Document DM5Dv0wkMjZNLg1V1VjKjY1yQ

UNITED STATES TREASURY DEPARTMENT PUBLIC HEALTH REPORTS ISSUED WXEKEY BY THE UNITED STATES PUBLIC HEALTH SERVICE Volume 50 Number 1 JANUARY 4 - 1935 THIS ISSUE Effect of Asbestos Dust on the Lungs of Asbestos Workers The Occurrence and Control of Endemic Typhus in Alabama Tbe Prison Educator's Viewpoint of Psychiatric Services Deaths in Large Cities During the Week Ended December 15 Current State and City Reports of Communicable Diseases Quarantinable and Other Diseases in Foreign Countries pfc; fKRTD STATES C0YEIUCMSN7 fJUNTINC 0?nCX WASHINGTON : lilt rr ah kr (W hkniMnknl ! DwimtH. YUiiijIM, O. C. Svktcnpiim friar. tS > * ' TOOTED STATES TUBLIC HEALTH SERVICE Hcco S. Ctnmurc; Surftan Gmtral division or s-injtabt nirocrs and statistics AM. (on. Cea. n. C. Wiuadia. OJtf of Birhit* The Public Ucaltr Retorts, first published in 1S7S under authority of aa set of Congress of April 29 of that year, is issued weekly by llic United Slates Public Health Service through the Division of Sanitary Reports end Statistics, ' pursuant to the folio* Ing authority of law: United States Code, title 42,'sections 7, 30. 93; title 44, section 220. It contains (1) current information regarding the prevalence end geographic distribution of communicable diseases in the United States insofar ns data arc obtainalde, and of cholera, plague, small|ox, typhus fever, yellow fever, and otlicr uu|iurtanl eoiunuuiicablc diseases throughout the world; (2) articles ro uting to the cause, prevention, and coalrt>r<>T diseases; (3) other pertinent infor mation regarding sauiiatinn and the conservation of the public health. The Prnue Health Retorts is puhlishvtl primarily for distribution, in ac cordance with the law, to health ofliccrs, members of . hoards or departments of health, and other persons directly or indirectly engaged in public health work. Article* of special interest are issued as reprints or as supplements, in which forma they are made available for mure economical and general distribution. llmpicst* for ami conunuuiralioits regarding the Pcauc Health Rcronra, reprints, or supplement* should >>c addressed to the Surgeon General, United States Pulilie Health Service, Washington, D. C. Subscribers should remit direct to the Superintendent of Dueurucnis, Washington, D. C. Librarians aad others should preserve their copies for bindir.g, as the Publie Bealth Service is unable to supply the general demand for bound copies. Iodcxes will be supplied upon request. on Tata Effects of the lahalation of asbestos dust on tlie lungs of asbestos workers. . 1 Endemic typhus hi Alabama^...............................----- --- 12 The educator's viewpoint of psychiatric service in a penal Institution.-- - 21 Court decision on public health...__________ ___ ________ --_____ --... 21 Deaths during week ended December 15, 1934: Deaths ami death rates for a group of large cities in the United Stain. 25 Death claims reported by insurance companies______------ --------- 25 pbcvalencs or disease Dnited States: Current weekly State reports: Reports for weeks ended Dee. 23, 1934, and Dee. 23, T933.------- 2 Summary of monthly reports from Slates...................----* 2S Cases of venereal diseases reported for October 1934........--.-- 27 Tfeekly reports from cities: City reports for week ended Dec. 15, 1034..--..--.------- ...... 3C Foreign and insular: Canada--Provinces--'Communicable diseases--3 weeks ended Dee. 1, 1934..... 31 Ceylon--Malaria_____ ....------ ----------------------------- ------- ------- 3-: Italy--Communicable diseases--4 weeks ended May 37, 1931-------------- 3; Cholera, plague, smallpox, typhus fever, and yellow fever: Plague.--------.----.--------------------- 3: Typhus fever--________ ---------- :---------------- --------------- 3: Yellow fever----.-------------------------------------------------------- 3;  --------- PUBLIC HEALTH REPORTS VOL. SO JANOA.RV 4. 