r. K o e l s c h , Chief Medical Inspector, Munich. D r . Legge, Medical Inspector, London. J. C a v a i l l e , Inspector of Labor, Castres. RECOMMENDATIONS BY PROF. L. DEVOTO AND F. MASSARELLI.1 1. Compulsory antianthrax vaccination of animals. The committee can not ignore the fact that such a measure is very difficult if not impossible of execu tion in foreign countries where anthrax is endemic, and if limited to our own country it can not have the slightest influence in the prevention o f occupational anthrax. 2. Concentration o f the cargoes of animal material coming from foreign sources in specially designated ports having special and exclusive storehouses for said material, fitted up with smooth walls and floors to facilitate periodical disinfection. 3. Adoption of sanitary regulations for the transportation of said material at the points o f disembarkation— regulations which might be formulated as follow s: (a) Isolate from other merchandise the hides, etc., of suspected animals on board sailing vessels and steamboats, and after the discharge of every invoice disinfect the place o f storage while in transit. (&) Use for discharging cargoes o f animal material special lighters which, until disinfected, are not to serve for other transportation. (c) Forbid the transportation o f suspected material on the bare shoulder, and furnish laborers with impermeable clothing and head covering, this last to protect securely the throat, back of the head, and face by means of a cape; also supply all facilities for washing after work, soap, etc., if not disinfecting solutions. Analogous regulations should be adopted in railway transportation. 4. Request the Governments to make compulsory sanitary regulations (after the manner of those established in Germany, France, etc.) obligatory on the part of manufacturers and on the part o f workmen in establishments where animal substances are handled. 1 From an article on II Charbonchio Professionale, II Lavoro, July 15, 1914. p. 197. 124 BULLETIN OP TH E BUREAU OP LABOR STATISTICS. 5. Preventive vaccination o f the workmen who come into immediate contact with the imported material. 6. Diffuse among the workmen by means o f pictures, publications, and models a knowledge o f methods for the early recognition o f the pustules, and institute a propaganda in favor of using antianthrax serum as a prophylactic and curative agent. RECOMMENDATIONS BY C. H. W. PAGE.1 The fact that practically all bristles and horsehair on arrival in this country are centered for a time in two or three London warehouses raises the question whether it would not be possible to disinfect the material before distribu tion. Were disinfection thus centralized it would be a comparatively simple matter to protect the limited number o f people exposed to risk in cutting the knots o f the bundles and spreading the horsehair out for disinfection; then the necessity for formal regulations in horsehair and brush-making factories and workshops in a great measure would be obviated. The manufacturers would gain in being freed from risk o f anthrax among their employees and, further, would be able to use hair that many of them have preferred to discard on account o f its dangerous properties. With regard to the measures introduced in Germany a few years ago, and quite recently in England, more stress might be laid on the necessity of washing, use o f nailbrush, keeping the nails short; in washing, the use o f an efficient disinfectant is advisable; for this purpose Cyllin does admirably, being compatible with soap. Experience shows that soap and water are the true safeguards after handling infected material, and those who use the same stuff after disinfection should wash hands, face, and neck before going home to a meal. By these means, too, the likelihood o f workers carrying infection outside would be diminished. The ignorance and carelessness of the workers are undoubted factors in the spread of anthrax. The use o f overalls and gloves, though unpleasant and disliked by the workpeople, yet is very necessary, as cases quoted show. Facilities for bacteriological examination given by the Home Office since 1899 for verification of doubtful cases might with advantage be extended to exami nation of suspected samples of hair, etc. It would be advisable to require the registrar to communicate with the coroner in all fatal cases of anthrax. When possible, walls and pavements of factories and workshops should be painted or glazed so as to be easy to clean and disinfect. Early diagnosis o f anthrax being difficult, it is essential for a medical man to be attached to each factory, or group of factories, to whom all cases may be referred, so that in making a diagnosis the nature o f the employment may be taken into consideration. By this timely vigilance, remedies, harmless in any case, may be used with far greater prospect o f success. The duties of certifying factory surgeons might be extended with advantage to include the above work, and that there might be no delay they should be supplied with serum by the Home Office. The surgeons should collect samples of suspected material for bacteriological examination, should undertake the entire treatment of all cases o f anthrax, and, in conjunction with the local factory inspector, conduct an inquiry into the source of infection. 1 From summary of article on British Industrial Anthrax, Journal of Hygiene, Decem ber, 1909, pp. 390—395. AN TH RAX AS AN OCCUPATIONAL DISEASE. 125 Employees absent from work should report to the employer the cause, and in the case of illness of any kind the employee should be visited at once by the certifying factory surgeon. The employer should exclude as far as possible workpeople with cuts or abrasions unless suitably covered, and for the carrying out of all regulations each factory and workshop should be supplied with, or compelled to supply, means for dressing small cuts, etc. All cases of human anthrax, whether industrial or agricultural, should be notified. Both human and animal cases o f anthrax should be notified to one authority, or to both the board of agriculture and the Home Office, so that if thought advisable the inquiry may be made in common. Human anthrax being so closely associated with animal anthrax, more sys tematic efforts should be made (1) by limiting the spread of the disease in nature, and (2) by the immunization of animals against anthrax to exterminate the disease among animals. It is necessary to dispose of the carcasses without shedding of blood, so that no part may be used, either (1) by burning, or (2) by deep burial, preferably in quicklime. These methods are equally effective, but perhaps for smaller carcasses burning is to be recommended and for larger ones deep burial. All places likely to have been contaminated with any discharges should be thor oughly disinfected, as with 1 in 1,000 corrosive sublimate. Investigations should be undertaken in each country or by some international organization, to determine accurately the nature and extent o f anthrax districts, which should be then kept under supervision and, where possible, drained or rendered innocuous by other means. Such measures would result in a consider able reduction in anthrax among animals and consequently among human beings. Such an organization would give warning o f the prevalence of anthrax in these districts, so that export of infected material might be controlled. Dust from horsehair factories is not infrequently sold. * * * Hence it is necessary to prevent the sale of dust arising in the manipulations of dangerous or nondisinfected raw animal products and t o , do this separate tables and rooms should be used for such material. Such dust should be burned. The effluent from wool, hair, and skin factories should be rendered inert by some reliable process, such as prolonged boiling, before being discharged, or treated by a suitable strength o f some such disinfectant as Cyllin. Other general measures, as notification o f all cases of deaths of animals from any acute disease and of those rendering necessary slaughter on the farm are desirable. A fee should be paid for notification and compensation for animals slaughtered, while failure to comply with these regulations should be punishable by a heavy penalty. Animals, except in emergencies, should not be slaughtered or their carcasses disposed of except on licensed and inspected premises, and, in all cases of ani mals slaughtered otherwise than by butchers in the ordinary course of their business, a veterinary should inspect the carcasses and give a certificate of the cause of death or disease, stating the uses to which the carcass may be put, a copy o f the certificate to be forwarded to the board of agriculture as well as to the medical officer o f health. Information should be furnished to factory and market officials; no butcher or knacker should purchase the carcass without having seen the certificate. APPENDIX A.— RULES AND REGULATIONS IN THE UNITED STATES. UNITED STATES: TREASURY DEPARTMENT AND DEPARTMENT OF AGRICULTURE JOINT ORDER NO. 1. REGULATIONS GOV ERNING THE CERTIFICATION AND DISINFECTION OF HIDES, FLESHINGS, HIDE CUTTINGS, PARINGS, AND GLUE STOCK, SHEEPSKINS AND GOATSKINS AND PARTS THEREOF, HAIR, WOOL, AND OTHER ANIMAL BY-PRODUCTS, HAY, STRAW, FOR AGE, OR SIMILAR MATERIAL OFFERED FOR ENTRY INTO THE UNITED STATES, 1916. [Effective January 1, 1917.] W a s h i n g t o n , D. C., October 21, 1916. Under authority of the act of Congress approved October 3, 1913, entitled “An act to reduce tariff duties and to provide revenue for the Government, and for other purposes ’’ (38 Stat., 114), and the act of Congress approved Feb ruary 2, 1903, entitled “ An act to enable the Secretary of Agriculture to more effectually suppress and prevent the spread o f contagious and infectious dis eases of live stock, and for other purposes ” (32 Stat., 791), the following regu lations are issued for the purpose of preventing the introduction of anthrax, foot-and-mouth disease, and rinderpest from a foreign country into the United States. R e g u l a t i o n I. HIDES AND SK IN S. S e c t i o n 1. All hides of neat cattle, calfskins, buffalo hides, sheepskins, goat skins, and deerskins offered for entry into the United States from any foreign country (except abattoir and hard, sun-dried hides and skins as hereinafter pro vided) must be accompanied by a certificate signed by the United States con sular officer of the district from which such hides or skins are shipped or by a certificate issued by the chief of the veterinary service or the duly authorized sanitary inspector of the country from which such hides or skins are shipped, authenticated by the said United States consular officer, stating that anthrax is not prevalent, and that neither foot-and-mouth disease nor rinderpest exists in such district, or by a certificate signed by the said consular officer showing that such hides or skins have been disinfected by immersion for not less than 24 hours in a 1 to 1,000 bichloride o f mercury solution. Sec. 2. I f such hides or skins (other than abattoir and hard, sun-dried hides and skins) offered for entry into the United States are certified, as required by section 1, to be from a district where anthrax is not prevalent, but in which either foot-and-mouth disease or rinderpest exists, they will be admitted if certified by the United States consular officer of the district from which shipped to have been disinfected by immersion for not less than 30 minutes either in a 1 to 1,000 bichloride o f mercury solution or in a 5 per cent solution of car bolic acid. 126 ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX A. 127 S ec. 3. Such hides or skins (other than abattoir and hard, sun-dried hides and skins), if packed in bales the exterior surface o f each of which is thor oughly whitewashed under consular supervision prior to shipment, may be imported without previous disinfection upon the conditions that they will be disinfected at the owner’s expense after arrival at destination in the United States; that the destination is a tannery having proper facilities for disinfect ing the same; that they will move from the port o f entry only under customs seal; and that they will be disinfected at destination under the supervision of the Bureau of Animal Industry ( a ) when certified as required by section 1 to be from a district where anthrax is not prevalent by immersion in a 5 per cent solution of carbolic acid or a 2 per cent solution o f chloride o f lime or a 1 to 5.000 solution of bichloride of mercury, with not less than 24 hours’ exposure; or (b ) when not certified in any of the forms aforesaid by immersion in a 1 to 1.000 bichloride of mercury solution with not less than 48 hours’ exposure, or in a 1 to 5,000 bichloride of mercury solution with not less than 6 days’ exposure plus not less than 5 days in lime of the usual strength for dehairing. Sec. 4. Hard, sun-dried hides and skins may be imported without disinfec tion if certified as required in section 1 to be from a district or districts where anthrax is not prevalent, if each bale or hide is distinctly marked for identifi cation, each shipment showing invoice number, names, and addresses o f con signees and consignor as such hard sun-dried hides and skins so certified showing freedom from anthrax can be considered as having been disinfected by the process of curing and need not be submitted to any further treatment, or such hides or skins may be imported without being certified to be from a dis trict where anthrax is not prevalent if accompanied by a consular certificate showing them to have been disinfected prior to shipment by immersion for not less than 24 hours in a 1 to 1,000 bichloride o f mercury solution, or such hides and skins may be imported without any certification upon the conditions pre scribed in section 3 for importations to be disinfected at destinaton in the United States by immersion in a 1 to 1,000 bichloride of mercury solution with not less than 48 hours’ exposure, or in a 1 to 5,000 bichloride of mercury solu tion with not less than 6 days’ exposure plus not less than 5 days in lime of the usual strength for dehairing. R e g u l a t io n II. ABATTOIIl HIDES AND S K IN S. Abattoir hides and skins taken from animals slaughtered in Sweden, Nor way, Australia, New Zealand, Great Britain, Uruguay, and Argentina, when accompanied by a certificate of an official veterinarian of the country where such animals were slaughtered, showing that such hides or skins were taken from animals free from disease at the time of slaughter, may be imported into the United States without disinfection. R e g u l a t io n III. GLUE STOCK. Fleshings, hide cuttings and parings, or glue stock shall be subject to disin fection and certification under the requirements o f these regulations the same as hides and skins, except that such fleshings, hide cuttings and parings, or glue stock may be imported without disinfection if shown by a consular invoice used upon entry or by a consular certificate to have been sterilized by heat (not less than 200° F.) or by acidulation, or to have been lime dried after 42806°— Bull. 205—17------ 9 128 B ULLETIN OF THE BUREAU OF LABOR STATISTICS. soaking for not less than 7 days in a strong lime wash made by slaking quick lime in water in such proportion as to be of a creamy consistency, or to have been dried by exposure to the action of the sun and air for a sufficient time to render each piece of the hardness of a sun-dried hide, provided the consignee or his agent files a satisfactory bond or agreement that said materials and containers will be handled or sterilized in a manner acceptable to the Bureau of Animal Industry before distribution from the factory or establishment to which consigned. R e g u l a t i o n IV. BONES, HOOFS, AND HORNS. S e c t i o n 1. Bones, hoofs, and horns which are clean, dry, and free from pieces of hide, flesh, or sinews may be imported without restrictions other than a satisfactory agreement on the part of the consignee or his agent to destroy or sterilize the bags or containers thereof at destination. S e c . 