Document rpaGNVvj2e2296NJROVwwqY4V

I t^e%i v>, -SHSiSS UNITED STATES TREASURY DEPARTMENT PUBLIC HEALTH REPORTS ISSUED WEEKVt BY THE UNITED STATES PUBLIC HEALTH SERVICE VOLUUZ 50 NUIUBER 1 JANUARY 4 - - - 1935 IN THIS ISSUE Effect of Asbestos Dust on the Lungs of Asbestos Workers The Occurrence and Control of Endemic Typhus in Alabama The 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 UNITED STATES C0VEENMEN7 TIUNTINC OfnCI WASHINGTON HJJ r^uhkrtw Su9*riaUnd*t ! D. C. - SobacntliM rie>, I t jn? ?hfi i mu O'Ss l>)7 TJKITED STATES PUBLIC HEALTH SERVICE Hcca S. Cnuiixc; Svrften Central sivitio.v or saxitaot nxroirr* and statistics AM. tun- Gem. n. C. Willum, OJrf rf JKrtau The Public Uc.vt.Tn RcronT*. lint published in 1S7S under authority of an act of Concrete of April 29 of that year, U issued weekly by the United Slates Fublie Health Service through the Division of Sanitary Reports and Statistics, ' pursuant to the folio* Inc authority of law: United States Code, title *12,'factious 7, 30. 93; title 44, ruction 220. It contains (1) current information regarding the prevalence and geographic distribution of communicable diseases in the United States insofar ns data are obtainaide, and of cholera, plague, rntaJl(tox, typhus fever, yellow fever, and ether iiu|<urtant communicable diseases throughout the world; (2) articles ro uting to the cause, prevention, and control of diseases; (3) other pertinent infor mation recording sanitation and the conservation of the poblie health. The Pvmlic liealts RrrouTs is publisheil primarily for distribution, in ac cordance with the law, to health o.Ticcrs, inembers of hoards or departments of health, and other peruana din-rtly or indirectly engaged in public health work. Article* of special interest are issued as reprints or aa supplement*, in which forms they arc made available for mure economical and general distribution. llmpiest* for and euiiuuuniealions regarding the Pvrauc lir.vJ.Tii HrroRTa, reprints, or supplements should i*c addressed to the Surgeon General, United States Public Health Service, Washington, D. C. Subscribers should remit direct to the Superintendent of Documents, Washington, D. C. Librarians aad others should preserve their copies for binding, as the Public Health Sendee is unable to supply the general demand for bound copies. Indexes will be supplied upoa request. on 0*l9& CONTENTS Effects of the Inhalation of asbestos dust on tla lungs of asbestos worker*. . Endemic typhus in Alabama--...___ ...___ ............---------------The educator's viewpoint of psychiatric service in a puna) in*murioo------ Court decision on public health.............________ _--........-------- Deaths during week ended December IS, 1934: Deaths and death rates for a group of large cities in the United Stales. Death claims reported by insurance eoni|anics,,---- ---------------------- 1 12 21 21 23 2S pbevalencs or Disease United States: Current weekly State reports: Reports for creeks ended Dec. 22, 1934, and Dec. 23, 1933.----- Summary of monthly reports front Slates................--------Cases of venereal diseases reported ior October 1934........------... Weekly reports from cities: City reports for week ended Dec. IS, 1934..------------------- ------ - Foreign and fnsular: Canada--Provinces--Communicable diseases--2 weeis ended Dee. 1, 1934............................................................................................................. Ceylon--Malaria...........--.......................------Italy*--Communicable diseases--4 weeks ended May 27, 193i-------- Cholera, plague, smallpox, typhus fever, and yellow fever*. Plague...........__---------- ---......----------- ------------ 2 2S 2? 3C 3'. 3-' 3-: 3; Yellow fever--...__________ ___________ --------....--.---- <SQ 3; 0kl99 PUBLIC HEALTH REPORTS VOL. SO JANUARY 4. 