193S NO. 1 EFFECTS OF THE INHALATION OF ASBESTOS DUST ON THE LUNGS OF ASBESTOS W02KERS A Preliminary Study By A. J. Lanza, duiitui MtdieaJ Dtrtcior, ITiluau 3. McCon-xcll, Assist ant' Medical Director, and J. WiUJASr Fciincl, CLtmiJ, Mc'.rapolUzn Lift Insurance Co. INTRODUCTION In 1929 the Metropolitan Life Insurance Co. was approached by officials representing tlie Asbestos industry in the United States, who were desirous of ascertaining-whether asbestos dost wns an occupa tional hazard in their establishments and, if so, what wns the nature of this hazard and what should be done to prevent or control it. About this timo several articles had appeared in English medical journals describing a pneumoconiosis due to asbestos dust. While in one or two isolated instances the occurrence of this type of pneumo coniosis had been described in Amcriean journals, the industry itself appeared to bo quite uninformed of the existence of any such occupational disease. The hazard of sOica dust, with special reference to the lungs, has long been appreciated, and n great deal of study apd research has been applied to the problem (in the metal mining and certain other industries) in Great Britain, the United States, the British Do minions, and in other countries. The nature of the effects of siiica dust expressed in the term "silTcesis", with the resultant extraor dinary predisposition to pulmonary tuberculosis, is well known. These effects have been associated with the inhalation of dust con taining free silica in varying amounts. The effects upon the pul monary tissue of dusts containing combined silica--silicates--aro still a fertile field for investigation, but evidence is accumulating that certain of these dusts produce pathological results quite distinct from true silicosis. The name "asbestos's" lias been applied to the pneumoconiosis caused by asbestos dust and it will be so used in this report. Cltem- ieallv, the asbestos of commerce is a hydrated magnesium silicate consisting primarily of silica (combined silica) 41.1 percent, mag nesia 43 percent, and water 12.9 percent, wjdlc ferrous iron and nickel ore present in small quantities. This commercial variety of jma.-.i---aj-- i oj (f /C <Xy<r>~^7*:---v^tjg[2ii .Imbit i ins 2 asbestos most commonly encountered is designated as ebrysotile and is one of the four varieties of the mineral serpentine, in which it usually occurs in seams. It should he. borne in mind that silicosis (anti presumably nsbostosis) develops very slowly, taking from 5 to 15 and even 20 or 25 years to become established. This rnto of progress is influenced mainly, by tbc dosage of .silica which the lungs receive, and tills dos age, in turn, depends upon three variables--the" amount of silica in the dust, the quantity of dust in the air, and the length of exposure. Individual idiosyncrasy might be included as a fourth variable; however, little is known of the variations in susceptibility in those exposed to dust. It might well be assumed that similar variables would influence the occurrence of asbestosis. In places where asbestos is mined or fabricated in North America tbrrc docs not appear to he present the clear-cut cluneal picture which is so uncscnpable in communities with a true silicosis hazard, such as hard-rock mining communities. It may be that some of tho asbestos plants are of too recent origin for tho typical effects of a silicate dust to become manifest, but this would not apply to tbe older mines or to all of the fabricating plants. The industrial health service of the Metropolitan Iifo Insurance ( Co. undertook tho following investigation during tbe period from October 1029 to January 1031, which included: 1. A study of dust conditions in asbestosjnincs and mills in Canada and in fabricating plants along the Atlantic Seaboard in the United States. 2. Physical examinations of asbestos workers, including X-ray films.* 3. A study' of dust exhaust systems designed to eliminate asbestos dust. Data on the fabricating plont* only are included in this study and arc designated in the report as plants .Vr B, C, D, and E. This is a preliminary report. A more extensive study of the asbestos industry is now under way. DUST STt'OtKS Apparatus and nxthods j sampling.