2 . Bones, hoofs, and horns with pieces of hides or tendons attached and also horn piths either will be subject to the requirements of Regulation III or may be forwarded to a factory or other establishment in sealed cars after the bags or containers have been sprayed with lime wash under the supervision of an inspector of the Bureau o f Animal Industry, provided the consignee or his agent files a satisfactory bond or agreement that such materials will be sterilized in an acceptable manner before distribution from the factory or other establishment to which shipped, and that the bags or containers thereof will be sterilized or destroyed. R e g u l a t i o n V. w ool and h a ir . S e c t i o n 1. Clipped wool may be imported in bales if accompanied by an affidavit of a competent authority of the district from which the wool is shipped, authenticated by the United States consul at the port o f shipment, designating the bales by their markings, indicating the consignor, consignee, and number of the invoice, and stating that all the wool contained in such bales was clipped from live animals free from foot-and-mouth disease, rinder pest, and anthrax, and that the same has not been exposed to the infection of these diseases. S e c . 2. Picked or pulled wool or hair may be imported if accompanied by a declaration of the exporter, authenticated by the United States consul at the port of shipment, to the effect that such wool or hair, designated in the manner provided in section 1 o f this regulation for clipped wool, came from animals free from anthrax. The consignee or owner of such wool or hair or his agent shall be required to file a satisfactory bond or agreement assuring proper facilities of disinfection at the establishment to which the shipment is consigned, and that all of such wool or hair will be disinfected or sterilized by proper exposure to a temperature of not less than 200° F. prior to any transfer or reshipment from such establishment. I f such wool or hair, when offered for entry, is un accompanied by the above-mentioned declaration, its entry will be permitted upon the condition that the consignee or owner thereof or his agent files a satis factory bond or agreement assuring proper facilities for disinfection at the establishment to which the shipment is consigned, and that all of such wool or hair will be disinfected or sterilized by proper exposure to a temperature of not less than 212° F. for at least 15 minutes prior to any transfer or reshipment from such establishment. ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX A. 129 S ec. 3. Importation of abattoir pulled wool will be permitted without restric tions from any country maintaining a veterinary inspection system ascertained by the Secretary of Agriculture and certified by him to the Secretary of the Treasury, from time to time, to be the substantial equivalent of the veterinary inspection system maintained by the United States, when accompanied by a certificate signed by an official veterinary inspector o f such country to the effect that said wool was procured from sheep slaughtered therein under Government inspection, and that in the process of wet pulling and drying it has been subjected to a temperature o f not less than 200° F. Such certificate must indicate the number of bales, marks, names, and addresses of consignor and consignee, district of origin, date of shipment, invoice number, and vessel transporting. Sec. 4. All wool and hair unaccompanied by certificates, affidavits, and decla rations herein provided, when permitted to be entered without such certificates, affidavits, and declarations, must be shipped from port of entry to destination in sealed cars after the bales or bundles have been whitewashed at such port of entry under the supervision o f an inspector of the Bureau o f Animal In dustry, and the destination of such wool or hair must be a factory or estab lishment having satisfactory facilities for sterilizing or disinfecting the same in the manner provided by these regulations or as may be directed by the Chief of the Bureau of Animal Industry. The consignee, owner, or his agent will be required to file a satisfactory bond or agreement to fulfill all requirements as to shipment and disinfection or sterilization. R e g u l a t io n VI. H A Y , STRAW, ETC., AND MEATS PACKED IN H A Y OR STRAW. S e c t i o n 1. On account of the existence of foot-and-mouth disease in the countries of continental Europe and South America, and the impracticability of disinfecting hay and straw used as the packing on meats offered for entry without injuring the meats for food purposes, the entry into the United States from any of those countries of any meats packed in hay or straw is prohibited. Sec. 2. Bran, middlings, and mill feed may be imported from Argentina with out being disinfected as prescribed in section 4 if accompanied by a certificate signed by the United States consul of the district from which shipped showing that such bran, middlings, or mill feed was conveyed by chutes directly from the mill in which produced into the vessels transporting the same to the United States. S ec. 3. Because of lack o f danger of the communication of disease through the importation of hay, straw, forage, and similar materials, including bran, middlings, or other mill feed originating in and transported directly from Great Britain, Ireland, the Channel Islands, Cana4a, and Mexico, such articles may be imported into the United States from these countries as long as the above condition continues to exist without being disinfected as prescribed in section 4. S ec. 4. Except as otherwise provided in this regulation all hay, straw, for age, or similar materials, including bran, middlings, or other mill feed, offered for importation from any foreign country shall be disinfected in the manner prescribed by the Chief of the Bureau of Animal Industry, at the expense of the owner, before being unloaded from the vessel or conveyance bringing the same into any port of the United States, and when unloaded and landed shall be stored and held in quarantine for a period of not less than three months 130 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. at some place acceptable to the Chief of the Bureau of Animal Industry and under directions prescribed by him. R VII. e g u l a t io n CANADA. Because of the lack of danger of the introduction of disease into the United States through the importation of the articles enumerated in these regulations originating in and transported directly from Canada, such articles may be im ported from Canada as long as the above condition continues to exist without being disinfected or certified as prescribed by these regulations. R e g u l a t io n VIII. PRODUCTS FROM DISEASED A N IM ALS. Importation into the United States of any hides, skins, fleshings, hide cut tings, parings, and glue stock, hair, wool, or other animal products covered by these regulations, taken or removed from animals affected with anthrax, footand-mouth disease, or rinderpest, is prohibited. R e g u l a t io n IX. DISINFECTION OF CARS, BOATS, OTHER VEHICLES, AND PREMISES. Cars, boats, other vehicles, yards, and premises which have been used in the transportation, handling, and storing o f uncertified or nondisinfected imported hides, skins, and parts thereof, hair, wool, and other animal by-products, hay, straw, forage, or similar material, permitted entry subject to disinfection, shall be cleaned and disinfected, under the supervision of the Bureau of Animal In dustry, subject to the conditions and in accordance with the requirements o f the regulations of the United States Department o f Agriculture contained in B. A. I. Order 245, governing the disinfection of cars, boats, other vehicles, yards, and premises used in interstate movement o f live stock, except that all such cars, boats, other vehicles, yards, and premises, storage places used in the transportation, handling, and storing of any of said articles uncertified for nonprevalence of anthrax, or which have not been disinfected against anthrax, shall be disinfected with a 1 to 1,000 bichloride of mercury solution. The per mitted disinfectants specified in the said B. A. I. Order 245 may be used in disinfection against the other communicable diseases. PRIOR ORDERS ANNULLED. Treasury Department Circular No. 23, dated May 2, 1910, and all amend ments thereto, and B. A. I. Order 129, dated October 4, 1904, and all amend ments thereto, shall cease to be effective on and after January 1, 1917, on and after which date this order, which for purposes of identification is designated as United States Treasury Department and Department of Agriculture Joint Order No. 1, shall become and be effective until otherwise ordered. (Signed) W m . P. M a l b u r n , Acting Secretary of the Treasury. D. P. H o u ston , Secretary of Agriculture. ANTHRAX AS AN OCCUPATIONAL DISEASE---- APPENDIX A. 131 MASSACHUSETTS: RULES AND REGULATIONS SUGGESTED FOR THE PREVENTION OF ANTHRAX, 1916.1 PREAM BLE. Anthrax may be transmitted to man by infected hides, skins, wool, horse hair, cow hair, goat hair, pigs’ bristles or pigs’ wool, as well as by dried blood, bones, and other animal products. The bacillus o f anthrax soon dies out when dried at the ordinary temperature, but the spores o f the disease may remain active, under favorable circumstances, for many years. These spores, inclosed in blood clots, dried and caked on the hair, skin, or wool, are the usual sources of infection, owing to the clots breaking up into dust. The dust arising in the handling, sorting, and manipulation of the animal products readily finds its way into the lungs in breathing, or is swallowed in the act of eating or drinking. More often, however, the dust finds its way into broken skin by cuts, bruises, or scratched pimples. The result of this infection is anthrax. Anthrax, therefore, is chiefly a dust disease. (It can be caused by eating diseased meat and by the bite o f an insect which has fed upon infected carcasses or other material.) While the, danger o f anthrax is greatest, according to all statistics, in the manipulation of animal products imported from China, Russia, and Siberia, nevertheless the disease is so widely dis tributed that in no country is it unknown. Consequently, the precautions which are most necessary where hides, skins, hair, and wool from the, coun tries named are handled can, with advantage, be applied to products from other countries. In the United States there is no interstate, quarantine law nor disinfection regulation against anthrax. Protection against anthrax can be grouped under these headings, v iz .: 1. Disinfection of the material. 2. The avoidance o f dust. 3. The instruction o f the workers. The experience o f countries where anthrax has been more prevalent than it has been in this country shows (1) that wool or hair can be readily disin fected by steam without injury to the material, and (2) that hides and skins can be disinfected without damage to these articles and without injury to subsequent manufacturing processes. The following rules and regulations shall apply to all establishments where hides, skins, fur, horse hair, bristles, wool, horns, bones, or other animal prod ucts liable to be infected with anthrax are handled. For the enforcement of these rules and regulations all products or parts of animals shall be considered in a raw state unless they have undergone a treatment as follow s: Hides and skins— tanning. W ool— scouring. Horse hair, fur, and hog bristles— bleaching. Horns and bone— boiling for two hours, or treatment with a strong antiseptic. The following industries shall be considered dangerous within these rules and regulations, and they shall apply in a special manner in those departments where these processes are carried on, v iz .: 1. The unpacking, unloading, or other handling, when dry, or before disin fection of the material. 2. The preparation of horse hair. 3. Tawing, tanning, and fur dressing. 4. The pulling, scouring, and sorting of wool. 1 Massachusetts Board of Labor and Industries, Industrial Bulletin No. 6 . 