Document 13yEO0ov4Zdxz6LLLzn600qK

FILE NAME Insurance Industry INS DATE 1974 DOC INS081 DOCUMENT DESCRIPTION Transactions of The Assoc of Life Insurance Medical Directors of America - TOC Presentation Industrial Carcinogens & Attendee List TRANSACTIONS of | The Association of Life Insurance Medical Directors of America SECOND ANNUAL MEETING / ; Paul Entmacher D. Editor e 4 gu ber PLra SPERRY . SPERRY CONTENTS OF VOLUME LVII Page Officers Executive Former Council for Officers V .............-....00--00: Guide Professional Conduct to 20... 0.000. o eee ccc cee aes be ee eens - X Nelson Opening Remarks President Richard A. 1 bee be eves eeees Remarks Em C.m Emme et t M.D. ................ bce eee eben teens 2 Benoit Boucher ......., be eas aeteewer peed week eter nec eee 3 The Medical Information Bureau . .... eee eee es be en eee ees $ Joseph C. Wilberding Remarks RogeAr. Bush M.D. 00.0 fete eee e eee .... 10 For Crisis Sake What's Next .......,... se eee e eee reas ete eens 13 Russell B. Roth M.D. Papers Genetic and Other Biochemical Bases of Human Behavior 31 ................ Mark D. Altschule M.D. The Outpatient Management of Psychoses ................. . Shervert H. Frazier M.D. TreadmillTesting- Bolts I. Thomas Wilson C.R.T. ......... bere eee eee ence aes . They Thymus Comes ...... becca siete eae Seen ences ... VaughnP. Simmons M.D. The Problem of Human Obesity Abstract ve tee ees beeeceeseceas JulesHirsch M.D. Century Twentieth Stress and the Subendocardium of the Left Ventricle ..... Robert S. Eliot M.D. The Power of Wordless Persuasion sete ee ateeees William J.BeenersD.D.D.D. 48 66 86 124 130 a Rougraff M.D. eee cece 2 or a a rc M.D. M.D. Ae ee sevccens ba ae SS 2 sineeeeeee 170 174 176 TEE iiede ee nee ae ceeeee 195 RECENT DEVELOPMENTS IN INDUSTRIAL CARCINOGENS ROBERT E. Eckardt MD PhD Director Medical Research Division Esso Research and Engineering Company Company Linden NJ Printedwithpermission ofJournal of Occupational Medicine It is a real pleasure for me to have been invited to talk tonight to your combined meeting am quite convinced that cooperative ac- tion between industrial hygienists industrial physicians and indus- trial nurses can do nothing but improve the health of the American worker As all of you are quite aware that goal the improvement of the health of the American worker is a new national objective since the passage of the Occupational Safety and Health Act of 1970. In- spections of industry by compliance officers is the method that will be used to insure that regulations promulgated under the law will be met But especially in the health area it will be the physicians nurses and industrial hygienists who will have to implement the regulations This is why educational activities carried on by the three societies both individually and jointly have such important impact on implementation Another important joint venture of the three professional disci- plines has been the creation of the Joint Accreditation Commission which brings together nurses industrial hygienists physicians and health physicists to develop a set of standards for occupational health programs Representatives of our national societies the IMA the AAIN the AIHA the AAOM the ACGIH the Health Physics Society and the American Academy of Industrial Hygiene are work- ing together with the Kettering Laboratory of the University of Cincinnati as a subcontractor under a contract from the National Institute of Occupational Safety and Health NIOSH to develop these An inspection will standards Once they have been developed and found acceptable by industry labor government and the professions they will be put into operation Accrediting an occupational health program will be something like accrediting a hospital An industry which wishes to have its program accredited will apply for such to the Commission team be dispatched to review the medical nursing industrial hygiene if applicable the health physics activities 5 180 SECOND ANNUAL MEETING measure be industry Their interaction with each other and with man- will reviewed and if the program is found to the standards a certificate accrediting the program will he up the is , industry The certificate will be good for a period of three reaccreditation through reinspection will be required IfIf changes