--Both tho impingcr (1) and the electric precipitator (2) were used (<ir the collection of air samples for dusts at the breathing levels and in close proximity to the workmen. Both of these forms of apparatus arc adapted for this work, ns they arc transportable, easily set tip and adjusted for tho tnking of tbe air samples nt the proper level, and are extremely efficient. Tho impingcr collects the dust by aspirating tho nir and then impinging it onto a flat surface coverrd by a liquid in a container. The liquid used was distflhd water, containing 50 percent alcohol to 082 01 llifcUi *> Suurr <. Ills prevent the solution of some of the dusts, particularly any silica which might be present. The impinger was actuated by an electri cally driven rotary pump and the rate of air sampled was measured by means of a resistance type of flow meter with an inclined manome ter for measuring tlio pressure difference. Jaaeh sample represents the dust collected from a rolumo of 100 cubic feet of air. Tho electric precipitator is designed upon the Cottrell precipitator principle used for recovering dusts and fumes commercially. This principle depends on electrifying the dust particles by making them pass through an electrostatic field and thus causing them to settle out upon a sheet of celluloid. Tho electrostatic field is set up by means of a transformer operating from tho lighting fines on 120 rolts, alternating current.' Air is drawn through the apparatus by a small rotary fan, run by a motor, the quantity being measured by a flow meter. Samples of dust brushed from beams and pipe lines near the ceiling also were secured for chemical analysis. All samples were shipped to the industrial hygiene laboratory of the Metropolitan Co., and the dust counts were made according to tho methods accepted by the- United States Bureau of Mines and tLc United States Public Health (1). Particles in tizo up to 300 microns in the greatest diameter were counted. Chemical analyses were made for total (free and combined) silica according to the ccccpted standard method of HQlcbmnd (3). In the first plant studied (A) only particles 10 microns r.ml under in size were counted. It has been demonstrated repeatedly that no silica particles exceeding 10 tnicroos (a micron equals one-millionth port of a meter or one-thousandth part of a millimeter) in greatest diameter enter the lung tissu ; for this reason, the larger particles usually aro not considered when determining dust counts. Later, as it appeared from somo of the published articles (4) (English) that asbestos particles much larger in size were found in lung tissue, it w.-.s decided to count all particles and make differentia] counts of ell thoio 10 microns and under.* . Total particles per cubic foot and the corresponding weight of the dust in milligrams were obtained. Since no rclationslup between tho dust counts and the corresponding weights was fouad, the weights arc not included in the tabulations in this report. Table 1 shows by plants and by departments the maximum and minimum dust counts in million particles per cubic foot of air. Although the counts in plant A are of particles 10 microns and under, *4am He* *7 fcetfc tti* iasplaiCT *iwf iim !rrtrtc wr In tboa cun particU* trtrt t; Ulsr pr!tr.H aemn %ib a Lauit* iIMi praiNur, its trU/pd ptfticte t<af mnajurc* vtlft a nJr. Kawis; tfca *:!?* fly U *u ur tt lnla( Uu yvtlcli it (3. fly tit* um tf lliwa'i mi T paper, Uw *f iba uic*i*a u bm (la ttu nw oawwi v CP -<! G ' f:4 T-. 3>-.-j- -.r.-.-. , -. and in the other plants are for all particles, direct comparison is possible, as in no samplo taken were tho number of particles 10 microns and under less than 94 percent of the whole. TaBLX I.--and minimum iuil Muni) in million partida per cubit/ool / air, by plant and tepartment ftut A ?)Ml S ruaio ruai s ru>< r DifwtaiAi MSItoe Kee* Knot* nil* pin UitU lni* fXJ *Ur Km |f rabid tot if Ntiffr lr if Ml* \4m toku xiiuim rani* ran pit (UbM tot if tir Now bra / UAH Pto (4k14 xi mu* ra** ptr cub* tot 4U be* if u Pirn MlUiro ber if parti* iam* o per pit* csbtc 1r tot if tube iit toe if xrrnup p*n> oo kt eubtc tot *f nr itr to . * JA-IM to-o S 3 -O 3 V *43 3 H-Im A JH-UU s at *74 hU IfMM !: 3 to- ti WntiK-..................M.... 3 W 4 < *: 1*44 H 1 h-i CJ 4 l i( 1 im- <h t >1 -34* . _ ___ . ___ 4 - IS 1 -T ) >|w|0 3 <!*- t 3 3 Uuib4MteuLkrtm..t.r.. .bud ------ ------ * 3 H- ft ------ i ImluJnl Is Missis*. 