132 BULLETIN OF THE BUREAU OF LABOR STATISTICS. DISINFECTION. All foreign1 hides, skins, horse hair, cow hair or goat hair, pigs’ bristle, and pigs’ wool, before they are manipulated in any factory or establishment in this State, shall be disinfected (unless exempted as hereinafter provided) at the choice of the manufacturer in one of the following prescribed w ays: A. Hides and Skins. - (1) By the Seymour-Jones method, viz: To 1 pound of per chloride of mer cury add 500 gallons of water, and to this mixture add 5 gallons of formic acid (commercial 50 per cent strength). In this bath steep the material for 24 hotirs; or, (2) By the Schattenfroh method, viz: In a 2 per cent hydrochloric acid solu tion to which 10 per cent of common salt has been added, steep the material for a few days. A quicker method can be used by substituting a 1 per cent solu tion of hydrochloric acid and 8 per cent o f salt, provided the temperature of the solution is maintained at 40° C. (104° F.) for a period of six hours. B. Hair, Bristles, and Pigs' Wool. (1) By letting a current of steam act on the material for not less than onehalf hour at a pressure of 17 pounds (0.15 above atmospheric pressure) ; or, (2) By boiling for at least one-quarter of an hour in a solution containing 2 per cent of per manga nite of potassium, and subsequent bleaching with a 3 or 4 per cent solution of sulphurous a cid ; or, (3) By boiling in water for not less than two hours. Exemptions. The disinfection by the manufacturer may be dispensed with if he presents proof in writing stating that the material has been disinfected in accordance with the requirements of the United States Treasury Department or o f the Massachusetts State Department of Health. The manufacturer shall not be required to disinfect white bristles which he subjects to a subsequent bleaching process before further manipulation, or w^hich he has bought already bleached (so-called French bristles) and which have been kept apart from nondisinfected material. Exemption from the requirements o f section B may be authorized by the State Board of Labor and Industries for those materials. that, according to present experience, would be seriously damaged, or for those materials that can be certified to as having already undergone an equally effective disinfection in the country or State from which they have been exported. Prior to disinfection prescribed by these rules and regulations only such steps as are indispensable to the examination of the quality of the material, to the prevention of their being spoiled, and to the preparation and the execution of the disinfection are permitted in relation to material required to be disin fected, e. g., unpacking and preparing for disinfection. The stock of nondisinfected materials which are required to be disinfected, or which are exempted from disinfection, shall be stored in separate rooms and kept apart from the stock that has been disinfected. Access to this room should be restricted as much as possible so, as to avoid unnecessary exposure of workmen. Records. The employer shall keep a record of the skins, hides, hair, bristles, wool, and other material mentioned in these rules and regulations, in such a manner that the quantity, the source of supply, and, so far as is known, the origin of the merchandise received, as well as the time and the method of disinfection, or the 1 Also domestic whenever anthrax is prevalent in the locality from which the material has been exported. AN TH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX A. 133 reason for its omission, are clearly set forth. Such records shall be accessible to the State Board of Labor and Industries or its representatives. SANITATION OF WORKSHOPS. Floors.— In those parts of the establishment where material capable of trans mitting anthrax is stored or manufactured the floors shall have a waterproof covering or other suitable material that permits the ready washing of such floors. The floors of these departments should be washed daily if the workroom is dusty or if cases of anthrax have occurred recently at the establishment. Walls and ceiling.— The walls and ceiling of such workshop or room, unless covered with a smooth washable coating pr oil painting, should be washed fre quently with a disinfectant solution. If whitewash is used this coating should be renewed on the outbreak of cases of anthrax among workmen employed in that establishment. Tables, workbenches and seats.—These articles should be washed twice a week with a disinfectant solution, especially if cases of anthrax have occurred recently in the establishment. Ventilation.— The workroom shall be well aired twice daily by means of open windows, for at least half an hour, viz, during noonday meal hour and after the day’s work has been finished, or before it has begun again. No work man should be permitted to remain in the room during this period. Dust removal.— In all workrooms in which dust is a factor there shall be an adequate exhaust system installed capable of removing the dust at its origin and conveying it to a suitable receptacle for subsequent destruction. It is recommended that hides and skins be submitted to the ordinary “ wet salting” process immediately after flaying; or if cured by drying, that the hides and skins be converted back to the “ wet salted ” state by the formic-mercury processes as soon as possible. In horsehair factories and horsehair dressing, the sorting and hackling shall not be done except in special workrooms separate from the other workroom. The dust created shall be collected and destroyed. Carding and dust-extracting machinery as well as mixing, willowing, and hackling machines, shall be closed over and provided with an adequate and effective dust exhaust system. The dust shall be collected in a dust chamber and burned. The treatment o f wool, horsehair, hog bristles, and furs shall take place whenever possible in closed vessels. In those operations, such as opening of bales or beating, which can not take place in closed vessels, the process shall be carried on in such a way as to allow the collecting of the refuse and its sub sequent destruction. PERSONAL PRECAUTIONS. Printed notices issued by the State Board of Labor and Industries shall be kept posted in a conspicuous place in each department, setting forth the dangers of anthrax infection, the early signs and symptoms of the disease, and the precautions that shall be taken in order to avoid this infection. Any employee who is suffering from a cut, scratch, pimple, or crack of the skin that has not healed readily shall report the same to the person in charge or to factory physician. Employers shall furnish to employees impermeable aprons and leggings (or rubber boots) in all operations where the body is liable to come in contact with the water used in tanning, scouring, boiling, or bleaching o f animal product. Employees shall wear a suitable respirator (loose g&uze cloth tied over nose and mouth may be used) while engaged in the dusty processes of handling, sorting, or of manufacture. 134 BULLETIN OF THE BUREAU OF LABOR STATISTICS. Employers shall provide for the use of employees overalls and gloves when handling raw material, and neck protectors when carrying raw material on the shoulder. Haw material shall be transported on carts or handbarrows when ever practicable. Employers shall see that the materials provided for the use of employees are worn by the persons for whom they are intended, and that when these articles are not in use they are kept in a special place, and that they are disinfected at least once a week. Dressing rooms, wash rooms, and a suitable dining room shall be provided and fitted up outside the place where dangerous operations are carried on. There shall be provided an adequate supply o f running hot and cold water, toilets, washing and drinking facilities, all in accordance with the rules of the State Board of Labor and Industries on toilets. Lockers shall be provided so that street clothes and work clothes may be kept separate and apart. Employees shall not bring food into the workroom. The eating of food in workroom shall be strictly prohibited. Employees shall be required to take off their work clothes before entering the dining room, and to wash hands, arms, neck, and face before taking their meals or leaving the premises. Employers shall keep posted in a conspicuous place in each department a notice legible to all employees stating— 1. The text of these rules and regulations. 2. Workshop regulations imposing on employees the following obligations: {a) To make use of the various working clothes and other articles provided for them by the employer. (&) To make use of the dressing room and washing facilities. (c) To take the necessary measures for cleanliness before eating and before leaving the workshop. ( d ) To bring no food into the workroom. 3. The dangers of anthrax infection, and the precautions that should be taken to avoid them, and the necessity of employees reporting at once all skin affections. 4. Name and address of physician in charge o f the medical service o f the establishment. Note. The first symptom of anthrax is usually a small inflamed swelling like a pim ple or boil. This is often painless. In a few days the pimple becomes black at the center and is surrounded by other “ pimples.” The poison is now liable to be absorbed into the system and will cause risk of life if not removed by prompt and effective treatment. Early treatment is usually successful; delay or neglect usually leads to blood poisoning, often to death. NEW YORK: STATE INDUSTRIAL COMMISSION, DIVISION OF INDUSTRIAL HYGIENE, RECOMMENDATIONS, 1916. I. Every physician should report at once to the State industrial commission every case of anthrax coming under his care. II. In every establishment where articles liable to be infected with anthrax are handled a competent physician should be employed. III. In every such establishment the employer should make such special provision for the protection of his employees as the commission shall deter mine. IV. Every employee should be required to make use of the means provided for his safety by the employer. ANTHRAX AS AN OCCUPATIONAL DISEASE---- APPENDIX A. 135 V. It should be the duty of the shop foreman or superintendent to enforce the use by the employees of the means provided by the employer. VI. Attention of physicians and of the public should be called to the dangers o f anthrax. A ll. Cooperation with Federal and contiguous State authorities should be maintained to prevent the entrance of infected materials into commerce. THE PH YSIC IA N . 1. He should visit the establishment every day and sign a register showing the time of his visit, this register to be subject to inspection by the State indus trial commission. 2. He should examine every workman at entrance upon employment, and as often thereafter as necessary. He should instruct new employees individually, and the others frequently in classes, in methods of preventing anthrax. 3. He should be provided with facilities for the prompt diagnosis and early treatment of anthrax. He should have charge of the first-aid kits, as approved by the commission. He should instruct foremen and others selected in the use of first aid. 4. He should keep a record of all examinations and of all treatments, such record to be subject to inspection by the commission. He should report promptly to the commission every case of anthrax, together with a record of the source of the infecting material. THE EMPLOYEE. 1. In factories the floors should be of cement or waterproofed easily washed material. The walls should be whitewashed. When a case o f anthrax de velops the floors should be thoroughly cleaned and the walls whitewashed. Tables, work benches, and other articles coming in contact with materials should be washed as often as necessary with a disinfecting solution. 2. Dressing rooms, wash rooms, and lunch rooms should be provided, sepa rate from the work rooms. The dressing room should be so arranged that the working clothes may be kept separate from the street clothes. The wash rooms should be provided with basins, water, soap, individual towels, etc., as directed by the industrial code. No food should be allowed in the workrooms. 3. Where dust is evolved in the process special ventilating apparatus should be installed according to the judgment of the commission. 4. To avoid, as much as possible, contact with materials, suitable clothing, waterproof aprons, overalls, shoes, gloves, etc., should be provided the work men. 5. Notices in different languages should be posted conspicuously throughout the workrooms: (a) Requiring the use of protective clothing; requiring the use of dressing rooms and wash room s; forbidding food in workrooms. (b) W'arning of dangers of anthrax; instructing as to methods of avoiding i t ; requiring the report to foremen of even slight accidents or injuries. 6. The foreman or superintendent should be held responsible for observance of the regulations. THE EMPLOYEE. 1. He should realize the danger of anthrax and the necessity o f avoiding infection. 2. He should wear the clothing and use the dressing rooms, wash rooms, and lunch rooms provided by the employer. No food should be taken into the work rooms. 3. He should report at once to the foreman even slight injuries and should follow strictly directions of the physician. 4. He should assist the foreman in enforcing the regulations. APPENDIX B.— TEXT OF EUROPEAN REGULATIONS.1 GREAT BRITAIN: REGULATIONS FOR HANDLING DRY AND DRYSALTED HIDES AND SKINS IMPORTED FROM CHINA OR FROM THE WEST COAST OF INDIA, 1901. DUTIES OF OCCUPIER. 1. Proper provisions to the reasonable satisfaction of the inspector in charge of the district shall be^ made for the keeping of the workmen’s food and clothing outside any room or shed in which any of the above-described hides or skins are unpacked, sorted, packed, or stored. 2. Proper and sufficient appliances for washing, comprising soap, basins, with water laid on, nailbrushes and towels, shall be provided and maintained for the use of the workmen, to the reasonable satisfaction of the inspector in charge of the district. 3. Sticking plaster and other requisites for treating scratches and slight wounds shall be kept at hand, available for the use of the persons employed. 4. A copy of the appended notes shall be kept affixed with the rules. DUTIES OF PERSONS EMPLOYED. 