occur in the industry before the three years are up reinspection may be required and the certificate recaled recalled standards are not being met When this program of accredita- ready put to be into action we certainly hope that each of you your full support and cooperation by urging your com- for accreditation We anticipate that in the future this of Accreditation of an Occupational Health Programa displayed as a hospital accreditation certificate company loses its accreditation it will immediately measures which will permit its reinstitution 1 for straying so far from the topic of my this is such an important activity that you you you are not already today one about which there is much confusion misunderstanding This in turn leads to the develop- apprehensions As in clinical medicine the word immediately seems to lead to despair whereas our have some knowledge of the experimenIn the oncologists test for carcinogenicity relatively straightforward You will note a skin carcinogenesis test complicate it Thus we know develop skin cancers response , while rats and guinea pigs h confusion he develop- e the word hereas our k of cancer problem in wledge knowledge to arrive industry is xperimen-xperimenIn the men me PO eS serSR INDUSTRIAL CARCINOGENS 181 damage damage the skin as to make interpretation of results difficult frequently the latent period for cancer done development mayshdoouneld that the animals die before developing cancer Painting with a minimum of rubbing to avoid damaging the skin workers even use a micropipette so that no rubbing at all is letting the material spread over the shaved skin in measured dose at each application The animals shoualndabce- periodically because if the material being painted is toxic it inteinrterffereere with their growth and we know that this in turn will with tumor development Because a painting experiment takes so long to two atspeople are always looking for shortcuts They want a chemi- few accelerated biological test that will give them the answer days or a few weeks However desirable this may be so far them have held up when examined closely Thus it was found carcinogens would cause atrophy of the sebaceous glands skin 130 compounds and this was once proposed as a quickie test However Bock & Mund 1 found that some car- compounds did not cause sebaceous gland atrophy while carcinogenic compounds did Some chemical tests may application but because of the wide variety of chemical have been shown to have carcinogenic activity it anticpated that no single chemical test would have univer- ap licability Suffice it to say that an expert panel convened to the Food & Drug Administration concluded that no truly implanted subcutaneously into rats or mice ofknown dose and minimal handling of the method so far has been shown to produce malig) in response to cellophane Dacron poly- chloride silastic Pliofilm Nylon polymethyl polystyrene Saran Ivalon Kel Teflon silk 4 and our hands we found that a complex oil shown the skin when painted caused a local abscess subcutaneously which subsequently sloughed out with- this route of testing may have limited ap- are produced at a site distant from the sarcomas sarcomas the site of injection are the only 182 SECOND ANNUAL MEETING tumors formed interpretation of their ly difficult significance becomesbecomes extreme- Another suggested test is that of implanting extreme- bladder of mice This suggestion implanting the material material conception Thus in the study ofabrloasdederI bteulmioerves from an entire in occurring ers in the dye industry betanaphthylamine when administered cutaneously was shown to produce bladder tumors in mice In searching for the reason for this discrepancnyaimpphrteghnyatle-d hexadecanol that both man and dogs excrete naphthol naphthylamine of as in their urine whereas metabolite mice do not Dr. Geor- gianna Bonser in England concluded that maybe amine was not the carcinogen after all but that the naphthol was To test out this theory she metabolite 2 small wax pellets with naphthol and surgically into the bladders of mice Sure implanted them oped bladder cancer However enough the mice devel- subsequently it has been shown that cholesterol glass stearic acid magnesium stearate octadecanol and naphthalene 6 the fashioned moth ball all