Document Dv8e5EK2e0qKpBxjrBg9RX3BO

i 4> - *'v. i Summation Z PLAINTIFFS |S' EXHIBIT 1 EPG- 1 4 - A El C EI I V o r editorial hoard . iMiii.tr DutMcr.r,, a.i^f K.iin-r jj Sit itnck Stftel, i.'i riicnnnni-: r. i.'.victt. i,iti>'.:iir^ii fi-lnx k. imhiI.i., Gu-Miat*. r:,tir. HOIIIX.T A. KCIIOR, Clncimiutl MtAM; IMMNM.I. JJifivcr l-M'.AXK A. I'ATTV. n. troit WII.I.JAM A. SAW VIA!, r.tu-tir*tvr, N. V. jami:s it. > rr.'.txr.tt, r.u.-iitfr.i.i-, N. y. maiAitn j. ri.vMti.rr. m.h.. chk.^o. >t:nta^inj i:ati-.r 4 l' i t .i . *' Vni \ y<i: -I i-.r.i AMi>;o.vx *:. \i. v :ftATiys ':<> 1 Il [,, ETIOLCGIC FACTORS IN CRONCHIOGENIC CARCINOMA WITH SPECIAL REFERENCE TO INDUSTRIAL EXPOSURES . Report et Eijht Hundred Fifty-Seven Proved Caret .- ... . . ' ERNEST L. WYNCER, M.D. HEW TCKIC ANO EVARTS A. GRAHAM, M.D. ST. IOUIS ' - -' . IN' A PR lr. VIOLS paper we *1 2brought forth evidence directin'; attention to tobacco smoking as a factor in the carnation of primary cancer ot the lung. ] hiring the. past year similar conclusions have h.ecn drawn Ly others in this country (Schrek anrl assiiciatcs,5 *Levin and associates,'' ami Mills anil Porter*). Indirect evidence has hecn supplied from Iceland hy Dungal,' who has dot non?; rated through his autopsy records a low incidence of hronchiogcnic carcinoma in that country, noting at the same time that the animal consumption of tolmcco in Iceland did not reach 1 !!>. (0.5 kg.) i>cr capita until 1945, an amount reached in Great IJritain, which has. a high incidence of Imtg cancer, as early as I920. Recently a large-scale sia'.i.-iical .-.indy of this suldecl has hecn published in Great Rritaiti-hv the well known statisticians Doll and Kradford llilt.* That survey imolvcs 709 lung-cancer jeiti'.iiis and L based, as is our own survey, on cases collected only through personal interviews. It presents results remarkably similar to those shown in our own investi gation. Among 649 male patients with primary carcinoma of the lungs the Hritish workers found two iionsmokers. Do'.l and Bradford Hill concluded that ``smoking ;> a factor, and an important factor, in the production oi carcinoma of die lungs." They emphasized, furthermore, that "the risk of developing carcinoma of the lungs increases steadily as the nmmmt smoked increases." . From the Department of Medicine. Ccurjtetmvit University School ui Medicine. Wsrkia^- I>. and the Department of Sr.rdry, WasliiiiRton University School oi Medicine, Se l."uis. ... 1. Witultr, K f... an<r Graham, Jv. A.: Toh.iceo SnnAiiie as a Po-'sihJc litio'ogic Facti.r in lireaciiMi'eni.: Carcinoma, J. A. M. A. 143:.v2l,-c.'f> (May 27) 1123. 2. >rhrvk, 1\.: linker, I.. A.; lisllard, (j. I3..4 and DolgolY, S.: Teliaeeo Smokim} as an r.'.mluuii: Factor in Disc.cc: f. Cancer, Cancer He#. 10:41-5.'' flan.) 1150. a. l evin. ,\f. 1..: Cohlslein, II. and C>vi leio'.t. P. It.: C.y.'.cer am! Tohaeco Sir.okir.e, J- A. M. A. 113:3_V.-.U'5 (May 27) 1150. ' 4. Mills, C. A., and Potter, M. M.: Tobacco Smokim: lfa*.its mi.l Cancer of tiro M 'c.th ii-4 h'i -;hr..:ury Sy-lcm, Cancer levs. )il:5.'D(Si |U.) I'.'5'i. l.uc.i; Cancer in ia-.il. 1'i.ivi ttolt-MJ-J-i" i Am:. 12) pit). i'.'U. if, r.r.ri It-!!, A. 1:,; Himr.r 1 l':rvka.in.i of th.e here. !t i it. M. J. iT'd-ztS IS.1C. to I V- > if Ili.il. y {.!.' Cl*..;. . :'.hr :1. t;-.:i. ;1 !;.., ?''>. n h t. - -i -* i. *n cn-.:*l ..j 1!;. in: an-1 tr-r.H.d Mv-.'.ai: s. :>s-.-. i- ; ; -v . h t i* G c > j I iptf^w>T - j - ? - I' - *. ! .t* *' - *M ' 1 J* * ' ` - . * ' * n ;i ri x, r.s t -`Vt I!-' r '* ` *; ., a :- ii>: t!tn . 222 * i.xnrsiKi.ii. nn;u. \;: ,j.vn au'enn iox.ii. .ui-.nicixr. 