1 Isdwiaa kraml loms una_ Whereas the dust in the preparation room is practically oil due to asbestos, the contrary Is the cane in the other departments. In the carding, spinning, and weaving rooms asbestos comprises about 25 percent of the material used. On special jobs tho percentage of asbestos maybe higher, but in general the figure quoted is approxi mately correct, the oilier material consisting principally of cotton. In the insulating departments of plant A, asbestos is but 5 percent of the total material used. In the molded brake-lining and clutch division of plant D, .asbestos comprises about 25 percent of the total material. The actual exposure to asbestos dust, therefore, is consid erably less than is indicated in the dust counts in table 1. CONDITIOXS ix Tr. rtASCTS Tb6 processes in these plants were very similar to those in cotton mills in general. For illustration, the process in the preparation room of plant B is here detailed at length: ^ Asbestos is received in bag?. These are emptied upon the floor and the asbestos is shoveled into pug mills and run for about 5 minutes 3* in order to crush und open the fibers. From there the asbestos is ^ shoveled into trucks ami wheeled to hoppers with either horizontal or vertical openers, similar to those used in textile mills. After passing ^ through the opener, the material is discharged into trucks. Wasto manufacturing material U first run through a garnet machine and 0 lUQVT (. IU discharged into trucks, which ara wheeled to the openers, and the material is fed into these in the same manner as k the new material. Alter bein'; discharged from the opener, the material is put onto a ribrating or shaking screen, where tbo long fibers arc picked off hr a suction hood and blown into a bin to be used again in textiles. The short fibers falling through the screen are either sold ns such or used in making an asbestos cement. The cotton is received in bales, opened, and also run through ertical openers. It is discharged into trucks. The filled trucks from ` the vertical and horizontal openers containing either the asbestos fiber, the cotton, or tbo wasto material are taken to separate storage bins. As needed, these materials are weighed and dumped onto the floor in proportion to the mixture desired, and the resulting mixed materials aro then passed through a mixing picker. As this mixture is discharged from tko picker, it is sprayed with a light mineral .oil. The material is then taken by a mechanical conveyor to the storage bin in tbo eard room. Two of these mixing pickers discharge onto this eonveyor system, whilo a third machine is equipped with n suetion device which conveys tbo material to a storage bin in the eard room. The object of the two systems is to facilitate the handling of two grades of material at the same time. The third machine is not equipped with an oil spray. The object of the oil spray is pri marily to entrap the small asbestos fibers and hold them enmeshed in the cotton fiber throughout-the processes of carding, spinning, and weaving. Incidentally, it is apparent that it also diminishes the amount of dust. The material is saturated with about 4 permit of oil at tliis point; but by tbo time it reaches the looms, tho oil had diminished to less than 1 percent. Whilo mineral oil was used in the preparation room of plant C. it apparently was not as efficacious as in plant B. In plant E oil was not used, nor was there any attempt at humidification nr any system of dust exhausting. Curding machines ware fed by hand. In plant A there was a humidifying, ventilating, and heating system, while . plant B depended on natural humidity. In plant E the carding machines were equipped with a dust-exhaust system, hut it was not efficiently used. In plant C carding was done in 2 buildings, 1 of which wns equipped with an air-conditioning system, and in both buildings the machines had exhaust equipment. Two plants, B and C, bad artificial humidity installations in their spinning rooms. In the former the temperature was 7G* F., relative humidity 7S percent. One plant, C, had a humidification system in the twisting, department and also in the weaving department, where tho relative humidity was 76 percent with a cry-bulb temperature of 69* F., as compared with a relative humidity of <4 percent in the wearing room of plant A. Q/ & Q 5" :e= .` v.a* j. . 1 r. j; - a.-i.T.T;- ----- "dy - .-'a- :-? '.-ft rr.