produced bladder tumors and cancers when implanted into the mouse bladder None of these are suspected of being carcinogenic Thus this test does not seem to be a very sound one |. Incidentally amine these studies of the metabolism of naphthyl- have led to extensive metabolic studies and brisk scientific argumenttsheabout what truly is the carcinogenic agent One school naphthol metabolite as the carcinogen believes that hydroxylation of the nitrogen atom of called different N hydroxylation is the carcinogen while metabolites are the true carcinogen These fascinating from a biochemical standpoint and cancer biochemists hard at work in the not have much practical implication for the implantation of cholesterol glass materials bladder previously men- serious materials are claimed by some to have produced bladder.can- never developed ' question then arises INDUSTRIAL CARCINOGENS 183 taken with such bladder implantation techniques and had to be dis- feeding counted amil the experiments were completed Even now countcedyclamate the experimental picture is not clear because there is some question that experimental animals may have been infected with bladder para- the c It is well know that Bilharzia a bladder infestation of humans schistosoma hematobium is associated with bladder cancer In EcgyptThwehere body the Bilharzia is endemic bladder cancer incidence is quite Egypt schistosomes enter through the skin from water there which the Egyptians are walking in caring for their fields From ultimately there they enter the bloodstream and end up in the blad- m Incidently the secondary reservoir for schistosoma hemato- is m the snail and much work is going on trying to find an agent that will kill the snail without producing other undesirable ecologi- cal effects The approach is like killing the mosquito to eliminate 2 ~~" Another approach that has been recommended to try to shorten the Recessary test period for carcinogens is the use of newborn or very young suckling mice 7 It was suggested that an increased incidenacned earlier appearance of malignancies could be obtained from a single injection of potent carcinogens However newborn did not respond rats they in the same way as newborn mice 8 Rather responded like adult mice Further more complete studies this test method probably has few true advan- be that the use of newborn or very young mice was predicated on the absence of detoxifying enzymes in the new- j subsequently appear as the animal ages It is known hydroxylase exists in the gastrointestinal tract 10 known that newborns are frequently lacking enzyme experimental lung carcinogenesis it is now beginfactors are probably necessary to pro- and pyrene 12 or dimethylindia ink 13 or in hamsters hematite 14all have led to lung cancer production that pure polyaromatic compounds like 184 EIGHTY-SECOND ANNUAL MEETING ciltary removal SECOND 184 EIGHTY EIGHTY SECOND ANNUAL ANNUAL MEETING 184S mechanisms SECOND mechanisms this within MEETING the | residence removal and residence time time much prolonged prolonged is this increased residence lung may nie may which be believe believe leads production of the production very lung early interesting lactones carcinogenic carcinogenic potential 24 in carcino- from review complete experimental carcino- to been like to should now some interesting % turn MPhasiztehe complexity of tg Some recent incersin experimental omoacetateand eps inogens The demon 1 animals with these human exposure withpulmonaryvigilance . INDUSTRIAL CARCINOGENS 185 epidemiological work I shall not try to cover skin cancers in coal tar epidemiological spinners workers mule cutting oil users wax pressmen and the like workerscancersinchromate workers nickel refining or asbestos work- other thaninsulators bladder cancers in the dye industry nasal 25 in canceris n nickel refining and isopropyl alcohol manufacture or bone sarcomas in radium dial painters because these have been coveredin my book or other works Presumably we are discussing recent developments developments ge publicity beengiven recently to asbestos as a pulmo- pleural peritoneal mesothelioma asbestosworkers has been recognized The condition was catapulted into prominence of Wagner27 inin South Africa among miners Selikof unusual of Selikoff and his associates has been