'l`iir ptoent paper presents data mi possible exogenous faclurs other tobacco smoking that have been considered hy sonic writers In play a role in [|1(. induction <'f long cancer. Tin-4'.- data concern 1 lie urban and rural distributions :m<l th.c occupation-; of Imtjj-canccr patients. ft is dear that ail factors of irrit:<>ii-n must lie investio.atcd in order in determine which one or which jjrmip of factors, if attv, td.avs a rcs|"M:sible part. Uy comparing' the data of this paper with those of our previous publication, we may nedr whether lobaccu, and more particularly cqpircts. is a major factor or just one of many factors involved in the etiology of cancer <>i the hit'"4. v:f:i iH.fi >ti .*v Tlic present paper is based r.:i V?7 case* of p-mcd brouebiugi uii i aiviiiMiu.i. All of ip._. patients were individually mtcrvicwwl and data collected. This sur.ey included 7(71 males who had. epidermoid. undifferentiated, or unclassified l.rnurhii'geuic carcinoma, imhtdim; SI inter viewed in Humpy. The study also includes 4.1 stales who hid adenocarcinoma, as well as 54 teiiiales, of whom .12 had epidermoid or undifferentiated caninoiua and 22 arlenocarciuonia. l-'ur the comparative eialiutii n of the remits rega/ding the tishati and rural di-lrihntiutss of the patients, respectively, v.e give only tiic data from the Harncs Hospital Chest Srreice, Si. 1 i nis. For proper evaluation of the other data, similar Control studies would have to he made in eai.h section of the country. The size of the locality in which a given patient was placed depended on where lie had lived dm in;; most of his adult life. In the presentation of occupational data the Umg-canrer patients are compared with the patirnts laving other diseases of the chest seen at the lhirm-s Hospital Chest Service, l.th groups being of similar aj;c and economic distribution. These groups in turn are compared with the occupational groups of lung-canccr patients in hospital, elsewhere in the United States. To he placed in a given occupational category the patient must have winked in that job at least rive years anil within the last 40 yr. of his'life, li a given worker was employed in more than one major occupation, that occupation was selected in which he felt lie hail Inin exposed the most to irritative du-t or fumes. The orrupatinunt history taken includes all j,,hs that a given person had held in his lifetime. It attempted not merely to get the names of the occupations but to learn .the specific tasks that such job, involved with special consul,-ration of tho.c in which the patient was exposed In irritative substances. The search for such sub-.lances was extruded by questioning the patients about hobbies which might expos-.- them to irritative factors. . KF.SLT.TS ' Tobacco CoHsiwsj'lion of I'alicnts httcri-icxccJ.--Tltis report adds data on 12S additional cases of Imt" cancer to our previous data. Among tin- 7f>0 male patients (/O') American and 51 liuropeati) with proved epidermoid, undifferentiated, or 'unclassified bronehiugcnic carcinoma of the lungs there were l.-l'f nonsiuokcrs, 2.6'i liglit smokers, 9.7'/r moderately h.eavy smokers, 3l.9^e heavy smokers, ' 30.5^& excessive smokers, and JU.F'/h chain smokers.7 Tahir 1 shows the results broken doWtt into three imlepenilcm surveys, in all of which, however, the same ' questionnaire was used. Group A includes \(/> persons interviewed by nonmedical 7. Nun-nil.Vers were persons who smoked les than one cig.net per day for mine llun 20 yr.: light smokers, front one to nine rigarets |ht day for more than 20 yr.; modeiately heavy smokers, from 10 to 15 cigaret per day (-T mole than 20 yr.: heavy sufokers, from U> to 2d cigatets per day lor more than 20 yr.; excessive smokers, from 21 to 31 rigarets per day lor more than 20 yr.: chain smokers. 