- . >>aurr . IS) v Aside from plant E, jt would appear that the dost hazard was not excessive except in the preparation reams of plants B and C. The dust counts nre interesting, too, when considered in the light of the permissible standard for granite dust, established by tho United States Public Health Service (7), namely, about 10 million particles (10 microns and under) per cubic foot. However, we are not justified in assuming that because available information suggests that osbestosis is a milder diseaso clinically than silicosis, the threshold of `permissible dust counts is higher. Asbcstosis appears to be patho logically different from silicosis, and the experience jo far docs not warrant an attempt to define a standard of dustiness for asbestos dust. bust coxTaot Various measures, such as oiling, humidification, and local exhausts, tended to reduce the dust. Nevertheless, it was evident that they were only partly successful. . If it is expected to control dustiness in these plants, final reliance.must rest upon properly constructed exhaust equipment. In plant C in one department an experimental installa tion was set up. In spite of rome obvious faults, this equipment, on the basis oY comparative dust counts, reduced the dust by 50 percent and with further ultcratinns will probably be 75 percent effective. In this ease such a reduction seemed quite satisfactory. It is neither practicable nor economically desirable to install such equipment as will make the air entirely dust free. Tile normal defensive mechanism of the body takes care of a fair amount of atmospheric pollution. It is when the body is exposed to an excessive amount of dust that this defense mechanism breaks down. The application of exhaust equipment to textile machinery involves considerable difficulty, especially where the construction of the plant u such that it is not possible to npply down-draft suction to the looms. It U desirable to iustall exhaust apparatus in any plant on an ex perimental basis first, and then check its efficiency by dust counts. Tlibi practice will result in saving a needless expenditure of money. . ^ rilVStCAL EXAMINATIONS X-ray films were made of 12G persons (10S men, IS women) working in aslxstus plants in the United States. All but five of these wera given physical examination. The cases were selected more or lcss\^ u at random from among tlmse having more than 3 years of employ- ^ c nscr.t in the industry. It was soon obvious that the early diagnosis q c of mdicsiost* must rest to a large rxtent on X-ray pictures of the ^ v. chest. As in the early stage* of siT.ctisU, the clinical symptoms of ^ t the asbestos workers were usually indefinite and inconclusive. Tho interpretations of these films are based on the readings of one comfifif'iit rnfiit('(-tinif.''i l, l#ut limy La'*'* heru reviewed by several 7I luurr 4, ini ollicrs experienced in lliis field. The dilTrrcnccs of opinion were of a minor nature, and there wns general agreement as to interpretation. The films were rend conservatively, taking into account Lite physical examination and the age of tho individual, and were classed as positive only when there was no major disagreement. All examiners were guided by tlieir experience in silicosis and other types of pneumoconioscs. The films classed ns negative for asbestosis were further subdivided into doubtful and negative. Only time can tell whether the individuals dossed as doubtful arc progressing toward a definite asbestosis. Particular attention was focussed on the presenro or aliscacc of indications of tuberculosis, and in this respect all the reviewers of the films were in accord. With the unhappy experience of silicosis in mind, it wns felt that a great deal of care should b: devoted to ascertaining, if possible, whether or not asbestosis pre disposes to tuberculous infection. The cases of asbestosis were divided into two dasses, first stage and second stage. The first stage embraces those who show hy X-ray examination definite lung pathology suffident in extent to warrant a diagnosis of pneumoconiosis, but who have no definite symptoms. The second-stago cases exhibit more extensive lung pathology and also definito symptoms. All these individuals 1 were actively engaged in factory work, and it was not practicable to make any distinction on the basis of working ability or disability. Had any individuals been found who exhibited extensive pulmonary involvement end marked phvsieol disability or total disability, they would have been classified as third stage, but no such eases were found. Of the total of ICG X-ray examinations, 4 were diagnosed as second-degree asbestosis, G3 as first degree, 39 as doubtful, and 20 as negative. There is a definite increase in the percentage diagnosed as positivo in relation to the years of exposure, as shown in table 2. Small numbers make it impossible to determine how far the factor of age enters into this increase. Tails 2.