their use of union records to study Because insulators usually don't thiscondition one employer but rather move from job to job available and thus work for multiple employers any kind picture of what their health through union records When these were 632 that of through workers who entered the trade 1962 45 had died of cancer of men would have been expected expected to die of normal incidence had prevailed An- rvation has been that the incid ofelun ngccaen- workers who smoke cigarettes is far this situation under control 30 There is still some workers this asbestos in field of whether the is a direct has been the observation that ; tungs very high percentage and never been exposed to as- Although Although thisis of concern to many peo- prepared to say what its significance isis Itis impor- 186 SECOND ANNUAL MEETING MEETING As many people suspected lung cancer uranium miners has been shown to be incidencinecidence risk seems to much higher increased 34 be miners among smoking nonsmoking Again miners There have been 62 lung cancer and deaths 3,414 white miners 2 among 761 nonwhite deaths miners hopeful y hopefully been established a response Recently hopefully permit the elimination of this relationship which may disease in the future may outbreak an of bladder cancers ers in the electric cable industry 35 This occurred among resulted from the former use of naphthylamine apparently as an antioxidant in the rubber sheathing used on the cables Since this rubber material has not been used by the rubber industry as an antioxidant since about 1945 it antici pated that these tumors will soon disappear However it does point latent out the long period that can occur and in point etiologic agents in occupational cancer searching may be important histori- cally to go far back into the processes to find the responsible agen Among 8,047 workers in a metal smelter works 147 respiratory cancer deaths among 1,877 total deaths were causative agent in this case was believed to be reported 36 The arsenic trioxide ures by inhalation although some relationship to SO expos was also demonstrated This recalls the exposures association between sulfur dioxide and pyrene in animals demonstrated by the NYU group and previously discussed 12 A real surprise has been the demonstration in England 37 of an increased risk of nasal cancer occurring in woodworkers in the furniture industry This seems to be associated with the use of hard woods To date no one has come forward with a good guess as to what the causative agent might be in this situation Undoubtedly this observation will lead to extensive laboratory studies both chemical and biological in an attempt to uncover the causative agent The accumulation in the literature of cases of leukemia follow- ing benzene exposures 38 39 40 41 42 43 leads to the inevitable conclusion that benzene is a leukemogenic agent particularly Ali-n cases that have previously displayed a panmyelopathy 44 though this had long been suspected the data reported in the litera- ture was not sufficiently convincing to establish the leukemogenic nature of benzene However the more recent observations observa- establish this association beyond a doubt More recent observa- tions of chromosome changes in workers exposed to benzene exposures en sulfur he NYL d 37 of rs in the of hard 255 av to ubtedly 5. both jusative follow evitable arly INDUSTRIAL CARCINOGENS 187 lend further weight to the leukemogenic nature of benzene In further 46 benzene in our own we are proceeding as if operations event awnays a leukemogenicleukemogenic agent eliminating exposures wherever possible reducing elimi- and them to the lowest possible level where complete be accomplished cannot nation It has been reported 47 48 that lung cancer incidence in and miners is 29 times the expected rate It was found in this Aluorspar situation that radon radon daughter exposures are in excess of is the the maximum permissible concentrations and it is believed that this cause In this respect these lung cancers are similar to those seen in uranium miners and in the old Joachimsthal mines A study of lung cancer among coke oven workers in the stoo industry 49 showed that they suffered a 2 1/2 times increased incis dence of that disease This increased to 5 times among men who worked