35 rigarets or more per day tor at feast 20 >r. Pipe and cigar smokers have been included by aibitiaiily counting one cigar as five rigarets and one pipeful a 2:' riuarits. . The term "agio smokers" used als've inch'dis minima! smokers, from 1 to 4 rigarets a da.' tor tl:e equivalent in pipe* or <igar~) for more than 20 yr. -- - t - r I: i >i i v ii *>i:r '<-. i * *i ! Ill aI-. it r c * *- Mu' \ :t < f I 1 1 l %.s fl n'YsnnR-GK.iu.iH--HKuxciuociiXic c.ixaxou.i ns investigators * at l'arncs Hospital, who did not know llie <!i:ij^iiosi< of any given c.i'f. in advance. Croup ]> includes those patients interviewed ami data collected hy one of ns (!'.. H. W.). Group C comprises the persons interviewed by other pin -iciansr' Group C includes 37 persons interviewed by Mr. John llnrrie, in Huidund.1" Ilonic's patients include 0.0% nunsmokers, 2.7% lignr smokers. 1S.9%> moderately heavy smokers, 37.8% heavy smokers. 2h3% excessive smokers, and 16.2% chain .smokers. - The 13 male patients with ndenoeareiuoma of the lung include 9.5% non smokers, 4.7% minimal smokers. 6.9% light smokers, 13.0'.' moderately heavy smokers, 39.5% heavy smokers. 9.3%, excessive smokers, and 16.3% chain smokers. .Mining the 52 female patients with epidermoid and undifferentiated carcinoma of T.m-ik I.-- PiaccrJege Dutrihuti. a of 7M Sf.ile Pe.iieuts with I'.pideriooiJ Unitifferentiulcd, or Unclassified Brimrhiogenie Carcinoma ehviio/fiiv to Tehaciv Consunied .-- Out ii Tzeeuty-Yenr Period* \ i ?rr**i|* A i.;; l.ii*M Mtinlvr* ................................................................. htvivy Mtiokcrs ................................... .. i( v v 1,1 f u j .*..1 Crr*nn u ini l.i: IIA v* * .-uitikirs ................................................................... ru I? 2 * K*r focipaiisuK to w.i< uro I-n-k.-u Into hur i:. ! TJn* n'lult* lu 1 :.* i..tniN,r in It** iJriHtp C iA 21.7 Total :ot 0.T 20.S which (he Takli: 2.-- Pereeu'tnge Distribution of -`OK f.uny-Cttncer Patients amt JtiK Patients nt'.'/i Other Diseases of the Chest front Hornes Hospital Chest Sorties, Both Groups of the Sattie elite and I'.eoiiamie Stotus Sin* uf f.<*-alit jr .7i/mi ............. . ],* ......... or tr**. Vann utrju* I'nlirpfK **> 1S.. II." ii/ !< r Hflh DUra*** f (*d*',*> 2K.II *.'.5 M..1 12.5 the Itmg- tln.-re are 45.7% nonsiwokers and 5.1% light smokers, with 53.1% liiing at k.i-t n.i..'eialt ly h'-tvv s o*;< <>. the 2.1 v..-i:. i n t.*, i.;,,- ... % tlie.lii .-_- e Ti^i: . l! r r I.i;;T: V *> : gi.'.- ihr'wj; A'/>/.i/(lion rj /".//a itt.s,- 'I be locality d:s;r;h:!< ion of 2tX) lung- e.mar puients and 2t;0 patiii.is with other chest disca--. hot!-, groups from the Iliii,'.' 1 Iii-pit.:! f.lie-t SiTiiir and foth ot tic -ante .age and economic lain-, are show m jo Tahir 2. ' 1'. tty <1 I'oit.-i. P A . It. ll......M \. *' 'r. 1'.. J i ' a '! ' U. I. i;i\ i v - I t... :t ii.*-. .'..T; t. | t , S. I \[. > J vn ! c -:..i::r>!i\ 1 I : -; i'.i! . i >i I I. A.'.r . .' o..:, :. ] j. ; a. : i , t.. pi ; | J,-. ( . T. 1 -T'. I vie V. ' ('.: 11. i. i,* v*. I i - j.:: !. t 'ii*' ! ; ! >c II. 1. a'c.- . it i i i :\ ;! a ,!. ,i, | ...ii. '. ,, lc : r. i In.'; lVc.,,1. i- i-t.ait -ai < :i S!-.!. i i i ;. - lu-isi ,i t:- : ,,i Sl,..t!i\ f.ii.t-.-v. ` t h Zi r* / -.JT * 1/ t' * Jv u c . ,, f tkv. ; r* l* 1 -4 ; i r -*t ti ! f, l y .*. * r-i ! iv*. ** u ^ i '. 