---CUnsifietUian of cairi 4y yeert mfczpotvro cr Tmn tfupnevn rmwtct liMln IwHit, Nurel--f -c _cs llwiitt:) I Siailn * Ortt 11 rnn_____ _...... 10 It II jnn......... ...... ............ lLu'OOlltf VI tJ--WI------ - Total imM. Ftn imu Om tilout wtriitr btrtml uH mlrml ot I 10 It-- --u.ly. li i. --ui tut, i*Km-- Ln I out mm--ii. ' mint btttunt oi U ait. 10 jrut J 13 8 Of the G4 persons given physical examination and diagnosed as haring positive esbestosis, only 8 were entirely free from symptoms, wliilc 10 out of 37 with doubtful and 7 out of 20 will) negative ding- noses were free from symptom*. Dyspnoea and cough were the symptoms most complained of, but none of these eases exhibited the urgent or evident type of "short wind'* seen in true silicosis. Several of those classed as negative stated that they were "short winded" and were so recorded, but too mueli emphasis should not be placed on statements of subjective symptoms. During tho progress of the study, physicians who were practicing in tho communities where asbestos workers lived were questioned and stated that they did not find an unusual amount of tuberculosis among these workers. The contrast between this state of affairs ami that found in a community with a silicosis luiaard is noteworthy. The incidence of tuberculosis (based upon X-ray films) is givea in table 3; 40 of the G7 examined had less linn 15 yean of employ ment in the industry. * Table 3.--IndJcnet if lubertuiarit - ftilUfi Doubtful Kaeitin TiikrrvM!* t1 1 - *1 CT 0 X 3D1 Tbit om nt Mf mhiHf inirt aa (be X-nr fiwlino. Table 4 gives information as to physical signs of cites* troublo. Tabu: i.--Cfttsi JSnHinfi ^ ' TwIUrt Dasbtful KfpUw nSutrlAi"nl MjUJk<BU' t!.m.,t-,tf,u.,u,L,,I,t ........-................................................T-,.... <s 113 8 J 7 U 0 ~-1-1 IT X X At kv* nal <Ntr I (MfrtilHNT villi i(D tmil vrw MM wit It Mf<Mei, with lirtial WM 4 ufyinii. What significance, if any, can be, attached to the presence of "asbestos corns" on the Intmls of workers appears doubtful, ns IS pcrcent-of the positives (12 nut of G4) ami 15 percent of the others (doubtful, 7 out of 37, negative, 2 out of 20) showed such corns. Each roentgenologist who reviewed the X-ray films called attention to the fact that these films indicated a very unusual incidence of enlargement of the heart. It is probable that tliis is a compensatory enlargement duo to the additional work put upon tho heart in oderts CPQ p7 to pump blood through tho fibrosed lungs. It is possible that not sufficient attention lias been paid to tho cfTccts of the pneumoconioses upon the heart. Many workers liad changed from one department to another and from ono plant to another during their years of employment in the asbestos industry. Sineo only tho amounts of dust collected at the timo of this surrey in tho various departments are known, there is no way of knowing the average amount of dust in tho atmosphere inhaled by these people over the years of their employment. Conse quently, it is not possible to correlate individual cases with definite amounts of dust exposure. 1KSXTR.OCCI CLAIMS To throw light on tho relationship between asbesiosis and pulmo nary tuberculosis, an analysis of death claims and total and per manent disability claims was .made in regard to companies carrying group insurance and having avnilablo figures. There were 2,099 lives involved, with a total exposure of 7,019 lifeyears. Tho death claims are so small in number that reliable con clusions cannot bo readied from an}* subdivision of the figures. The same is truo of the sickness claims under health insurauce. The number of claims for respiratory diseases is high in two of the plants studied but low for Lite others,'os compared with tho Metropolitan experience of 1927. However, during the latter part of 192S and the first part of 1929 there was an epidemic of influenza. Tho records of one establishment (plant B) showed that G of ?,G death claims and S of 10 permanent and total disability rliiims wrre listed ns due to pulmonary tuberculosis. This appeared to lie nn in ordinate amount of tuberculosis from this plant. However, many of the employees were Negroes, end .also tuberculosis claims nrc gener ally high in this section of die country. licaHzir.g the difficulty in diagnosing pneumoconiosis and the tendency to confuse it with tuberculosis, these claims were studied individually. The physicians who hml treated the individuals were interviewed, nnd the hospital and sanatorium records, including available X-ray film*, were investigated, until the following results: Death elnimt: 1. A typist, not exposed to dust; died of pulmonary and<y intcstinr.l tuberculosis. 