topside on the ovens and to 10 times if they worked Se years time topside It is likely that exposure to very high levels of pyrene and similar polycyclic aromatic compounds compounds occurred although it is quite possible due to the complex chemical nature of coal tar that other promoting or carcinogenic agents such as phenols or nitrogenous compounds have contributed to theincreased incidence Undoubtedly intensive chemical and bi- logical studies of this situation will be undertaken which will in time elucidate the causative agents and their comparative signifi cance - I to develop for you some of the more recent develop hianve tried ments experimental carcinogenesis as applied to industrial prob- lems and some recent epidemiological studies of industrial cancers believe our approaches to occupationally induced cancer should from the approaches we use in any potential occupational . We should study and become intimately ac- with the processes involved not simply by studying engt- flowdiagrams but by actually getting out into the work just what is done This will give us some idea of of the workers involved as well as possible designed toxicological tests in this case understanding fully the limitations and pitfalls conduct We should carefully examine the detect early signs of exposure or early pre- 188 SECOND ANNUAL MEETING cancerous exposures nickel or chromium should changces hanges Thus appropriate urine or blood analyses for chromium for phenols the case of benzenc In some cases early biopsy or Papanicolaou smears should be undertaken appropriaatpperopriate secretions every opportunity we should stress the avoidance of un- necessary exposure I can think of no area where the cooperative of industrial hygienists industrial nurses and industrial physicians physicians can have a more salutary effect than in the control of industrial carcinogens and thus in the control of occupational cancers BIBLIOGRAPHY 1. Bock F.G. and R. Mund A survey of compounds for activity in the suppression of mouse sebaceous glands Cancer Res 887 1958 2. Food and Drug Administration Advisory Committee on Protocols for Safety Evaluation Panel on Carcinogenesis Report on Cancer Testing in the Safety Evaluation of Food Additives and Pesticides Toxicol & Appl Pharmacol 419 1971 3. Grasso P. and L. Golberg Subcutaneous sarcoma as an index of carcinogenic potency Food Cosmet Toxicol 297 1966 4. Oppenheimer B.S. et al Further studies of polymers as carcinogenic agents in animals Cancer Res 333 1955 5. Shubik P. er of Studies on the toxicity of petroleum waxes Toxicol & Appl Pharmacol Supplement 1962 6. Boyland E. E.R. Busby C.E. Dukes P.L. Grover and D. experiments on implantation of materials into the urinary . BrilJ Cancer 575 1964 Manson Further bladder of mice Pietra G. H. Rappaport and P. Shubik The effects of carcinogenic chemicals in newborn mice Cancer 308,1961 Food 8 Della Porta G Use of newborn and infant animals in carcinogenesis testing * Cosmet Toxicol 243 1968 , and P. Shubik Toxic effects of dimethyl anthracene in adult swiss mice Nature 428 1966 Cancer Wisely D.V. L.W Benzpyrene hydroxylase activity in the gastrointestinal P. Kotin P.R. Fowler and J. Trivedi The combined effect of infection and exposure to carcinogenic aerosols on pulmonary C57 in black mice Am Assoc for Cancer Res Proc 278 and S. Laskin Combined effects of 10th CancCer ancer Conference Houston Texas atmospheric May 1970 pollutants Experimental : cancer of the lung J. Nat Cancer Inst 1305 AG < TING leum waxes Toxicol & Appl Further ver and D. Manson the urinary bladder of mice cts of carcinogenic chemical carcinogenesis carcinogenesis testing als in carcinogenesis of INDUSTRIAL CARCINOGENS 189 . et al Intratracheal injection of particulate carcinogens carcinogens into Am Assoc Cancer Res Proc 4:59 1963 ham- al Tumors of the respiratory tract induced 15. chloromethyl ether Arch Environ Health 135 1971 by inhalation of | Institute of Environmental Institute of Environmental Medicine Research in in Environmental Environmental Sciences Eighth Annual 16. 