1J3S NO. I EFFECTS OF THE INHALATION OF ASBESTOS DUST ON THE LUNGS OF ASBESTOS WORKERS A Preliminary Study By A. J. Lama, Attitiant Medical Director, IYu.uam J. MeCo.vxcuu, /lui<s ant' Medical Director, And J. WjluaJI Fcuxtl, C&cau'J, Mdropo'.Usn Life Insurance Co. INTRODUCTION In 1920 the Metropolitan Life Insurance Co. was approached by officials representing the asbestos industry in the United States, who were desirous of ascertaining 'whether asbestos dust was an occupa tional liazard in their establishmenu and, if so, what was the nature of this hazard and what should be done to prevent or control it. About tills time 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`American journals, the industry itself appeared to bo quite uninformed of the existence of any such occupational disease. The hazard of silica dust, with special reference to the lungs, has long been appreciated, and a great deal of study apd research has been applied to tbc problem (in the metal mining aud certain other industries) in Great Britain, the United States, the British Do minions, and in oilier countries. The nature of the effects of siiica dust expressed in Uie term "silTccsis", with the resultant extraor dinary predisposition to pulmonary tuberculosis, is well known. These cfTccts 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 sSica--siluate*--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 "asbestosis" has kern applied to the pneumoconiosis caused by asbestos dust and it will be so used in this report. Cliemically, the asbestos of commerce is a hydrated magnesium silicate consisting primarily of silica (combined silica) 4-1.1 perrent, mag nesia 43 percent, and water 12.9 percent, wjdlc ferrous iron and nickel ore present in small quantities. This commercial variety of *3 .luerr . ini Z asbestos most commonly encountered is designated ns ciirystilc and is one of the four varieties of the minimi serpentine, in which it usually occurs in scams. It should he borne in mind that silicosis (and presumably nsbestosis) develops very slowly, taking from 5 to IS and even 20 or 25 years to become established. This rnto of progress is influenced mainly, by the dosage of silica which the lungs receive, and this dos age, in tum, depends upon three variables--the* amount of silica in the dust, the quantity of dust in the nir, and the length of exposure. Individual idiosyncrasy might be included as & fourth variable; however, little is known of the variations in susceptibility in those exposed to dust. It might well bo assumed that similar variables would influence the occurrence of nsbestosis. In places where asbestos is mined or fabricated in North America there docs not appear to be present the clear-cut clinical 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 bccomo manifest, but this would not apply to the older mines or to all of the fabricating plants. Tho industrial health service of the Metropolitan Iifo Insurances Co. undertook the following investigation during tbe period from October 1920 to January 1931, which included: 1. A study of dust conditions in asbestosjnines and nulls 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 plants only are included in this study and arc designated in the report ns plants Ar B, C, D, and E. This is a preliminary report. A more extensive study of the nsbestos industry is now under way. DUST STUDIES Apparatus and methods oj sampling.--Both tho impingcr (1) and the electric precipitator (2) were used for 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 axe transportable, easily set up and adjusted for tho taking of tbe air samples nt the proper level, and arc extremely efficient. The impingcr collects the dust by aspirating tlio nir and then impinging it onto a flat surface covered by a liquid in a container. The liquid used was distilled water, containing 50 percent alcohol to C5 3 JuuUTT t. U2S prevent the solution of some of the dusts, particularly any silica which might be present. Tlie 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 Hour meter with an inclined manome ter for measuring tho pressure difference. Each 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 Held and thus causing them to settle out upon a sheet of celluloid. The electrostatic field is set up by means of a transformer operating from tho lighting lines on 120 volts, 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 line near the ceiling also were secured for chemical analysis. Ail samples were shipped to the industrial hygiene laboratory of the Metropolitan Co., and the dust counts were made according to the methods accepted by theUnitcd States Bureau of Mines and the United States Public Health Service (1). Particles in sizo up to 300 microns in the greatest diameter were counted. Chemical analyses wero made for total (free and combined) silica according to the accepted standard method of