5. No workman shall keep any food, or any articles o f clothing other than those he is wearing, in any room or shed in which any of the above-described hides or skins are handled. He shall not take any food in any such room or shed. 6. Every workman having any open cut or scratch or raw surface, however trifling, upon his face, head, neck, arm, or hand shall immediately report the fact to the foreman, and shall not work on the premises until the wound ia healed or is completely covered by a proper dressing after being thoroughly washed. N o t e 1. [States that these rules must be kept posted in conspicuous places in the factory, workshop, or other premises to which they apply, where they may be conveniently read by the persons employed. Any person who is bound to observe them and fails to do so, or acts in contravention o f them, is liable to a penalty; and in such cases the occupier is also liable to a penalty unless he proves that he has taken all reasonable means, by publishing and, to the best of his power, enforcing them, to prevent the contravention or noncompliance. A printed copy must be supplied by the occupier to any person affected by them if such person applies for it. Pulling down, injuring, or defacing any copy so posted is punished by a fine not exceeding £5 ($24.33).] N o t e 2. [Is an earlier and less complete form o f the note shown on page 140.] N o t e 3.— Suitable overalls, protecting the neck and arms, as well as ordinary clothing, add materially to the safety of the workmen, and should be provided and worn, where practicable, if dangerous hides are handled. They should be discarded on cessation of work. Similarly, for the protection of the hands, gloves should be provided and worn where the character of the work permits. 1 From monthly bulletin of the International Labor Office. 136 ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX B. 137 GREAT BRITAIN: SORTING, WILLEYING [WILLOWING], WASHING, COMBING, AND CARDING WOOL, GOAT HAIR, AND CAMEL HAIR, AND PROCESSES INCIDENTAL THERETO, 1905. DEFINITION. For the purpose of regulations 2, 3 and 18, opening of wool or hair means the opening of the fleece, including the untying or cutting of the knots, or, if tlie material is not in the fleece, the opening out for looking over or classing purposes. DUTIES OF OCCUPIERS. 1. No bale of wool or hair of the kinds named in the schedules shall be opened for the purpose of being sorted or manufactured, except by men skilled in judging the condition o f the material. No bale of wool or hair of the kinds named in schedule A shall be opened except after thorough steeping in water. 2. No wool or hair of the kinds named in schedule B shall be opened except (a) after steeping in water, or (b) over an efficient opening screen, with mechanical exhaust draft, in a room set apart for the purpose, in which no other work than opening is carried on. For the purpose o f this regulation, no opening screen shall be deemed to be efficient unless it complies with the following conditions: (a) The area of the screen shall, in the case of existing screens, be not less than 11 square feet, and in the case of screens hereafter erected be not less than 12 square feet, nor shall its length or breadth be less than 3£ feet. (&) At no point o f the screen within 18 inches from the center shall the velocity of the exhaust draft be less than 100 linear feet per minute. 3. All damaged wool or hair or fallen fleeces or skin, wool or hair, if o f the kinds named in the schedules, shall, when opened, be damped with a disin fectant and washed without being willowed. 4. No wool or hair o f the kinds named in schedules B or C shall be sorted except over an efficient sorting board, with mechanical exhaust draft, and in a room set apart for the purpose, in which no work is carried on other than sorting and the packing o f the wool or hair sorted therein. No wool or hair o f the kinds numbered (1) and (2) in schedule A shall be sorted except in the damp state and after being washed. No damaged wool or hair of the kinds named in the schedules shall be sorted except after being washed. For the purpose of this regulation, no sorting board shall be deemed to be efficient unless it complies with the following conditions: The sorting board shall comprise a screen of open wirework, and beneath it at all parts a clear space not less than 3 inches in depth. Below the center of the screen there shall be a funnel, measuring not less than 10 inches across the top, leading to an extraction shaft, and the arrangements shall be such that all dust falling through the screen and not carried away by the exhaust can be swept directly into the funnel. The draft shall be maintained in constant efficiency while the sorters are at work, and shall be such that not less than 75 cubic feet of air per minute are drawn by the fan from beneath each sort ing board. 5. No wool or hair of the kinds named in the schedules shall be willowed except in an efficient willowing machine, in a room set apart for the purpose, in which no work other than willowing is carried on. 138 BULLETIN OF THE BUREAU OF LABOR STATISTICS. For the purpose of this regulation, no willowing machine shall be deemed to be efficient unless it is provided with mechanical exhaust draft so arranged as to draw the dust away from the workmen and prevent it from entering the air of the room. 6. No bale of wool or hair shall be stored in a sorting room ; nor any wool or hair except in a space effectually screened off from the sorting room. No wool or hair shall be stored in a willowing room. 7. In each sorting room, and exclusive of any portion screened off, there shall be allowed an air space of at least 1,000 cubic feet for each person employed therein. 8. In each room in which sorting, willowing, or combing is carried on, suit able inlets from the open air or other suitable source shall be provided and arranged in such a way that no person employed shall be exposed to a direct draft from any air inlet or to any draft at a temperature of less than 50° F. The temperature of the room shall not, during working hours, fall below 50° F. 9. All bags in which wool or hair of the kinds named in the schedules 1ms been imported shall be picked clean and not brushed. 10. All pieces of skin, scab, and clippings or shearings shall be removed daily from the sorting room and shall be disinfected or destroyed. 11. The dust carried by the exhaust draft from opening screens, sorting boards, willowing or other dust-extracting machines and shafts shall be dis charged into properly constructed receptacles and not into the open air. Each extracting shaft and the space beneath the sorting boards and opening screens shall be cleaned out at least once in every week. The dust collected as above, together with the sweepings from the opening, sorting, and willowing rooms, shall be removed at least twice a week and burned. The occupier shall provide and maintain suitable overalls and respirators, to be worn by the persons engaged in collecting and removing the dust. Such overalls shall not be taken out of the works or warehouse, either for washing, repairs, or any other purpose, unless they have been steeped over night in boiling water or a disinfectant. 12. The floor of every room in which opening, sorting, or willowing is car ried on shall be thoroughly sprinkled daily with a disinfectant solution after work has ceased for the day, and shall be swept immediately after sprinkling. 13. The walls and ceilings of every room in which opening, sorting, or willow ing is carried on shall be limewashed at least once a year and cleansed at least once within every six months, to date from the time when they were last cleansed. 14. The following requirements shall apply to every room in which unwashed wool or hair of the kinds named in the schedules, after being opened for sort ing, manufacturing, or washing purposes, is handled or stored: (a) Sufficient and suitable washing accommodation shall be provided out side the rooms and maintained for the use of all persons employed in such rooms. The washing conveniences shall comprise soap, nailbrushes, towels, and at least one basin for every five persons employed as above, each basin being fitted with a waste pipe and having a constant supply o f water laid on. (&) Suitable places shall be provided outside the rooms in which persons employed in such rooms can deposit food, and clothing put off during working hours. (c) No person shall be allowed to prepare or partake o f food in any such room. Suitable and sufficient meal-room accommodation shall be provided for workers employed in such rooms. ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX B. 139 (tf) No person having any open cut or sore shall be employed in any such room. The requirements in paragraph (c) shall apply also to every room in which any wool or hair of the kinds named in the schedules is carded or stored. 15. Requisites for treating scratches and slight wounds shall be kept at hand. 16. The occupier shall allow any of H. M. inspectors of factories to take at any time, for the purpose of examination, sufficient samples of any wool or hair used on the premises. DUTIES OF PERSONS EMPLOYED. 17. No bale of, wool or hair o f the kinds named in the schedules shall be opened otherwise than as permitted by paragraph 1 of regulation 1, and no bale of wool or hair of the kinds named in schedule A shall be opened except after thorough steeping in water. If on opening a bale any damaged wool or hair of the kinds named in the schedules is discovered, the person opening the bale shall immediately report the discovery to the foreman. 18. No wool or hair of the kinds named in schedule B shall be opened other wise than as permitted by regulation 2. 19. No wool or hair o f the kinds named in the schedules shall be sorted other wise than as permitted by regulation 4. 20. No wool or hair of the kinds named in the schedules shall be willowed except as permitted by regulation 5. 21. Every person employed in a room in which unwashed wool or hair of the kinds named in the schedules is stored or handled shall observe the following requirements: ( a ) He shall wash his hands before partaking of food or leaving the premises. (&) He shall not deposit in any such room any article o f clothing put off during working hours. He shall wear suitable overalls while at work and shall remove them before partaking of food or leaving the premises. ( c) I f he has any open cut or sore, he shall report the fact at once to the foreman and shall not work in such a room. No person employed in any such room or in any room in which wool or hair of the kinds named in the schedules is either carded or stored shall prepare or partake of any food therein or bring any food therein. 22. Persons engaged in collecting or removing dust shall wear the overalls as required by regulation 11. Such overalls shall not be taken out of the works or warehouse, either for washing, repairs, or any other purpose, unless they have been steeped overnight in boiling water or a disinfectant. 23. If any fan, or any other appliance for the carrying out of these regula tions, is out of order, any workman becoming aware of the defect shall imme diately report the fact to the foreman. SCHEDULE A . (W ool or hair required to be steeped in the bale before being opened.) 1. Van mohair. 2. Persian locks. 3. Persian or so-called Persian (including Karadi and Bagdad), if not sub jected to the process o f sorting or willowing. 140 BULLETIN OF THE BUREAU OF LABOR STATISTICS. SCHEDULE B. (W ool or hair required to be opened either after steeping or over an efficient opening screen.) Alpaca. Pelitan. East Indian cashmere. Russian camel hair. Pekin camel hair. Persian or so-called Persian (including Karadi and Bagdad), if subjected to the process of sorting or willowing. SCHEDULE C. (W ool or hair not needing to be opened over an opening screen, but required to be sorted over a board provided with downward draft.) % All mohair other than Van mohair. Note. The danger against which these regulations are directed is that of anthrax— a fatal disease affecting certain animals, which may be conveyed from them to man by the handling of wools or hairs from animals which have died of the disease. The germs of the disease (anthrax spores) are found in the dust attaching to the wool or in the excrement, and in the substance o f the pieces of skin, and may remain active for years. In this country and Australia anthrax is rare, consequently there is little danger in handling wools from the sheep of these two countries; but in China, Persia, Turkey, Russia, the East Indies, and in many other parts o f the world, the disease is common, and infected fleeces or locks (which may not differ from others in appearance) are often shipped to Great Britain. Hence, in handling foreign dry wools and hair, the above regulations should be carefully observed. Greasy wools are com paratively free from dust, and therefore little risk is incurred in handling them. The disease is communicated to man sometimes by breathing or swallowing the dust from these wools or hair, and sometimes by the poison lodging in some point where the skin is broken, such as a fresh scratch or cut, or a scratched pimple, or even chapped hands. This happens more readily on the uncovered parts of the body, the hand, arm, face, and most frequently o f all, on the neck, owing either to infected wool rubbing against the bare skin, or to dust from such wool alighting on the raw surface. But a raw surface covered by clothing is not free from risk, for dust lodging upon the clothes may sooner or later work its way to the skin beneath. Infection may also be brought about by rubbing or scratching a pimple with hand or nail carrying the anthrax poison. Use of the nailbrush, and frequent washing and bathing of the whole body, especially of the arms, neck, and head, will lessen the chance o f contracting anthrax. The first symptom o f anthrax is usually a small inflamed swelling like a pimple or boil— often quite painless— which extends, and in a few days becomes black at the center and surrounded by other “ pimples.” The poison is now liable to be absorbed into the system, and will cause risk of life, which can be avoided only by prompt and effective medical treatment in the early stage, while the poison is still confined to the pimple. Hence it is of the utmost importance that a doctor should be at once consulted if there is any suspicion o f infection. ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX B. 141 GREAT BRITAIN: REGULATIONS FOR THE PROCESSES INVOLVING THE USE OF HORSEHAIR FROM CHINA, SIBERIA, OR RUSSIA, IN EFFECT APRIL 1, 1908.1 DEFINITIONS. “ Material ” means tail or mane horsehair from China, Siberia, or Russia, whether in the raw state or partially or wholly prepared, notwithstanding that such preparation may have taken place in some country other than those named. “ Disinfection” means (a) exposure to steam at a temperature not less than 212° F. for at least half an hour of material so loosened, spread out, or ex posed as to allow the steam to penetrate throughout; or ( b ) exposure of material to such disinfectant under such conditions of concentration and temperature of the disinfectant, and duration and manner o f exposure of the material to it, and otherwise, as are certified to secure the destruction of anthrax spores in all parts of all horsehair subjected to the process: Provided, That such a certificate shall have no force unless and until (1) a copy o f it has been submitted to the secretary of state, and (2) a copy of it is kept in the register required under regulation 1: Provided further, That any such certificate may at any time be disallowed by the secretary of state, either generally or with regard to a factory or workshop in which anthrax has occurred. “ Certified ” means certified by the director of a bacteriological laboratory recognized by a corporation in the United Kingdom having power to grant diplomas registrable under the medical acts, 1858 to 1905. It shall be the duty o f the occupier to observe Part I of these regulations. It shall be the duty of all persons employed to observe Part II of these regu lations. PART I.— DUTIES OF EMPLOYERS. 1. A register shall be kept containing the prescribed particulars2 of the disinfection of all material. 2. Material which has not undergone disinfection shall not be stored except in a room set aside for the purpose, in which no other horsehair shall be placed. 3. Material which has not undergone disinfection shall not be opened from the bale or sorted except in a room set aside for the purpose, in which no other horsehair shall be placed; nor shall any such material be opened from the bale, except over or by the side of an efficient screen, or sorted except over an efficient screen. For the purposes of this regulation no screen shall be deemed to- be efficient unless it is provided with an exhaust draft so arranged that at every point of the screen within 18 inches of the center the velocity of the exhaust draft shall be at least 300 linear feet per minute. 4. No material shall be subjected to any manipulation other than opening or sorting until it has undergone disinfection. 5. Every willowing and dust-extracting machine shall be covered over and provided with efficient exhaust draft so arranged as to carry the dust away from the worker. 6. The dust from the opening and sorting screens, and from the willow or other dust-extracting machines, shall be discharged into furnaces or into chambers so constructed as to intercept the dust. 7. Each extracting shaft and the space beneath the opening and sorting screen shall be cleaned out at least once in every week. 1 Great Britain, Home Office. Factory and Workshops Orders, London, 1909, p. 93. 2 See appended schedule, p. 143. 142 BULLETIN OF TH E BUREAU OF LABOR STATISTICS. 8. All dust collected from the opening and sorting screens shall be burned. 9. There shall be provided and maintained for the use o f persons employed on material which has not undergone disinfection— ( a) Suitable overalls and head coverings, which shall be collected at the end of every day’s work, and washed or renewed at least once every week, and shall not be taken out of the works for any purpose whatever unless they have previously been boiled for 10 minutes or have undergone disinfection after last being used; and ( b ) A suitable meal room, separate from any workroom, unless the works are closed during meal hours; and ( c ) A suitable cloakroom for clothing put off during working hours; and a suitable place, separate from the cloakroom and meal room, for the storage of the overalls; and ( d ) Requisites for treating scratches and slight wounds. 10. There shall be provided suitable respirators for the use of persons employed in work necessitated by regulations 6, 7, and 8. Each respirator shall bear the distinguishing mark of the worker to whom it is supplied, and the filtering material shall be renewed after each day on which it is used. 11. There shall be provided and maintained in a cleanly state and in good repair for the use of all persons employed on material which has not undergone disinfection, a lavatory, under cover, with a sufficient supply of clean towels, renewed daily, and o f soap and nailbrushes, and with either— (a) A trough with a smooth impervious surface, fitted with a waste pipe without plug, and of such length as to allow at least 2 feet for every five such persons, and having a constant supply of warm water from taps or jets above the trough at intervals of not more than 2 fe e t; or ( b ) At least one lavatory basin for every five such persons, fitted with a waste pipe and plug or placed in a trough having a waste pipe, and having either a constant supply of hot and cold water or warm water laid on, or (if a constant supply of heated water be not reasonably practicable) a constant supply of cold water laid on and a supply of hot water always at hand when required for use by persons employed. 12. No person under 18 years o f age shall be employed on material which has not undergone disinfection. 13. No persons employed on material which has not undergone disinfection shall be allowed— (a ) To work having any open cut or sore; or (&) To introduce, keep, prepare, or partake o f any food or drink, or to bacco, in any room in which such material is stored or manipulated. 14. A cautionary notice as to anthrax, in the prescribed form, shall be kept affixed with these regulations. PART II.— DUTIES OF PERSONS EMPLOYED. 15. No person employed shall— (a) Open, sort, or willow or otherwise manipulate any material except in accordance with the foregoing regulations. (&) Introduce, keep, prepare, or partake of any food or drink, or tobacco, contrary to regulation 13 (&). 16. Every person employed on material which has not undergone disinfection shall— (a) Wear the overall and head covering provided in pursuance o f regula tion 9 (a) while at work, and shall remove them before partaking of food or ANTH RAX AS AN OCCUPATIONAL DISEASE---- APPENDIX B. 143 leaving the premises, and shall deposit in the cloakroom provided in pursuance o f regulation 9 (c) all clothing put off during working hours; and (b) Wash the hands'and clean the nails before partaking of food or leaving the premises; and (c) Report any cut or sore to the foreman, and until it has been treated, abstain from work on any such material. 17. Every person employed shall wear the respirator provided in pursuance of regulation 10 while engaged in work necessitated by regulations 6, 7, and 8. 18. If the arrangement for disinfection, or any fan, or any other appliance for the carrying out of these regulations, appears to any workman to be out of order or defective, he shall immediately report it to the foreman. SCHEDULE: PROCESSES INVOLVING THE USE OF HORSEHAIR, 1908. By an order dated March 11, 1908, the particulars to be entered on the register under regulation 1 o f the order as to use of horsehair are to be: With regard to each consignment of such horsehair received in the factory or workshop— 1. Weight of material. 2. Date of receipt on the premises. 3. Country of origin. 4. Whether raw or partially or wholly prepared. 5. Method of disinfection. And in the case of material disinfected on the premises— 6. Date of disinfection. And in the case of material disinfected elsewhere than on the premises— 7. Name of person from whom the material was obtained. FRANCE: DECREE RELATING TO SPECIAL HYGIENIC MEASURES FOR ESTABLISHMENTS WHERE THE WORKERS ARE EXPOSED TO ANTHRAX INFECTION, 1913. 1. In the establishments contemplated in section 65 of Book II of the Labor Code, where are handled in the raw state skins, fur, horsehair, liogs’ bristles, wool, horns, bones, or other animal products liable to be infected with anthrax, the principals, directors or works managers shall be required, irrespective of the general measures prescribed by the decree of July 10, 1913,1 to adopt the special measures of protection and hygiene mentioned in the following articles. In regard to the application of the present decree, such product or animal remains as have not undergone the treatment mentioned below shall be consid ered as in the raw state: Horsehair, hogs’ hair and bristles: Stoving at 103° for one hour, or soaking for two hours in boiling water, or bleaching. Skins: Tanning. W ools: Industrial degreasing. Bones and horns: Stoving at 103° for one hour or soaking for two hours in boiling water, or treatment with powerful antiseptics. All other methods of disinfection which the minister of labor, after taking the opinion of the consultative committee for arts and manufactures, shall recognize as equivalent, may also be allowed. 1 p. 63. For text of this decree see Bulletin o f the International Labor Office, Vol. I X , 1914, 42806°— Bull. 205— 17-------10 144 BULLETIN OF THE BUREAU OF LABOR STATISTICS. 2. A physician appointed by the principal of the establishment shall carry out the following inspections and make the required reports; his remuneration shall be at the expense of the establishment. As soon as it shall come to the knowledge of principals, directors, or works managers that a workman is suffering either from a form of pimple, cut, abrasion, or crack which has not healed up after three days’ dressing in the factory, they shall have him at once examined by the physician, who shall prescribe the necessary treatment. The name and age of the worker and the work in which he was engaged, the origin of the materials recognized as liable to have caused the infection, as also the riesult of the medical examina tion, shall be entered in a special register. Every establishment shall be provided with a “ first-aid ” box containing the remedies and materials for dressing, as prescribed by ministerial order. This ♦box shall always be kept in good condition, and placed in an easily accessible place. 3. The principals of works, directors, or managers shall be required to pro vide the workers with impermeable aprons and legging overalls for all work in which the body is liable to come in contact with the water used in the treatment of the products of animal remains mentioned in section 1. 4. The following industries shall be considered as dangerous within the mean ing of section 5 hereunder, where materials are treated which have come from districts indicated in an order o f the minister of labor, after consultation with the minister o f commerce and industry and the minister o f agriculture. (1) The preparation o f horsehair. (2) The plucking, washing, and sorting of wools. (3) Tawing, tanning, and furriery. (4) The sorting and working up of bones and horns. The following operations shall also be regarded as dangerous within the meaning o f the same section: The unpacking, manipulation, and other opera tions performed in a dry condition, before disinfection of the materials enu merated in section 1, which have come from the regions indicated in the order above referred to. 5. In those parts of the establishment specially devoted to the carrying on o f the industries or to the performance of the dangerous operations defined under section 4, the following precautions shall be observed: In the workrooms the flooring shall consist of an impermeable covering or of a sectional paving which can be easily washed. The walls shall have a coating which can be thoroughly washed, or shall be limewashed. This limewash coating shall be renewed whenever necessary, and especially when a case of anthrax has occurred. The tables, benches, and seats, also the floors and walls, shall be washed as often as may be necessary with a disinfect ing solution. The tools shall be subjected to frequent disinfection. In the storehouses where the materials referred to in section 1 are kept, every space temporarily unoccupied shall be cleaned with a disinfectant. In the case of wool, horsehair, hogs’ hair and bristles, the handling shall be done wherever possible in closed vessels. As regards the material referred to in the preceding paragraph, the operations which it is impossible to carry out in a closed vessel— such as the opening of bales and, if necessary, the beating—must be carried out under such conditions as will allow o f the collection of all the offal and its subsequent destruction. The dressing and washing rooms for the use o f the workers shall be fitted up outside the places where dangerous operations are carried on. ANTHRAX AS AN OCCUPATIONAL DISEASE— APPENDIX B. 145 The said dressing and washing rooms shall be fitted with a sufficient num ber of basins or taps, with an ample provision o f water and soap and a towel for each worker, which latter shall be renewed at least once a week. They shall, moreover, be provided with wardrobes or boxes which can be closed by key or a padlock, and which are divided into two compartments, so that the outdoor clothes may be kept separate from the working clothes. In default of a separate cupboard divided into two compartments, every worker shall have at his disposal two clothes pegs on opposite sides of the dressing room, for the purpose o f receiving on one side his ordinary and on the other side his working clothes. The clothes pegs shall be separated by a space of at least 30 centimeters [11.8 inches]. The workers shall be provided with overalls for handling materials in the raw state. They shall also be provided with protections for the neck, for the transport of those materials which have to be carried on the shoulder. Un less impracticable, all raw materials shall be carried in carts or handbarrows. 6. The minister o f labor, by order issued on the report o f the industrial in spectors, and after consultation with the consultative committee of arts and manufactures, shall have power to grant to an establishment, for a fixed term, relief from the whole or a portion o f the provisions of section 5 (paragraphs 5 and 6) if it is recognized that the application o f these provisions is practically impossible, and that the health of the workers is insured under conditions at least equal to those which are fixed by the present decree. 