1 -M .f ;1 t Stilt ;.'tk ;:! cs r i* |i .*.":luv rh^i; |]*,,.t i* m (!.i(.:t l;\ Mr. |<T*jitu* C/;i nl'ti-li! cliiri 'i tlu* Tv1':.-''..'Lrcii Stwlics I nit. I'.!'nn'iric Sf'Cii'm, N'alinii.il Cunivr Iti-iitnri- 1 At.i.i: *' /'./'/*i:/.s C7ii\/ /;uiii.rrj p:.< /\i.'iY*r : *;//: f #;7:Tvrrii.'M.Vi/, or ( l.inio C*mccrt of !'.iri`,'S I-vrl!.,: ill;,/ ()/;.vr f :::.v7 Vm.Vj Ji\V MY/V Ai7i.\'v7 rf A co.'iw- /. /Ai;v /Vyj /;.:f 'Jni It* /m/7j.\w m7 V*r / ffiu/i V/if'i"-' f*'iiil:i! I ).r*l >i*:x ;.r ...... . ft* * Otli* : T'i;i I.-.'./ Ii *-r. 1 .i: - f. tWvtV.K .Tot-! tr. S. ('ittu 'r. Cut.ri r - !' ' -f * f-/i u..'.r....... (. ill.I >!.*? 1; ....... Atitomol.il- jj.-ctjtjnk*... ................... lUilrir iit wfi-k.*f............ i 'otxtr.trttoa t*..rk*r... FlriM.un.......................... Tnitk lr:-.rf..................................... Twllor....................................................................... Omi.l*! v*or>r...................................................... r*iiiinl***r.................................................................. *ork-r..................................................... L**.n1 m!ri-f............................................................ lukvr.......................................................................................................................................... .Uniter.................................................................... hriniff..................................................................... iarl-:w................................................................. *uMr vj. .............................................. .Inttl:ni.ji................................................................ ('util ir::rif ''r;i <*r................................................ Stntftirmry ........................................... It*i-rinj; e:'.'.r.-*r................................................ I'llJiCr M.U.T.......................................................... ItnoV .Jilll-r.......................................................... Quarry u.o.r.k..v.:.................................................................................. I(uiltir:i>f -rif............... ........................... <`il trt.cV IrY.-r............... *................................... tinvliti? mi-! (:! hitinller.................................. w:k-f.................................................... l*.u k- r...................................................................... A'i iM'.** \w*rk*`f.................................................. Wl.*ihi.v*u:*.,!.-...................................................................... rvlt'f <*rk-r.................................................... firm* !-rl<................................................ 'fltrr................................................ m* rr*|-r...................................................... Motor itl.................................................... ....................................... Stilf.iav rn 'i'*............................................ fftY'-'t-ir....................................... Kffriu*.Ta;*-r ffp.iin.*J*................................... U;m? lilux;.......................................................... *. i.r. I In 0,. I*.:* i.`* ? i 0-*. s.i* - ft.l* l.n I. 1.** IJ' (I *i .ft II.41 f'.ft fll* r.i ii n o.* ift./:. i*.' n.i* f*.:. C.ft M." ll.M ft.ll I *I.M III On ft.o (Ml II I* Oil l*.i !.( it 3 ft ;i J." '.'.ft S..'* * I.M 2.(` *.\i* 2.:* *.t a.ft ft.*. to l.o l.ft ft.:. o *. d.ft t.o ft .* ft.'. ft.:. ft.M O.ft ii.;. o.:. ii.