Hillcbrund (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 microos (a micron equals one-millionth part of a meter or one-thousandth part of a millimeter) in greatest diameter enter the lung tissu ; for tlds reason, the larger particles usually are not considered when determining dust counts. Later, as it appeared from some of the published articles (4) (English) that asbestos particles much larger in size were found in lung tissue, it was decided to count all particles and make differential counts of all thoso 10 microns and under.' . Total pertidcs per cubie foot and the corresponding weight of the dust in milligrams were obtained. Since no relatioaslup between tho dust counts and the corresponding weights was fouad, tbc weights are not included in the tabulations in this report. Tabic 1 shows by plcnts end by departments the maximum and minimum dust eounts in million particles per cubic foot of air. Although the counts in plant A arc of particles 10 microns end under, hT feetfe th iM ite ilrttf.t wt ewtsiM. In eiotbi:7rajhJ tSc tiurt parucU* v?f# tsJwrrt 57 fctlit proier.rl u.vuit- U4* projector, x4 ecl*/t*4 ptnitim Uiat 9toa*xre4 vtU ruJcr, Kttti:; tt.t to:ir* tcbmr..ts.i a? caul ffi4u/s)caf)# it *u iuy to ailcwUu Uu Mihail ptrilclt alu (7). Of im im <*.) WcwUboic prebibUttp paper, U* it^nClQi of tbe luoctlo* I# bo Bjg*ii (la itu r&M ourveui v f4otll u rViUisJr k(Uut (U* |*v4s*14lsljr *4 murrr*.a * 0 0 2i and in the other plants nro for oil particles, direct comparison is possible, as in no samplo takcu were tho number of particles 10 microns and under less than 94 percent of the whole. Tabu 1.-0/onmam and minimum dwtt count* in million partiAa per tubiejoel / air, bf plant and itpartmtnl Steal A Steal 0 Steal 0 Steal S Steal Dr*na*si Kus* l*f n* uk won* lni* fin Mir flHM Nut*lr at Mat* \*m bln Unites Mntttt% |**f tceuatl*a*t Ir Now^l wmu* brr if um* t*m uku Jfw&1 }TLt (cmutb9*i ir Nombtr at IWla Iteu Mttiro mriitcmapp*er Air Kqd> ttnw pte tm lfuuMbicf MflUca oa rer eubto Mr tlr frrTnfvuia,. . ) 3 H-l 4 loci Iruaa t|aeia; 3 Vt- ! Stub rn>r.uc,....._ T *IH1XX__ WfWifS....... ...._ ll lift Vliwtll J 10 44 h-i` I w-ii !*! --r 1>M4H ii-i ei * !* Putt Infalvme...... .. lUli!0 lr*far bud 3 iM 1 3 -O 4 3HUI* 3 ni 4\* 4 4 l 31* 3ft-tO T r.r 3 34- ) ys -c s 1* -74 3 33 >m--ie fwtt-NK i lailtalaj Is ttAsntat. leOtala bnad loafs fiilSw M*hcreas the dust in the preparation room is practically oil due to asbestos, the contrary Is the ease in the other departments. In the carding, spinning, anil weaving rooms asbestos comprises about 25 percent of the material used. On special jobs the percentage of asbestos may be higher, but in general the figure quoted is approxi mately correct, the other material consisting principally of cotton. In the insulating departments of plant A, asbestos is but 5 percent of tho total material used. In the molded brake-lining and clutch divi>ioo of pleat D, asbestos comprises about 22 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. CONDITIONS )X Ttir. PLANTS Tb6 processes in these plants were very similar to those in cotton mills ia general. For illustration, the process in the preparation room of plant B is here detailed at length: ^ Asbestos is received in bags. These are emptied upon the floor and v the asbestos is shoveled into pug mills and run for about 5 minutes in order to crush and open the fibers. From there the asbestos is shoveled into trucks and 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 is first run through a garnet machine and 0 2uwf7 C 1^ discharged into trucks, which are. wheeled to the openers, and the material is fed into these in the same manner as is the new* material. After being discharged from the opener, the material is put onto a ' vibrating or shaking screen, where the long fibers are 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 as such or used in making an asbestos cement. Tito cotton is received in bales, opened, and also run through vertical openers. It is discharged into trueks. The filled trucks from ' the vertical and horizontal openers containing either the asbestos fiber, the cotton, or the trazto material are taken to separate storage bins. As needed, these materials are weighed and dumped onto tire floor in proportion to the mixture desired, and the resulting mixed materials are then passed through a mixing picker. As this mixture is discharged from tho picker, it is sprayed with a light mineral .oil. The material is then taken by a mechanical conveyor to the storage bin in tbo card room. Two of these mixing pickers discharge onto this eonveyor system, while a third machine is equipped with a suction device which conveys the material to a storage bin in the card room. The object of the tw-o systems is to facilitate the handling of two grades of material at tlic same time. The third machine is not equipped with an oil sprny. 