00260 Sciences Environmental Report of Progress USPHS Center Health Grant ES Vorwald Urban 17. A.J. A.L. Reeves and E.C.J. Experimental Beryllium Toxic- Stokinger ology H.E. Ed Beryllium Industrial Hygiene Aspects Monograph of the Am Indust Hyg Assoc and U.S. Atomic Energy Com mission Chapter 7 pp 201-234 New York Academic Press 1966 18. SundermanSunderman F.W. and A.J. Donnelly Metastasizing pulmonary tumors in rats induced by the inhalation of nickel carbonyl Am J. Pathol 1027 1965 19. Lisco H Discussion at the Scientific Session of the Annual Meeting of the 20. Steffee C.H. and A.M. Baetjer Histopathologic effects of chromate chemi- studies in rabbits guinea pigs rats and mice Arch Environ Experimental Animals Brit J. Ind Med 20 1963 cancer in mice and rats by chromium compounds see . A transplantable mesothelioma induced by et al Carcinogenicity of epoxides lactones and peroxy comresponse in epithelial and connective tissue in mice and rats 825 1966 Industrial Carcinogens Carcinogens New York Grune& Stratton 1959 : Inspector Factories for the Year 1954. London archand Diffuse pleural mesothelioma and Cape Province BritJ. Ind Med 12 Hamesmond Asbestos exposure and neopla- Hammond smoking and neoplasia J.A.M.A. 20 ) Insulation Hygiene Progress Reports from Containing benzpyrene and related natura and contaminating asbestos asbestos exposure Am J. 190 SECOND ANNUAL MEETING 34. 35. 36. 37. 38. hardrock Hofaday exposure Lundin F.E. J.W. Lloyd E.M. Smith V.E. Archer tality of uranium miners in relation to radiation cigarette smoking- 1950 through September 1967 1969 and D.A. hardrock Mor- Health Physics mining and Physics 16-571 Davies J.M Bladder tumors in the electric industry industry 1965 The The Lancet 143 J. Lee A.M. and J.F. Fraumeni Arsenic and respiratory respiratory cancer in occupational study Nat Cancer Inst 1045 1969 man : An An Acheson E.D. R.H. Cowdell E. Hadfield and R.G. J. Nasal in woodworkers in the furniture industry Brit Med Macbeth 587 1968 Nasal cancer Vigliani E.C. and G. Saita Benzene and leukemia New Eng J. Med 1964 872 39. Girard R. et al Malignant haemopathies and benzene 62:71 1971 poisoning poisoning poisoning MeMedd Lavoro 40. Aksoy M. et al Acute leukemia due to chronic exposure to benzene Am Med 160 1972 " 41. DeGowin R.L Benzene exposure and aplastic anemia followed 15 years later Semiannual Report to the Atomic Energy CommissiboynlAeuCkRemHi-a 19. Argonne Cancer Res Hosp Chicago III 1963 p 31. Nuclear Abstracts 28665 1963 Science 42. K^/hler H.J. and H. Merker A case of chronic myeloid leukemia alter pro- longed exposure to benzene Deut Med Woch 86 1135 1961 43. Forni A. and L. Moreo Cytogenic studies in a case of benzene leukemia Europ J. Cancer 251 1967 44. David A Assessing the occupational character of leukemia in persons exposed to benzene Pracovn^>Lekarstv^>16:13 1964 Occup Safety Health Abstr 2 114 1965 45. Forni A. and L. Moreo Chromosome studies in a case of benzene erythroleukemia Europ J. Cancer 459 1969 46. Hartwich G. and G. Schwanitz Chromosome studies after chronic benzene exposure Disch Med Wschr 97:45 1972 47. de Villiers A.J. and J.P. Windish Lung cancer in a fluorspar mining com- Sn Radiation dust and mortality experience Brit J. Ind Med 8 in fluorspar mining community II Preva- and disability Brit J. Ind Med 110 1964 study mortality of steelworkers V. Respiratory cancer 13:53 1971 Colonial Penn Life Philadelphia presentation very much There Lit, The first one it's what you said that Doctors Present A.B. Abrutyn Jr. N.E. Adamson M.R. Alberg M.D Altschule D.A. Anderson B. Argano W.H. Atkinson F. Bach J.W. Barch R.H. Barr P.G. Bartsch S.F. Bassett H.C. Bates Jr. A. Baumgart R.E. Beamish D.E. Bean W J. Beeners G.E. Bell M F. Bell G.W. Benson B Boucher D.W. Bowne W.R. Bradley B.A. Bradlow K F. Brandon D.J. Breithaupt J. Brochier H. Brodsky A.E. Brown R.F. Buchan D.E. Bulluck M.F. Bures J.A. Burke C.A. Burkhart R.A. Bush R.H. Butz D.W. Cardwell J.P.Carey J.P.Carey JR Cavett Jr. | A.H. ClagetJtr. PRESENT AT MEETNG H.A. Cochran Jr W.F.X. Coffey M.A. Compton F.R. Congdon C.E. Cook H.K. Cooper Jr. R.A. Corne K. Courage R.H. Craig S. Dann A. Beer T.G. Debyanidis J. Delvin R.J. DiSalvo A.H. Domm D. Dove R.L. Dross L. Durieux L.H. Earle Jr. C.M. Eberhart R.E. Eckardt J.R. Eddy J.M. Edington W.J. Elder R.S. Eliot J.C. Emmett JA End P.S. Entmacher S.M. Erba R.E. Fidelino D.M. Fleming P.M.L. Forsberg G.E. Fort J.G. Fraser C.R. Fravel S.H. Frazier M Fr^hlich Y. Fukuda J. Gajewski J.E.D. Gardam J. Geerling