7. The principals, directors, or works managers shall be required to affix in a conspicuous position of the working premises— (1) The text of the present decree. (2) Shop rules, imposing on the workers the following duties: That they shall use the various working clothes and other working articles placed gratui tously at their disposal; that they shall make use o f the dressing room and the washstands referred to in section 5 (paragraphs 7, 8, and 9) ; make good use o f the provisions for cleanliness whenever leaving the premises; and bring no food into the workroom. (3) A notice pointing out the dangers of anthrax, as also the precautions to be taken to avoid them, and the necessity o f the workers to make the declara tion indicated in section 2. (4) The name and address of the physician intrusted with the medical serv ice of the establishment. The terms of the notice mentioned in the present section under (2) shall be fixed by a ministerial order. GERMANY: ORDER CONCERNING THE EQUIPMENT AND OPERA TION OF HORSEHAIR SPINNING ESTABLISHMENTS, OF SHOPS WHERE OTHER ANIMAL HAIR AND BRISTLES ARE MANIPU LATED, AND OF BRUSH FACTORIES, 1902. GENERAL RULES. 1. The following rules apply to all establishments where horse, cattle, and goat hair and bristles or hair o f hogs are manipulated or spun into curled hair, as well as to brush factories. 2. Imported animal hair and bristles must not be manipulated unless disin fected in the establishment where they are to be used. Disinfection must be effected by one of the following methods: (1) Exposing the materials for at least half an hour to a current of steam under a pressure of 0.15 over atmospheric pressure. 146 BULLETIN OF THE BUREAU OF LABOR STATISTICS. (2) Boiling the materials for at least a quarter of an hour in a 2 per cent solution of permanganate o f potassium and then bleaching them in a 3 or 4 per cent solution o f sulphurous acid. (3) Boiling them for at least two hours in water. Other processes o f disinfection may be authorized by the imperial chancellor. The higher administrative authorities may order that the disinfection pro vided in section 2, No. 1, be effected in a public disinfecting establishment if there is one in the place where the factory is situated or in its immediate vicinity. 3. The manufacturer may be permitted to dispense with disinfection if he can prove, in conformity with regulations to be issued by the central State authorities, that the materials had already been disinfected according to the above rules when he received them and that he has stored them separately from nondisinfected material. The manufacturer may omit disinfection of white bristles provided that he bleaches them before they are being worked up or if he has received them bleached (so-called French dressed bristles) and stored them separately from other nondisinfected material. 4. The central administrative authorities may authorize exemptions from the rules in section 2 for materials which— (1) According to previous experience can not be subjected to the disinfec tion prescribed in section 2 without beihg exposed to considerable injury. (2) Are proved to have been subjected abroad to treatment which is con sidered equivalent to disinfection in conformity with the rules in force in the German Empire. The central administrative authorities must keep a register of the cases and reasons for which exemptions are granted. It must also indicate in the cases mentioned in paragraph (2) o f this section the kind of treatment to which the materials have been subjected abroad. A copy of this register must be sub mitted annually, not later than February 1, to the central authority o f the State. 5. The materials for which disinfection is required must, before disinfection, be subjected only to operations required to ascertain their condition, to pre vent them from deteriorating, or to prepare them for disinfection, such as unpacking, cutting the hair adhering to the tails, transporting to the disin fecting apparatus, tying o f the bristles in bundles, etc. Sorting is allowed only so far as it is necessary for the separation of hair which has to be subjected to different processes o f disinfection. 6. Juvenile workers must not be employed either in disinfecting processes, or on materials exempted from disinfection in conformity with section 4, para graph (1 ), nor are they allowed to work in the processes specified in section 5. 7. The employer must see that workers who have skin sores, especially on the neck, face, and hands, are not employed in the processes specified in section 6., 8. The employer must keep a register in which he must enter the stock of hair and bristles received by him in such a way that the quantity o f these mate rials, the seller and, if possible, also the place of origin, the time at which they were disinfected and the processes used, or the reason for which disinfection was omitted become evident. If the disinfection took place in a public establishment, the certificates given on that occasion must be collected, preserved, and produced whenever required by the supervisory officers. 9. Supplies of nondisinfected materials which are subject to disinfection and those which are exempt from disinfection according to section 4, para- ANTHRAX AS AN OCCUPATIONAL DISEASE— APPENDIX B. 147 graph (1 ), must be kept in special locked rooms and may be taken to these rooms or removed from them only by passages and staircases which are not used by workers occupied on disinfected or on domestic materials. Disin fected or domestic goods must not be transported through those passages and staircases. The operations which must necessarily precede disinfection, disinfection itself, and the manipulation o f materials exempted from disinfection in ac cordance with section 4, paragraph (1 ), must not take place in rooms where disinfected or domestic materials are kept or manipulated. The places where disinfected materials or those exempted from disinfection according to section 4, paragraph (1 ), are kept or manipulated, the entrance ways to those rooms, also the passages and staircases through which the mate rials of this category are transported, must be kept constantly clean. In clean ing them care must be taken to make as little dust as possible. The sweepings from, and the wrappings in which the nondisinfected materials arrived, must be burned or disinfected ( section 2, paragraph 2 ). These measures apply equally to dust generated by, and refuse resulting from, the working up of nondisin fected materials and to rubbish. REGULATIONS FOR LARGE ESTABLISHM ENTS. 10. In establishments regularly employing 10 or more workers, the floor of the workshop must be solid and tight and must allow an easy removal of dust by washing. Wooden floors must be smoothly planed and water-tight. The walls and ceilings, unless they are covered with a hard glazed surface which allows washing or are oil painted, must be whitewashed at least once a year. In the construction of new and the enlargement of existing establishments, measures must be taken that in new workrooms where operations generating considerable dust are to be carried out, the number of workers should be so calculated that each will have at least 15 cubic meters [530 cubic feet] air space. 11. Workrooms must be completely aired for at least half an hour twice a day, i. e., during the noon hour and after the close or before the beginning of work. During this time workers must not be allowed in the shops. The floors of rooms where work generating dust is carried on must be cleaned at least once a day by washing. The work tables in these rooms must be washed at least twice a week. 12. In establishments where horsehair is spun or otherwise prepared the sorting and hackling must be done in special rooms separated from the others. The dust generated and the rubbish must be gathered and removed. 13. Mixing, cleaning, and hackling machines (beating and willowing ma chines) must be covered and provided with effective exhaust drafts. The dust must be collected in a special chamber, and if it comes from nondisinfected materials it must be burned. 14. The workers employed on the processes preliminary to disinfection or in disinfection itself or in the treatment of materials exempted from disinfection according to section 4, paragraph (1 ), must be provided at the employer’s expense with working clothes and caps in sufficient number and of proper materials. By issuing suitable regulations and providing supervision the employer must see to it that the work clothes are used only by those workers to whom they are assigned, and that during the time when they are not in use the work clothes are kept in places designated for that purpose and disinfected at least 148 BULLETIN OP THE BUREAU OF LABOR STATISTICS. once a week. The employer must give to the workers mentioned in the first paragraph of this section the opportunity of taking a warm bath at least twice a week. 15. In a part o f the establishment, free from dust, a dressing and washing room shall be kept for the w orkers; also a lunch room if necessary. The lunch room must be separated from the dressing room. These rooms must be kept clean and free from dust, and during the cold season they must be heated. In the lavatory the workers must be supplied with a sufficient quantity of water, soap, and towels, and with an adequate number of places for keeping the clothes which are taken off before beginning work. 16. The employer must issue for the workers manipulating the materials mentioned in the first paragraph of section 2 the following rules: (1) The workers must use the working clothes provided for them during those operations for which these clothes are assigned. (2) The workers must not bring any food into the workshops. They must eat only outside o f these places. (3) The workers are not allowed to enter the lunch rooms, to eat, or leave the establishment, except after taking off the working clothes prescribed in the first paragraph of section 14 and carefully washing their faces, necks, hands, and eyes. In rules which are issued it must be stipulated that workers who violate the above regulations in spite of repeated warnings will be discharged without notice before the expiration of their time. If shop rules are issued for an establishment, the above regulations must be included. 17. Sections 1-16, legibly written or printed, must be posted in each work shop, dressing room, and lunch room. PRUSSIA: ORDER RELATING TO THE PROPAGATION OF ANTHRAX THROUGH ANIMAL SKINS, 1902. INSTRUCTIONS W IT H REGARD TO THE DANGERS TO H E A LTH IN V O L V E D IN THE M A N IPU L ATIO N OF R A W FOREIGN SKINS. Experience has shown that the traffic in raw skins and hides, especially those of foreign origin, involves danger to the health of human beings and animals. Researches have proved that some of the raw skins (especially deer and kipskins coming from America, East India, and China) were taken from anthrax-infected animals. The cause of the disease is contained in these skins and hides in the. form o f very resistant anthrax spores. The usual processes to which the skins are subjected, such as drying, or treatment with salt, salt peter, or arsenic, do not destroy the spore. The dust which is generated during sorting, packing, and transportation, and also during the opening of the bales and becomes mixed with shed hair is the principal carrier of the disease. The particles o f dust and the hair, to which the anthrax spores adhere, are deposited on the clothes and bodies of persons near by, and enter the mouth, nose, ears, etc. Even the smallest abrasion of the skin may be instrumental in producing infection. Danger lies in the manipulation of raw materials and in the evil habit o f removing with the finger nails dry crusts on the skins. The persons employed on raw skins can carry infection to other places on their soiled clothes, hair, hands, etc. It has also shown that anthrax may be produced by the pollution of fodder and straw with particles of dust and hair from imported raw skins by the use of tanbark refuse as bedding in stalls and passageways, and by the tending ANTHRAX AS AN OCCUPATIONAL DISEASE— APPENDIX B. 149 of animals by persons handling raw foreign hides. Even the use of refuse from tanneries for the purpose of fertilizing pastures and fields, also the soaking of skins in rivers and similar waters, may lead to the propagation of anthrax. A reliable and practical process of disinfection which does not injure the skins is not known. For the purpose o f minimizing the danger of infection the following precautionary measures can be recommended, especially to persons regularly engaged in the handling o f raw skins: (1) Storage places for raw foreign hides should be situated in out of the way localities at considerable distance from dwellings and from stables. They must be carefully fenced so that animals can not enter them. (2) Sheds, etc., for the storage of straw and fodder must not be used as storage places or workrooms for the preparation o f raw hides. (3) The generation of dust must be avoided as much as possible during the opening of the bales, also during sorting, piling, packing, and other manipula tions of skins; when necessary the skins should be sprinkled with water. (4) The places where raw foreign hides are stored or worked up must be carefully cleaned after they are used; they must be disinfected at proper intervals. (5) Tanbark used in the tanning, the hair and other refuse from the tan neries, and other remains, the straw, rags, cords, etc., which were used in pack ing the raw foreign hides, as well as the sweepings, must be either burned or buried after disinfection. (6) Persons having external wounds should not be allowed to manipulate raw foreign hides. (7) Before leaving the work place persons occupied in handling raw foreign hides must carefully clean their faces, arms, hands, hair, and beard. (8) The storerooms, work places, etc., must be cleaned only by wet processes. (9) A solution of chloride o f lime (one part chloride of lime and three parts water) or a mixture o f sulphuric and carbolic acid (one part of sulphuric acid, two parts of crude carbolic acid, and four parts o f water) are recommended as disinfectants. These disinfectants should be also used on sweepings and other refuse. PRUSSIA: REGULATIONS FOR THE PROTECTION OF WORKERS AGAINST THE DANGERS OF ANTHRAX, 1910. 