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, end weaving. Incidentally, it is apparent that It also diminishes the amount of dust. The material is saturated with about 4 percent of oil at tills point; but by tbo time it reaches tb* looms, tho oil had diminished to less than 1 percent. Wltilo mineral oil was used in the preparation room of plant C, it apparently was not as efficacious os in plant II. In plant E oil was not used, nor was there any attempt at humidification or any system of dust exhausting. Curding machines were 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 was equipped with an air-conditioning system, and in both buildings the machines had exhaust equipment. Two plants, B and C, had artificial humidity installations in their spinning rooms. In the former the temperature was 7G* K., relative humidity 7S percent. One plant, C, had a humidification system in the twisting, department and also in the weaving department, where the relative humidity was 76 percent with a cry*bulb temperature of 69* F., as compared with a relative humidity of <4 percent in the weaving room of plant A. 0/ 2 0^ r.*>/ t%/.> ...r_ , Jaurr . >*U 0 Aside from plant E, ;t would appear that the dost hazard was not excessive except in the preparation reams of plants B and C. The dust counts arc interesting, too, when considered in the light of the permissible standard for grnnito dust, established by tho United States Public Health Sendee (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 discaso clinically than silicosis, the threshold of 'permissible dust counts is higher. Asbestosis appears to be patho logically different from silicosis, and the experience so far docs not .warrant an attempt to define a standard of dustiness for asbestos dust. bust cotmot. Various measures, such as oiling, humidification, and local exhausts, tended to reduce the dust. Nevertheless, it was evident that they were only portly successful.. If it is expected to eootrol dustiness in these plants, final rcliftnee niust rest upon properly constructed exhaust equipment. In plant C in one department an experimental installa tion was set up. In spite of remc obvious faults, this equipment, on the basis o`f comparative dust counts, reduced the dust by 50 percent and with further ((Iterations will prs'oably be 75 percent effective. In this rose such a reduction seemed quite satisfactory. It is neither practicable r.or economically desirable to install such equipment as will make the air entirely dust free. Tiic normal defensive mechanism of the body takes care of n fair oniouct of atmospheric pollution. It is when the body is exposed to an exerssive 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 . is such that it is not possible to apply jown-draft suction to the looms. It ts desirable to iustall exhaust apparatus in any plant on an ex perimental basis first, and then cheek its efficiency by dust counts. This practice will result in saving a needless expenditure of money. y TllYStCAL EXAMINATIONS X-rav films wrre made of 12G persons (10$ men, IS w omen) working in aslxstos plants in the United Stales. All but five of these wera given physical examination. The cases were selected more or Icssl^ u at random irom among those having more than 3 years of employ- ^ C meet in the industry. It was soon obvious that the early diagnosis ^ e of n.