2. Colored male, age 27; worked in obentos 1 year and 5 months; died of pulmonary tuberculosis following a broiorrliage; was in sanatorium 10 months. Also had o four plus V.'as.-cr- mann. No evidence of nsbestosis. C 3. Colored male, ege 32; worked in asbestos plant 1 year and. 7 months; died of pulmonary tuberculosis after 1 month in hospital. Cavitation both lungs; no evidence of asbesiosis. 4. Colored male, ago 34; worked in asbestos plant 2 years and 6 months. His physician believes this was a case of uncom plicated tuberculosis. Was not inmate of hospital or sanatorium. No infonuation could be obtained on (ho other two eases. Total ant! permanent diftibHibj rlaiwx: 1. Male, employed in asliestos plant 3 years. His physician states tliat he first came under his observation with an old estab lished case of tuberculosis about 2 years after asbestos employ ment started. Also had tuberculosis of the kidney end cervical glands. 2. Male, employed in asbestos plant S months. Ilis physician slates finding of old fibroid tuberculosis with tubercle bacilli in sputum. No X-ray available; but according to physician, as bestos bodies were found in sputum. 3. Male, 10 rears' employment. Two physicians who treated him at different times ore now inclined to believe this man is not tuberculous, but has asbestosis. 4. "WTiitc male, was reexamined at time of investigation. His physician reports well nourished, husky looking, good color, no cyanosis: no dubbing of fingers; diminished expansion; incessant cough; X-ruy shows fine mottling disseminated through both lungs. No evidcnco of tuberculosis. Probably a second stago asbestosis. 5. White male, 13 years in asbestos plant. Is now in sanato rium. An interesting ease. His physician states that lie 1ms ex tensive asbestosis and pulmonary tuberculosis; cavity in right lung; sputum lonilrd with tubercle bacilli and asbestos bodies; believes tuberculosis long antedated nsbcslnsis. This patient is progressing in a satisfactory mannerT It was not possiblo to locate the other throo eases of total and permanent disability who had been diagnosed as having pulmonary tuberculosis. On the basis of the information obtained, tbo deaths in death-eluinis eases appear to he duo to uncomplicated tuberculosis; three of them were Negroes, who were probably tuberculous at tho time their employment in the asbestos plant commenced. Of the S disability claim eases, 1 was uncomplicated tuberculosis and 2 were uncomplicated asbestosis who were put on disability because of a mistaken diagnosis of tuhrreulosis. In this sr.mo com munity we know of one death due to uncomplicated asbestosis in an individual with many venrs' employment in the industry-9 - CONCLUSIONS 1. Prolonged exposure to asbestos dust caused a pulmonary fibrosis of A,type different from sificuiisjmri demonstrable on X-ray Sims. Clinically, from this study, it appears to bo of a typo milder than silicosis. 2. cs of dc&mU..axdi*&4oUcccmcnt were frequently found to be associated 0L2 0 9 i hnmaI nunxuilnUM. n JtaggVy (_ t3J 3. A predisposition to tuberculosis due to asbestos dust was not indicated in tins study. 4. Asbestosis as observed in this scries of eases hnd not resulted in marked disability in any case. 5. It is not known bow much asbestosis may add to the mortality of pneumonia and aeuto nontuberculous pulmonary infections. 6. It is not practicable as yet to establish standards for the asbestos dust content of air. . 7. The amount^of dust in the air in the asbestos plants studied can be substantially reduced. BXCOKXEXCA.TIOXS . It is recommended-- 1. Tlxat tho ind.H$l*gr,seriously face the problem of dust control in asbestos plant^, 2. That new employees be examined physically, including X-ray examination of llic chest, and rejected for employment if they show tuberculosis or pneumoconiosis. 