W.R. Gilliam 281 JP GloveJrr 6 Goodkin HM Goodman A Guotnick AC Grunow JR Gudger T F. Gumina R.C Has M. Haifer M Hall M Hansen FM FM Hard JR Hare 5 B Harper M Haskirs H Hawkins W Henry W Herbert E. Higgins EC EC Hillman fr M. Hirae J Husch CM Huffma N Hernick WH Hover RL Howard G Howe HG HG Howe Is 1C Host W. Huckabee CH Huddleston G 1 Hult GP GP Human A. A. Humphrey M. L. Hunt W. J. Hunzicker J. J. Hutchinson E Ikonen C. Isoardi F. Jenkins T. Jernigan J. W. Johnson Jr H. B. Jones N. Jones A. Jous ANNUAL zg MEETINMEGETING 5 SECONDL. Mitchell R.S Schaa^ : P.T. Moore K F. Schaefer P.T. Jr. 2 R. Moore D.O Schult 1. Scott F. Jr. J. Moran R.C Secor R. H. Morgan D. Shechan R. R. Murphy T. Murray D. Shieldsr P. Simmons , i S. A. Narins G. A Simpson R. A. Nelson C. A. Nordin T. Smiley H_A_W Smith M. Spall : , 5 if : i i 5 : : j - . *. > i i. we ~ _ potas D. O'Connor R.J.Ochrig D. Papadakos H. K. Pawsey S. Pearson N. E. Peatfield J.I. Peters Jr. J. Peytavy F.I. Pitkin K. W. Pleissner T. E. Plucinski A. Pollack E. M. Pollak . P. Powell Preschel Powell CH Stark H. Startde JA JA Stephens H. Stetthacher R Stickler R.Stock A. Storm D.J Sulinan Susaki S. Sylvester N.G Talwalkar Tanner C. Teall A. Teeger J. A Tesoriero JE Todd W. Unger H. Ungerleider B. W. Vale A. L. Van Ness E. E. Virts Jr D. O. Wainwright M. Walker Jr. J.G. Walsh O. Walwyn K. E. Ward D. R. Warren L. J. Warshaw Waterman COMPANIES AND THEIR REPRESENTATIVES Business Men's Assurance Company of America BMA Tower Kansas City Mo 64141 Tel 816 753 8000 H. Clark Lentz D Ivan E Lloyd M. P & Med Director Assoc Med Director Rodolfo E. Fidelino M D Asst Med Director California Life insurance Company Wilshire Boulevard 6420 Director Angeles Calif 90048 Yes 655-4920 Warren C. Breidenbach MD Medical GarthK Graham M Medical Director California States Life Insurance CompanyCompany P.O. Box 959 Sacramento Call Ralph Teall O 95804 Tel 444-7100 Medical Director Canada Life Assurance Company Toronto University Ont Canada Toronto Ont Canada 1R8 Tel Tel416 416 368-7432 President Raymond S. Purkis D 1R8 Med Vice RobertW GrahamM. D Asst Med Director Bruce$ M Hawkins D Asst Med Director Canadian Premier Life Insurance Company 360 Broadway Avenue Winnipeg Man R3COT7 Canada Tel 956 BarryJ Kaufman M Medical Director 1030 Canadian Reassurance Company 95 St Clair Avenue West Toronto 7. Ont Canada Tel 416 925-2261 Jonathan C. Sinclair M. Medical Director Capital Life Insurance Company PO Box 1200 Denver Colo 80201 Tel 303 534-8900 John Foster D Medical Director Central Life Assurance Company PO Box 1555 Des Moines Iowa 50304 Tel 515 283-2371 George Young M. Medical President Charter National Life insurance Company 8301 Maryland Avenue St Louis Missouri 63105 Tel 314 725-7575 Joseph P. Costello M. Medical Director Christian Fidelity Life Insurance Company Highway 316 Dallas Waxahachie Tex 75165 Tel (214)937-4420 Norman L West M D Medical Director Citizens Standard Life Ins Co. P.O. Box 808 Corpus Christi Tex Mclver Furman D. 78403 Medical Director City Mutual Life Assurance Society Ltd. 60-66 Hunter Street Sydney Australia George V. Hall M. D. Chief Med Officer Officer Civil Service Life Ins Co. 989 Market St San Francisco Calif 94103 Richard H. Barr D Medical Director Coastal States Life Ins Company 30309 P.O. Box 7037. Station C. Atlanta Ga Tel 404 892-1200 Ext.254 William H. Hill M. Asst Med Director Life Reinsurance Company SCotloagnme ford 06904 POStaBmofoxr3d00 Tel 203 327-4220 V.P. V.P. & Med Director PANIES AND THEIR REPRESENTATIVES 315 Business Men's Assurance Company of America BMA Tower Kansas City Mo. 64141 Tel 816 753-8000 Clark H. Lentz M. D. V. & Med Director Ivan E. Lloyd M. D. Assoc Med Director Rodolfo E. Fidelino M. D. Asst Med Director California Life Insurance Company 6420 Wilshire Boulevard Los Angeles Calif 90048 Tel 213 655-4920 Warren C. Breidenbach M. Medical Director Garth K. Graham M. D. Medical Director California States Life Insurance Company P.O. Box 959 | Sacramento Calif 95804 Tel 916 444-7100 Ralph C. Teall M. D. Medical Director M. Graham Asst Med Director ia Canadian Canadian Premier Life Insurance Company Broadway Broadway Avenue Winnipeg R3COT7 Canada Tel 204 956-1030 Company Reassurance Clair Avenue West Ont Canada TelTel 416 925-2261 Director Sinclair Tel Medical Director