-besta-is must rest to a large extent on X-ray pictures of the ^ ^ chest. As in the early stages of sHicusis, 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 com petent riKiitjfiiioh.'M t, 1ml they Li leeu reviewed by se.veral i JiaaiTj- (. ini others experienced in Uiis field. Tlic differences of opinion were of a minor nature, and tliere was general agreement as to interpretation. The film* were rend conservatively, taking into areount the phj-sieal examination and tlio ngc of tlio individual, and were clashed as positive only when there was no major disagreement. All examiners were guided by their experience in silicosis and other types of pneu moconioses. The films classed ns negative for asbestosis were further subdivided into doubtful and negative. Only lime can tril whether the individuals classed as doubtful are progressing toward a definite asbestosis. Particular attention was focussed on the presence or absence 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 be devoted to ascertaining, if possible, whether or not asbestosis pre disposes to tuberculous infection. The eases of asbestosis were divided into two classes, first singe and second stage. The first stage embraces those who show by X-ray examination definito lung pathology sufficient in extent to warrant a diagnosis of pneumoconiosis, but who have no definite symptoms. The sccond-slago cases exhibit more extensive lung pathology and also definito symptoms. All these individuals 1 were actively engaged in factory work, nr.d 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 and marked physical disability or total disability, they would have been classified as third stage, but no such eases were found. Of the total of 12G X-my examinations, 4 were diagnosed as second-degrrc asbestosis, G3 ns first degree, 39 as doubtful, and 20 as negative. There is a definite increase in the pereentnge 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. TaIU 2.--Clairificalion ef taut by ytert /apoturt Yon < upnran rroMUM |mUn Numlof c re -< Otm IS jtvi____________ ___ _ 10 it 10 ywn................... J to 10 vu>i_____________ ----. CMn 0 ___________ TotaJ (muw;______ ------------c n 1 7 ao 3 17 13 C * fun urn*. ' I *4 mmUmiamdi tt>tOWMi MUuloilSr.MUitVtC* altToll lrtir* uKutf UMi olfUfttlkfntf Kli MP# UTf\l, WflUi ti Mil 10 TTill _~ '-- -^7.gL~ ~-v. ~---a,4Trjr.'uc'_ryr a;. : * llMIMT t m % 8 Of the G4 perrons given physical examination and diagnosed ns baring positive osbestosis, only S were entirely free from symptoms, wliilc 10 out of 37 with doubtful and 7 out of 20 with negative ding* noses were free from symptoms. Dyspnoea and cough were the symptoms most complained of, but none of these cases 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, hut too much emphasis should not be placed on statements of subjective symptoms. During the progress of the study, physicians who were practicing in Iho 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 and that found in a community with a silicosis ha sard is noteworthy. The incidence of tuberculosis (based upon X-ray films) is givea in table 3; 40 of the 07 examined had less than 15 yean of employ ment in the industry. * Table Z.--InciJcnct if lubcrculcti* N* hiUI<i O--Wlitl Killn TmS tuaixU 7l 3 - t 0i C7 31 Tbit nu w SUcimmU if r**hiUr m the X-M7 BllntA Table 4 gives information as to physical signs of chest troublo. Taolk findings ' TwIUrt Daebiful KitilH* rbr?"** .'!** u*iW<r._________________ Xu |4jl ............. ................... .......... N( r ia*fnl.............. ... .................................................. TmiI >8 7 11 S u 3 e n 3D t At i^if tw ikii Bvf I frsHttf wild with jur*p MM viib itliUHiulvirmUuiMUitl. What significance, if any, can be, attached to the presence of "asbestos corns" on the hands of workers appears doubtful, as IS pereent-of the positives (12 out of G4) and 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 celled attention to the fact that these films indicated a very unusual incidence of enlargement of the heart. It is probable that tlus is a compensatory enlargement duo to the additional work put upon the heart in efforts ;jZz*: y _ luutfT * >SJ to pump blood through tho fibrosed lungs. It is possible that not sufficient attention lias been paid to Llio effects of the pneumoconioses upon the heart. Many workers had changed from one department to another and from ono plant to another during lliclr years of employment in the asbestos industry. Since 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 otnexpherc inhaled by these people over the years of their employment. Conse quently, it is not possible to correlate individual eases with deficits amounts of dust axposuro. IKSCTLOCCS CLAliiS To throw light on tho relationship between nsbesiosis 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 