3. That employees be examined physically, preferably every year, but at least every 2 years, this examination to include an X-ray examination of tbc chest. 4. That tbc y)glj$yMponsor studies on known cases of asbestosis as well as studies on.s*eU of asbestosis on the heart and circulation ACKNOWLSDCJJrXTS The authors wish to express their sincere thanks tn all those wht aided in making this study possible, especially the.officials and cm ployccsof tlio.9h<yifl*.wm panics who cooperated to the fullest ex ter. and gave every facility for securing data; also to Dr. I'nnenast, of ih. University of Pennsylvania, for Ids interest and valuable advice i: interpreting X-rny films, and to Dr. F. V. Meriwether, of the Unite* States Public Health Service, surgeon in charge of the United State Bureau of Mines Cooperative Clinic in Picker, Okht., who#r inter pretation of all the X-ray films listed in this report is followed. Ap pFeeiatiun is also expressed to Dr. IV. Atmar Smith, and Dr. Kennel! Lynch, of Cltosluiua^S. C., for information and advice, particular!, ns to the pathology of asbestosis; * to Dr. VT. W. Wild, of Charie<tor S. C.; to Dr. Joseph II. Wyatt, of Newark, X. J., ar.d Dr. If. 1; Fellows, of New York, for assisting in interpreting X-rny'films; t Dr. Paul 0. Snoke, of Lancaster, I*a.; to Dr. R. H. Stevenson, t Dor.ville, Quebec, Canada; and to Dr. L. U. Gardner and Mr. Dona! E, Cnmnitnri af tl0 Sonnnr Laboratory, wlm have undertaken it study of-tho pathological c/Tects of the inhalation of asbestos dur AsbaiAta Mist la<auioa edlua*. Or Xsettk it. Lracb. >1. UU. IbH, kui. SO. JCU, rl. U. M. I. r>7. U* <**U 0aail W. AH"5 cue. !i.. 12 through animal experimentation, with Iho aid of a grant from the Metropolitan Life Insurance Co. nr TERENCES (1) Greenburg, Leonard, and Bloomfield, J. J.: Tlie lmpinger dust lamptin; ap paratus os nsed hr the-Ualtcd State* TubUe Health Service. Pub. Health Rep., rol. 47, no. 12, Mar. 18, 1932. Reprint no. 132S. Drinker, rbilip, sad Tlioutson, Robert M.: Determination of suspeosoids by alternating-current precipitators. Jour. Ind. IIxe*. voL YU, no. 6, June 1023. (3) Hiilehrand, IT. F.: The analysis of silicate and carbonate racks. Bull. 422, United State* Geological Survey, Washington, D. C. Cooke, W. Pulmonary axhestesia. RriL Med. Jour., See. 3, 1027. Green, It.: A photomicrographic method lor the determination of partIds size of paiot sod rubber pigments. Jour. Franklia Institute, 1921, pp. 192, 637. Whipple. C. C.: Yilal statistic*. John Wiley and Sons, Hew York, 1026, p. 451. (7} Russel. A. E.. Britten, IL H., Thompson, L TL, and Bloomfield, J. J.: Th*. health of workers in dusty trades. II. Exposure to siliceous dust (granite Industry). Pub. Ilealtb DulL No. IS7. 1929. ENDEMIC TYPHUS IN ALABAMA1 By J. K. Bases, M. D., Jaucs G. MeALrjNt, Ph. D., and D. G. Ctu, M. D,, ' D. P. H.. Alabama Slate Department af Health, JUonlgamerp, Ala. I. INTRODUCTION- In a preliminary report made in June of tlu's year before the Con ference of State and Provincial Health Authorities, held in Wash ington, the authors discussed (lie epidemiological aspects of endemic typhus as it occurs in southern United States. In tliot report it was noted that there had been a rapid increase in this disease in certain Southern States, ax is shown in table 1. That other countries have experienced a similar rise in incidence is evidenced by the figures in table 2. The distinction between epidemic typhus and the endemic typhus of this country was first recognized in ISOS by Brill. He (1) found in the United States a type of fever which, rosemilling typhoid, gave a negative Widal reaction. Jn further studies he (2, 3) demonstrated it; similnrily to typhus, hut showed that it was milder in character and less contagious, only one ease as a rule being found in a household. Also he rrported that it was most prevalent during the fall of the year instead of late winter or spring. In 1912 Anderson and Goldbcrger () proved that Brill's disease was immunologieally identical with Mexican typhus, or tahardillo. Naturally this led to the belief that^ it was louse lxsrnc. -- 0 % u i] Sc.-4 OH.** Hat kMuwr metma of ih lowton I'iiIJk IIcoHIi tn^iilii, Nwliii), CsSt, fr,j , n-i