1. Raw sheep and go^t skins, as well as dry imported raw skins, shall be stored in separate storerooms, capable o f being locked, which are used for this purpose only, and are not in direct communication with living rooms, stables or rooms for storing fodder. 2. The storerooms shall be provided with floors made of cement, asphalt or other impervious material, the joints being perfectly tight. Premises which have already been in existence may be used for a further period not exceeding 10 years, should they be provided with floors of the nature referred to above. The storerooms shall be cleaned at least once a week, by means of damp sawdust or damp tanbark, for instance. Storerooms shall be disinfected after they have been wholly or partially emptied, by washing them with a solution o f 1 part fresh chloride of lime in 20 parts water, in conformity with the regula tion that the whole of the storeroom shall be disinfected in this manner at least once a year, but walls and ceiling only in so far as they have come in contact with raw skins. The said whitewash shall not be removed for a space of 24 hours at least. 150 BULLETIN OF THE BUREAU OF LABOR STATISTICS. Refuse and valueless packing material (straw, bast, ropes, etc.) shall be burned. 3. Raw sheep and goat skins, as well as dried imported raw skins, shall be handled with special care. Above all, care must be taken not to subject the said skins to an unnecessary amount of shaking and not to throw them about. For the transport o f skins the use o f special contrivances, such as wagons (trolleys), etc., is very strongly recommended. Workers shall not be allowed to carry skins unless they have been provided with protective hoods, which cover the head, neck, and shoulders.; while they must also be provided with a sufficient number of smocks of good quality when handling dried foreign skins. The employer shall insure that, by means of suitable arrangements and proper supervision, smocks and protective hoods are worn only by those workers to whom they have been handed for use, and that they are disinfected at once after having been in use for one week. The said disinfection shall be effected as the employer may direct, either by steaming at a pressure of not less than 0.15 above atmospheric pressure, or by boiling for at least one hour. 4. Workers who come in contact with raw sheep or goat skins or dried im ported raw skins shall have their attention drawn at the commencement of their employment to the dangers o f anthrax, to which they may be exposed, and they shall be handed a copy of the regulations for the prevention of accidents, and likewise instructions in regard to anthrax. The said instructions shall further be posted up in the workrooms. The necessary number o f copies of the same will be placed at the disposal o f the employers by the association. 5. A part of the works, as far as possible free from dust and suitable for the purpose, shall be reserved for washing rooms and, where it is customary for workers to take their meals within the works, lunch rooms shall be provided. The said lunch rooms shall be kept clean and free from dust, and shall be heated during the cold season. 6. The employer shall also insure that any worker who exhibits symptoms o f anthrax shall immediately place himself under medical treatment, and, fur ther, that any workers suffering from anthrax shall be admitted to the hospital indicated by the trade association. 7. Workers who are engaged in working up raw sheep and goat skins, as- also dried imported raw skins, shall not be allowed to enter the lunch room, to take any meals, or to leave the works, until they have divested themselves of their working clothes and have thoroughly washed the face, head, hair and beard, neck, hands, and arms. The workers shall not be permitted to take beverages in open containers or foodstuffs into the workroom. They shall likewise be forbidden to take meals in the latter. 8. Should the worker become aware of an itching or burning sensation on the head, or pain arising from a darkish pimple, which, although at first of small size, rapidly grows larger, he shall immediately inform the works management and place himself under medical treatment or enter the hospital to which he has been referred, since delay is dangerous and would probably lead to the death of the worker. INDEX. A. Age. (S ee N ativity, age, sex, and conjugal condition of fatal cases, etc.) Page. Agriculture and other industries involving direct contact with anim als_____________ 19 Agriculture, Department of, and Department' of Treasury, joint order No. 1 _____1 2 6 -1 3 0 Agriculture, prevention of anthrax in, legislation in regard to, United States_____82, 83 Animal products liable to be infected with anthrax, imports of, 1910 to 191 5 _____ 84 Animal skins, propagation of anthrax through, text of order relatii;g to, Prussia, 1902 ______________________________________________________________________________________ 1 4 8 ,1 4 9 Anim als subject to anthrax, and countries where the disease is prevalent__________ 12 Anthrax, cases o f : Bradford (England) and D istrict Anthrax Investigation Board, 1906 to 1914_ 101 France, 1910 to 1 9 1 2 _ _________________________________________________________________ 104 Germany, Imperial Health Office, 1910 to 1912_________________________________ 103, 104 Great Britain, chief factory inspector, by industries, 1900 to 19 1 3 _____________ 100 Great Britain, workmen’s compensation act, cases compensated under, 1908 to 1 9 1 4 ------------------------------------------------------------------------------------------ --------------------------------113 Holland, 1898 to 1911__________________________________________________________________ 104 Italy, 1890 to 19 0 4 ____________________________________________________________________ 105 43 Massachusetts hospital, by occupations, June 27, 1881, to April 26, 1916_____ Massachusetts workmen’s compensation law, claims filed under_________________ 89 New York State Department of Labor, under occupational disease reporting law, September, 1911, to March, 1 9 1 6 ____________________________________________ 37 Philadelphia hospital, duration of illness among 32 cases in a __________________ 41 Philadelphia hospital, January 1, 1909, to April 30, 1 9 1 6 _______________________ 39 R u s s ia --------------------------------------------------------------------------------------------------------------------------------106 Tanning and leather m anufacturing establishments ( 1 9 ) ______________________ 4 4 ,4 5 United States registration area, 1910 to 1 9 1 5 _____________________________________ 5 5 -5 9 Anthrax in Europe (Chapter V ) _________________________________________________________ 9 5 -1 1 4 Anthrax in United States (Chapter I V ) _________________________________________________ 2 5 -9 3 B. Bacillus of anthrax and its spore, discovery, characteristics, etc., of_____________6 , 1 0 -1 2 110 Belgium, wool, hair, and bristles industry, protective legislation in _________________ Bichloride of mercury solution, disinfection of hides by, Treasury Department requirements as to_____________________________________________________________ 8 5 -8 8 , 126, 127 Boiling. ( See Disinfection.) Bones, hoofs, and horns, disinfection of, joint order No. 1 ____________________________ 128 Bradford (England) and District Anthrax Investigation Board______________________ 95, 96 Bradford (England) and District Anthrax Investigation Board, cases in wool in dustry reported by, 1906 to 1 9 1 4 -----------------------------------------------------------------------------------101 Bristles, imports of, into the United States, 1910 to 1 9 1 5 _____________________________ 84 C. China or W est Coast of India, hides and skins imported from, text of regula tions governing, Great Britain, 190 1 -----------------------------------------------------------------------------136 China, Siberia, or Russia, horsehair from, processes involving use of, text of regu lations governing, Great Britain, 1908______________________________________________ 1 4 1 -1 4 3 Compensation for anthrax as an industrial injury, Europe_________________________ 1 1 2 -1 1 4 Compensation for victims of occupational anthrax, legislation as to, United S tates- 8 9 -9 3 Conditions of soil and temperature favorable to the development of anthrax_______ 13 Conjugal condition. (S ee N ativity, age, sex, and conjugal condition of fatal cases, etc.) D. Deaths, recorded causes of, in fatal cases, registration area, United States, 1910 to 1 9 1 5__________ ____________________________________________________________________________ 5 5 -5 9 151 152 INDEX. Deaths. (See also F atal cases, etc.) Page. Delaware, morocco-leather center, experience in _________________________________________ 3 2 -3 5 Delaware, quarantine placards and notice to employees in_____________________________ 34 Devoto, Prof. L ., and F . Massarelli, recommendations by, for control and preven tion of anthrax__________________________________________________________________________ 1 2 3 ,1 2 4 Diagnosis, early, importance and difficulties of, etc____________________________________26—28 D isin fection : Bichloride of mercury solution, Treasury Department requirements__ 8 5 -8 8 , 126, 127 Boiling, general rules, Germany, 1 9 0 2 -------------------------------------------------------------------- 1 4 5 ,1 4 6 Boiling, in w a te r ; in permanganate of potassium solution---------------------------------115 Formaldehyde as a germicide for wool, report of Bradford (England) and Dis trict Anthrax Investigation Board_____________________________________________ 1 1 5 ,1 1 6 France, special hygienic measures, text of decree relating to, 1 9 1 3 ____________1 4 3 -1 4 5 Germany, horsehair-spinning establishments, text of order concerning, 1902_ 1 4 5 -1 4 8 Great Britain, general regulations, text of, 1905, 1 9 0 8 --------------------------------------- 1 3 7 -1 4 3 M assachusetts, suggested rules and regulations_______ =---------------------------------------1 3 2 ,1 3 3 Potassium, permanganate of, boiling in solution o f______________________________ 115 Problem of, present status of (Chapter V I ) --------------------------------------------------- 1 1 5 -1 2 0 Prussia, text of regulations, 1902, 1910___________________________________________1 4 8 -1 5 0 Schattenfroh method of, for hides and skins______________________________ 1 1 8 -1 2 0 ,1 3 2 Seymour-Jones method of, for hides and skins_____________________________ 1 1 8 ,1 1 9 , 132 116 Steam sterilization, effect of, on wool________________________________________________ United States, joint order No. 1, Departments of Treasury and Agriculture------- 1 2 6 -1 3 0 Duration of illness in 32 cases o f anthrax, Philadelphia hospital-------------------------------41 E. England, wool, hair, and bristles industry, protective legislation in------------------------ 1 0 7 ,1 0 8 England. (See also Great Britain.) Europe, anthrax in (Chapter V ) _________________________________________________________ 9 5 -1 1 4 F. Factory inspector, chief, anthrax cases reported to, Great Britain, 1900 to 1 9 1 3 __ 100 F atal cases, place and date of, in registration area, United States, 1910 to 1 9 1 5 ___ 5 4 -5 9 F atal cases reported in registration area, United States, 1910 to 1915, his tories, e t c ------------------------------------------------------------------------------------------------------------------------------ 4 6 -7 8 F atal cases to total number of cases, probable ratio of, United States______________ 7 8 -8 0 Formaldehyde as a germicide for wool, report of Bradford (England) and District Anthrax Investigation Board_________________________________________________________ 115, 116 F ra n c e : Cases reported, 1910 to 1 9 1 2 _________________________________________________________ 104 Establishm ents where workers are exposed to anthrax infection, text of decree affecting, 1 9 1 3 ____________________________________________________________________ 1 4 3 -1 4 5 ' Manufacturers’ Association for Prevention of Industrial Accidents, activ ity o f -----------------------------------------------------------------------------------------------------------------------------97 W ool, hair, and bristles industry, protective legislation________________________1 0 9 ,1 1 0 G. Germany : Compulsory reporting laws and resultant data__________________________________ 102—104 Em ployers’ Mutual Trade Association, activity o f_________________________________ 96, 97 Horsehair-spinning establishments, and hair, bristles, and brush factories, equipment and operation of, text of order governing, 1 9 0 2 __________________ 1 4 5 -1 4 8 Imperial Health Office, anthrax cases reported to, 1910 to 1 9 1 2 ______________ 1 0 3 ,1 0 4 W ool, hair, and bristles industry, protective legislation______________________ 1 0 8 ,1 0 9 Germany. (S ee also Prussia.) Glue stock, certification and disinfection, joint order No. 1 ________________________1 2 7 ,1 2 8 Governmental investigations, Europe_____________________________________________________ 98, 99 Great Britain : Compulsory reporting laws and resultant data__________________________________ 9 9 -1 0 2 Factory inspector, chief, anthrax cases reported to, 1900 to 1 9 1 3 ______________ 100 Hides and skins imported from China or W est Coast of India, text of regu lations governing, 1 9 0 1 _________________________________________________ •___________ ±S6 Horsehair from China, Siberia, or Russia, text of regulations governing use of, 1 9 0 8 _______________ _______________________________________________________ 1 4 1 -1 4 3 INDEX. 