available figures. There were 2,099 lives involved, with a total exposure of 7,019 lifeyears. Tho death claims ore so small in number that reliable con clusions cannot bo readied from any subdivision of the figures. Tha some is true of the sickness claims under health insurance. The number of claims for respiratory diseases is high in two of the plants studied but low for the 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 30 denth claims and S of 10 permanent and total disability claim* wrre listed ns due to pulmonary tuberculosis. This appeared to be an in ordinate amount of tuberculosis from this plnnL. However, many of the employees were Negroes, andjalso tuberculosis claims arc gener ally high in this section of the country. Itenlizir.g the riilliculty in diagnosing pneumoconiosis and the tendency to confuse it with tuberculosis, these claims were studied individually. The physicians who hud treated the individuals were interviewed, nnd the hospital and sanatorium records, including availublc X-rav funis, were investigated, with the following results: Death daimt: 1. A typist, not exposed to dust; died of pulmonary antU intestinal' tuberculosis. _ _\ 2. Colored male, age 27; worked in asbestos 1 year and months; died of pulmonary tuberculosis following a hemorrhage; was in sanatorium 10 months. Also had a four plus Y'a*.-er- mann. No evidence of nsbesiosis. 1 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; rio evidence of osbestosis. )uauT <- l* 10 4. Colored male, age 34; worked in asbestos plant 2 years and 6 months, liis physician believes this tvas a ease of uncom plicated tuberculosis. 'Was not inmate of hospital or sanatorium. No information could be obtained on (lie other two eases. Total and prrmanrnt ditabilihj claim*: 1. Mali:, employed in asliestos plant 3 years, llis physician states that he first came under his observation with an old estab lished ease of tuberculosis about 2 years after asbestos employ ment started. Also had tuberculosis of the kidney end cervical glands. 2. Mule, employed in asbestos plant S months. Ilis physician states finding of old fibroid tubcrrulosis with tubercle bacilli in sputum. No X-ray available; but according to physician, as bestos bodies were found in sputum. 3. Male, 10 years' employment. Two physicians who treated him nt different times arc now inclined to believe tliis man is not tuberculous, but has asbrstosis. 4. White male, was reexamined at time of investigation. His physician reports well nourished, husky looking, good, color, no cyanosis: no clubbing of fingers; diminished expansion; incessant cough; X-ruy shows fine mottling disseminated through both lungs. No cvidcnco of tuberculosis. Probably a second stago asbcstosls. 5. White male, 13 years in asbestos plant. Is now in sanato rium. An interesting ease. His physician states that lie has ex tensive nshestosis and pulmonary tuberculosis; cavity in right lung; sputum loaded with tubercle bacilli and asbestos bodies; believes tuberculosis long antedated nshestosis. Tliis patient is progressing in a satisfactory niannerT It was not possiblo to locate llie other tlirco eases of total and permanent disability who hod been diagnosed as having pulmonary tuberculosis. On the basis of the information obtained, tbo deaths in death-claims cases appear to be duo to uncomplicated tuberculosis; three of them were Xegroes, who were probably tuberculous at tho time their employment in the asbestos plant commenced. Of the S disability claim cases, 1 was uncomplicated tuberculosis and 2 were uncomplicated asbestosis who were put on disability because of a mistaken diagnosis of tuberculosis. In this samo com munity we know of one death due to uncomplicated esbestosis in an individual with many years' employment in the industry.3 CONCLUSION'S icosis. 2. Ceases of dcfuuU cordiM^otUacgcincnt were frequently found to be jm&ckttd G2209 Pmwnl ptan.<uiirtUM. ..'WD! 11 Jaasar? . iaj 3. A predisposition to tuberculosis due to asbestos dust was oot indicated in this study. 4. Asbestosis as observed in this series of cases had not resulted in marked disability in any ease. 5. It is not known bow much asbestosis may add to the mortality of pneumonia and ecuto non tuberculous 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. nrcouxca'DATioxs It is recommended-- 1. That tho jealously (ace the problem of dust control in asbestos plasty 2. That new employees be examined physically, including X-ray examination of tlio chest, and rejected for employment if they show- tuberculosis or pneumoconiosis. 3. That craployccs_bc examined physically, preferably every year but at least ofiSy t? years, this examination to include an X-ray exnmination of the chest. 4. That thc.i^dlttllMMPonsor studies on known eases of asbestosis os well as studies an..affects of asbestosis on tbo heart and circulation ACKN'O WLEDCUEXTS The authors wish to express their sincere thanks to all those wh< aided in making this study possible, especially the .ofiiri.-ds and eta ployccs of the.panics who cooperated to the fullf-s-t ester, and gave every facility for securing data; also to Dr. I'anenast, of tit. University of Pennsylvania, for his interest ar.d valuable advice i: interpreting X-ray films, and Jo Dr. F. V. Meriwether, of the Unite* States Public Health Service, surgeon in charge of the United State Bureau of Mines Cooperative Clinic in Piclier, Okla., whose inter pretation of all the X*rny films listed in this report is followed. Ap predation is also expressed to Dr. W. Atmar Smith, and Dr. Xcnr.el'. Lynch, of Chlfttua^S*.C., for information and advice, particular! ns to the pathology of asbestosis; * to Dr. W. W. Wild, of Charlotte:-S.C.; to Dr. Joseph II. Wyatt, of Newark, X. J., ar.d Dr. H. ] Fellows, of New York, for ossisting in interpreting X-rnv'films; t Dr. Paul 0. Snoko, of Lancaster, I*a.; to Dr. R. H. Stevenson, t Danville, Quebec, Canada; nnd to Dr. L. U. Gardner and Mr. Dona! E, Cnmminrii nf tl innnn* Laboratory, who have undertaken lb study of tho pathological effects of the inhalation of asbestos du- Atbnuui btditj ta ipuiaa tot lues. Sr eth St. Lrack. M. II. M<1 W. -M--- ! cus. M.. jMiS.an.01tJ.AMA, *i. JAMU. trtl. U. M.. W. **. Q ^ ^ *J Q e.i t- > rt: t-'-*-i.-s-vy IJj hawr C mi 12 through animal experimentation, villi tho aid of a grant from the Metropolitan Life Insurance Co. nsmcxcis (I) Crtcnburg, Leonard, and Bloomfield, J. J,: Tho Impinger dust umplia; ap paratus *j ttsed be the-United States Public Health Senriee. Pub. Health Rep., eol. -S7, no. 12, Mar. IS, 1932. Reprint no. 1S2S. (2) Drinker, Pbilip, and Tliouison, Robert M.: Determination of surpeosoida by alternating-current precipitators. Jour. Ind. llyt-. voL YU, no. 6, June 1924. (3) IliUciirand, TV. T.: The analysis of silicate and earbonato recks. Bulk 422, United States Geological Survey, Washington, D. C. ) Cooke, TV. E.: Pulmonary ashnstosla. liriL Mod. Jour., Dec 3, 1927. (5) Green, H.: A photomicrographis" method lor tho determination of partId* tire of paiat and rubber piemenla. Jour. FrankUa Institute, 1921, pp. 192, 637. (6) Whipple. C. C.: Vital ataUnties. John Wiley and Sons, New York, 1923, P. 5L (7) RuricI, A. Z.. Britten, IL I?., Thompson, I. It., and Bloomfield, J. J.: Ths. health of workers in dustjr trades. 11. Exposure to siliceous dust (gnxits industry). Pub. Health Bulk No. 1S7. 1929. ENDEMIC TYPHUS IN ALABAMA* By J. N. Bases, M. D., Janes G. MeAuuN-r. Pit. D., and D. G. Ciu, M. D., ' D. P. li., Alabama Siait Drpartmtnl *>/ lltalih, MonJgomtry, Ala. 1. IXTItOOUCTtOX In a preliminary report made in June of tliis rear before the Con ference of State and Provincial Health Authorities, held in "Wash ington, the authors discussed the epidemiological aspects of endemic typhus as it occurs in southern United States. In tliat report it was noted that there had been a rapid increase in tliis disease in certain Southi-ru States, as is shown in table 1. Tliat other countries luivo 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 ISDS by Brill. He (1) found in the UnitPtl Stales a type of fever which, resembling typhoid, gave a negative Widal rcurtion. in further studies he (2, 3) demonstrated its similarity to typhus, hut showed that it was milder in character and less contagious, only one ease as :: rule being found in a household. Alsu he reported that it was most prevalent during the fall of the year instead of late winter or spring. In 1912 Anderson and Goldbcrgcr () proved that Brill's disease was imnutnologically identical with Mexican ti'phus, or tahardillo. Naturally this led to the belief tliat i-t---w--a-s---l-o-u--s-e---lior^iic. ** 0 36211 v FrH,jiSrW.*ik, iIk U/<ni]r at lU AmrrloJl I*uIJk Health NuOna CaDl,