153 Great Britain— Continued. Page. W ool, goat hair, and camel hair, sorting, washing, etc., of, text of regulations governing, 1905 ------------------------------------------------------------------------------------------------------- 1 3 7 -1 4 0 W orkm en’ s compensation act, anthrax cases compensated under, 1908 to 1 9 1 4 ____________________________________________________________________________________ 113 Great Britain. ( See also England.) H. Hair, bristle, and brush factories, text of order concerning equipment and oper ation of, Germany, 1 9 0 2 _______________________________________________________________ 1 4 5 -1 4 8 H air, bristles, and pigs’ wool, disinfection of, suggested rules and regulations, M assachusetts, 1 9 1 6 _______________________________________________________________________ 132 Hides and sk in s: Disinfection by bichloride of mercury solution, Treasury Department require ments as to________________________________________________________________ 8 5 -8 8 , 1 2 6 ,1 2 7 Disinfection of, joint order No. 1 _________________________________________________ 126, 127 Great Britain, text of regulations governing hides and skins imported from China or W est Coast of India, 1901_____________________________________________ 136 Imports of, into the United States, 1910 to 1 9 1 5__________________________________ 84 Legislation, protective, covering the industry, E urope.;_________________________ 110, 111 Massachusetts, rules and regulations suggested as to disinfection of__________ 132 Histories, individual, of fatal cases reported in registration area, United States, 1910 to 1 9 1 5 _______________________________________________________________________________ 6 0 -7 8 History and general description of anthrax (Chapter I ) ______________________________ 9 -1 3 Animals subject to anthrax, and countries where disease is prevalent__________ 12 Bacillus and its spore, characteristics o f_________________________________________ 1 1 ,1 2 Bacillus, discovery o f_________________________________________________________________ 10 Conditions of soil and temperature. favorable to development of anthrax_____ 13 Disease, early studies of the-----------------------------------------------------------------------------------------9 Infections, modes of___________________________________________________________________ 13 Holland, anthrax cases reported in, 1898 to 1 9 1 1 ________________________________________ 104 Holland, compulsory reporting laws and resultant data________________________________ 105 Horse and other animal hair manufactured, imports of, into the United States, 1910 to 1915_______________________________________________________________________________ 84 Horsehair from China, Siberia, or Russia, use of, text of regulations governing, Great Britain, 19 0 8 ____________________________________________________________________ 1 4 1 -1 4 3 Horsehair-spinning establishments, equipment and operation of, text of order con cerning, Germany, 1902_______________________________________________________________ 1 4 5 -1 4 8 Horsehair workers, personal precautions of, text of regulations governing, Great Britain, 190 8 ____________________________________________________________________________ 142, 143 Hungary, wool, hair, and bristle industry in, protective legislation__________________ 110 Hygienic measures, special, affecting establishments where workers are exposed to anthrax infection, text of decree relating to, France, 1 9 1 3 -----------------------------------1 4 3 -1 4 5 I. Imports of animal products liable to be infected with anthrax, 1910 to 1915________ 84 Industries affected (Chapter I I I ) _________________________________________________________ 1 9 -2 3 Infants, fatal cases reported of, registration area, United States, 1910 to 1915_____ 53 In fectio n : Animal hair and bristle industry, risk o f____________________________________________20, 21 Horn and bone industry, risk of_____________________________________________________ 22 Leather industry, risk o f_____________________________________________________________ 19, 20 Modes o f________________________________________________________________________________ 13 Nonoccupational________________________________________________________________________ 23 Transportation industry, risk o f_____________________________________________________ 22 W ool industry, risk o f_________________________________________________________________ 21, 22 International Association for Labor Legislation, subcommittee of, recommenda tions o f___________________________________________________________________________________ 1 2 1 -1 2 3 International organizations and congresses, activity of, Europe______________________ 98 Italy, anthrax cases reported in, 1890 to 1 9 0 4 ___________________________________________ 105 Italy, compulsory reporting laws and resultant data_______________________________ 105, 106 L. Legislation, protective, in Europe_________________________________________________ ______ 1 0 6 -1 1 1 Legislation, United S ta t e s __________________________________________________________________8 0 -9 3 Locality. ( S ee Place, etc.) M. Page. Manufacture and trade, prevention of anthrax in, legislation in regard to, United States________________________________________________________________________________________8 4 -8 8 M assachusetts: Board of Labor and Industries, rules and regulations suggested by, 1 9 1 6 ___ 1 3 1 -1 3 4 Hospital, cases on record in a ________________________________________________________ 4 1 -4 3 Workm en’s compensation law, claims filed under, on account of anthrax, three years ending June 30, 1 9 1 5 _ _ ----------------------------------------------------------------------------------89 Massarelli, F ., and Prof. L . Devoto, recommendations by, for control and preven tion of anthrax___________________________________________________________________*------- 123, 124 M eats, packed in straw, import from certain countries prohibited, joint order No. 1 ______________________________________________________________________________________ 129, 130 Medical aspects of human anthrax, symptoms, treatment, etc. (Chapter I I ) ______ _ 1 5 -1 8 M ilan (Ita ly ) Labor Clinic, activity o f___________________________________________________ 97, 98 Morocco-leather center, in Delaware, experience o f--------------------------------------------------------- 3 2 -3 5 N. Nativity, age, sex, and conjugal condition of fatal cases reported in registration area, United States, 1910 to 191 5 ------------------------------------------------------------------------------------ 54—59 New Jersey occupational disease reporting law, cases reported under_______________ 37, 38 New York : Occupational disease reporting law, cases reported under________________________35—37 State Industrial Commission, recommendations_________________________________ 1 3 4 ,1 3 5 Nonoccupational anthrax------------------------------------------------------------------------------------------------------23 O. Occupations reported in anthrax c a se s: Barbers and hairdressers-------------------------------------------------------------------------------------------------52, Bristle com bing________________________________________________________________________ Customs w eigh in g--------------------------------------------------- -------------------------------------------------------Farm ing and ran ch in g________________________________________________________________ 49, Freight h a n d lin g_______________________________________________________________________ H air working and weaving____________________________________________________________ Hide and skin workers________________________________________________________________ Housekeepers_____________________________________________________________________________ L ab orers-----------------------------------------------------------------------------------------------------------------------------Liverym en________________________________________________________________________________ Longshore w o rk ----------------------------------------------------- ---------------------------------------------------------- 50, M u sicia n _________________________________________________________________________________ Paper making___________________________________________________________________________ Tanning and leather manufacturing, various occupations in____________________44, Tanning, United States_______________________________________________________________ Transportation workers________________________________________________________________ Truck driving___________________________________________________________________________ Veterinary surgery______________________________________________________________________ 53 52 51 50 51 51 43 53 53 52 51 53 52 45 49 43 51 52 W ool and hair workers________________________________________________________________ 43 W oolsortin g______________________________________________________________________________51, 52 P. Page, C. H. W ., recommendations by, for control and prevention of anthrax_____ 124, 125 Page, C. H . W ., recorded cases of human anthrax in Italy, 1890 to 1 9 0 4 ____________ 105 Pennsylvania infectious disease reporting law, cases reported under_______________ 38, 39 Personal precautions of workers : Great Britain, horsehair, processes involving use o f__________________________ 142, 143 Great Britain, wool, goat hair, and camel hair_____________________________________ 139 Massachusetts, suggested rules and regulations________________________________ 133, 134 New York, recommendations_________________________________________________________ 135 Philadelphia hospital, cases on record in a ______________________________________________ 3 9 -4 1 Place and date of fatal cases, registration area, United States, 1910 to 1 9 1 5 ________5 4 -5 9 Potassium, permanganate of, disinfection by boiling in solution o f_________________ 115 Prevention and control of anthrax : Devoto, Prof. L., and F. Massarelli, recommendations by_____________________ 123, 124 France, text of regulations_________________________________________________________ 1 4 3 -1 4 5 Germany, text of regulations_______________________________________________________ 1 4 5 -1 4 8 Great Britain, text of regulations________________________________________________ 1 3 6 -1 4 3 INDEX. 155 Prevention and control of anthrax— Continued. , Page. International Association for Labor Legislation, subcommittee of, recom mendations o f______________________________________________________________________ 1 2 1 -1 2 3 Legislation in United S ta te s __________________________________________________________ 8 2 -8 8 M assachusetts, rules and regulations suggested--------------------------------------------------- 1 3 1 -1 3 4 Page, C. H. W ., recommendations by_____________________________________________ 1 2 4 ,1 2 5 Prussia, text of regulations--------------------------------------------------------------------------------------- 1 4 8 -1 5 0 Prussia, propagation of anthrax through animal skins in, text of order relat ing to, 190 2 _____________________________________________________________________________148, 149 Prussia, protection of workers against anthrax in, text of regulations for, 1910_ 1 4 9 ,1 5 0 Prussia. (S ee also Germany.) Q. Quarantine and vaccination of farm anim als____________________________________________ Quarantine placards and notice to employees, Delaware------------------------------------------------- 83 34 R. Regulations for the control of anthrax. (S ee Prevention and control of anthrax.) Reporting, compulsory, legislation in regard to, United States------------------------------------- 8 0 -8 2 Reporting, systematic, and resultant data, Europe------------------------------------------------------- 9 9 -1 0 6 Russia, cases of anthrax____________________________________________________________________ 106 Russia. ( See also China, Siberia, or Russia, horsehair from, etc.) S. Sanitation of workshops, recommendations, New York_________________________________ 135 Sanitation of workshops, suggested rules and regulations, Massachusetts, 1916_____ 133 Sanitation of workshops, text of order concerning, Germany, 1 9 0 2 ________________147, 148 Schattenfroh method of disinfection, for hides and skins_____________________ 1 1 8 -1 2 0 ,1 3 2 Serums_________________________________________________________________________________________ 18 Sex of anthrax cases reported, in France, and in Germany, 1910 to 1 9 1 2 _________ 1 0 3 ,1 0 4 Sex. (S ee also Nativity, age, sex, and conjugal condition of fatal cases, etc.) Seymour-Jones method of disinfection for hides and skins_____________________ 1 1 8 ,1 1 9 , 132 Siberia. (S ee China, Siberia, or Russia, horsehair from, etc.) Steam sterilization, effect of, on w ool___________________________________________________ 116 Symptoms of human anthrax_________________________________________________________ 1 5 ,1 6 , 134 T. Tanners and leather manufacturers ( 1 9 ), cases reported by__________________________ 4 4 ,4 5 Trade and manufacture, prevention of anthrax in, legislation in regard to, United S ta t e s__________________________________________ 1 __________________________________8 4 -8 8 Treasury, Department of, and Department of Agriculture, joint order No. 1 ___ 126—130 Treatm ent of human anthrax_____________________________________________________________ 16—18 U. United States, anthrax in (Chapter I V ) _________________________________________________ 2 5 -9 3 V. Vaccination and quarantine of farm animals____________________________________________ 83 W. W ool and hair, disinfection of, joint order No. 1 ____________________________________128, 129 W ool, goat hair, and camel hair, sorting, washing, combing, etc., of, text of regu lations governing, Great Britain, 1905_________________________________________ ______ 1 3 7 -1 4 0 W ool, goat hair, camel hair, etc., imports of, into the United States, 1910 to 1 9 1 5 84 W ool, hair, and bristles industry, protective legislation as to, Europe_______ ______ 1 0 7 -1 1 0 W ool industry, anthrax, cases in, reported by Bradford (England) and District Anthrax Investigation Board, 1906 to 191 4__________________________________ ________ 101 Workm en’s compensation act, British, cases of anthrax compensated under, 1908 to 1 9 1 4 _____________________________________________________________________________________ 113 Workmen’s compensation law, claims filed under on account o f anthrax, M assa chusetts, three years ending June 30, 1 9 1 5 ____________________________________________ 89 Workshops, sanitation of, recommendations, New York___ _____________________________ 135 Workshops, sanitation of, suggested rules and regulations, M assachusetts__ _________ 133 Workshops, sanitation of, text of European regulations as to (Appendix B ) _____136—150 O