*> O.ft ft. ft.M ft.O ft.ft ft 11 ft.o ft.n ft.ft O.i ft.ft ft." ft.ft 0.0 .r; lift * i; .:* j.s !> 2 t 1> 2.ft . 1" 1.2 !.! i.r, fftt.ttf 0.4 ft.n i.o (.< >.i; ft.i: o.* o> O.ti v.f, 0.1 0.4 ft.l ft.4 ft.l 0.4 0.1 0.2 O.ft ft.O 0.? 02 0.2 ft1! . ft.2 ft.2 ft.2 0.2 0.2 ' 0.2 ft.ft . o.ft U.ft iia.ri rn ;; <1 2.!* 2 Jot 20 1 *s l* If, 1J t.-t 1.3 1.3 1.1 O.ft ft/' O.ft ft ! 0.7 0.7 0.7 ft.7 M ft.l ft.l ft.l ft.4 0.4 0.3 ft.l 0.2 0.2 0.1 0.1 0.1 01 ft.l 0.1 ft.l 0.1 0.1 01 ft.l 0.1 0.1 fU 0.1 ft.O 0.0 V.i*^i y.> rcvi-nlcd "jui vvitcmaiic >t;aitic:i!ly dilTtrcncc" ill locality dislrilitnkm lifiwem the hinjj-canccr patients and the other du-st-disease patients. Oi the remainder of t!;e 507 American htn^-eancer patients with epidermoid, undifferentiated or unclassified tanccrs. lived in fartn areas and in cities with 10O.C00 or more iHvpulation. Of the -Id male patients with aden->earci- tiomu, 9.3f< lived in farm areas and 53.5^* eame from cities with a population of 1irlll, < anil , w\ . i- If V\OHIO (ill. III. I.\I-- i11\ O\X1! 1 <JC!i\I( C. Ih'ClXO V. I >>; Iffl/i t) or more. Of ihi* 32 fcm.ile pr.tifiits with epi'h nnnid or undilVrrtiHiiited !up" i'iih'jit*. rm*l llu: 22 lvmal*j patients with aflenoearciiioina, I2.5^r an<l 18.2^, respec tively. vaiiic irom larut areas and (>5fi'c at.-d 54.5% eauie froat cities witlt a popula tion ]t\*.0C0 or niore. Data frrtm t!.e United States Census ilureaa sltow that in April. I'MIt, the' total civilian population living on farms amounted to lft.0%.!1 and. preliminary data 'how licit in 11*50 29.3% of the American population lived in cities of 100.000 or more.15 Taiii e J.-- Pereenlare Oeei'/alitatal Dis!rU"it:nn af Me.le Patten's with Chest Diseases and Me.le Patients teith li/iilennnui. (Xulincrenlie.ted. nr l'nelarsif:e:l l.nn-i Careers of Harnett Jlns/ita! ami Other [ititeJ Stales Itas/itnls ll'ha Were I'elie'eeJ Xot ta llaee lleen F..rf>oteJ In Irritative Dn.it am!/nr l::tu:es It;- mo* 1 f fI .tl 4. VI N-Iv'n* ot i l.-- r other T'mft I.iut *'.:r.ivr, Vc-I Ii:`JU.......................... ......................... I... i.:. l>'u*r r. s. .**0 . .r \\ r ,i..; V. S. I'iir.vr Ce'l 3.2 '-- ........................ ......................... ........ iilrtll.................................................. ......................... ........................ 1 ..t!. r............................ !.n |M 0.0 It', Ivitv. \**r......................... ......................... 01 thj 1.2 l.rt o.'i * 0> l.o . 1.0 rt.'i fl ii I'.'I tl I* l.o M 1 o.<; ot o.l i'll O I IT!--t.............................. . i> O.i . . (.ft * . > ... A ; . ........ t. ,f ' . m ;t M O.'l 1, ; ** ln\ 1 < * ll'l *. 11" M l ll.ll 0.0 1.0 l.o 1o O.T U.I o.7 0,3 O.j ti.;, O.l r o.l o.l <t ; .i i O o.'l I.V" . 30* V Y:r rt ,1 cI 4* +S ; t. -J 'K r-- l i, v t r* ?.*; --\ / iV/vi.M /.'!> ('n> ; I hr ;'!'vut' v. '..l ' 1* 1 ' ' * ,;! * * * > * * * .*, r: c u ! < ` >! ; a *. < ! t11!' .!u* '.ui l I ;iL* i f * l * Vli1 \. -r *^. *" * 1 1 ! p : ii' u r .ii | t >. *i . | : :*r:t;:tTc l : '* * . ''* ` "i' I 1 .i' \ .i * ''' ' ' i * 1 l* i I.:* v* 1 -> i*\ i* \ ^ 1 t* mi. Ii . i:! t1 r* : ' !r* V l * U' <- < ,rl I* (. \ J <! i> > (!.i|!\' cm *'.i i1:i( { [ ,Jm* t ). * l *- ! ; i i* . i!. * !'.:* *m. ..i > . \ I * ;'.! it; *it I.\ . 1. > t i** i* ./), N*v J`\ laii'Hi. 1 11 ^ i ^ Ii to i, I* l, \n. S. , '- : - '1 t! -I D V5 it Ji ip-' < sr u; v* .. ' .. ....... ,\i-. ,i.\ n (. l (//// ix.u. \innra.\h. I'ii'n dillere-nt mwere j .1 s.nlti! in ( t' .i: j > ,\ ;i i;-I 36 in f i r. .1: j> |: liil.ilm-.; Si 1 iK'tup.itiinix i"`:si:ri among `A>'> AmttIc.ui 1 ::iK- lung-c.mcir ji;icit-:tl>. Group A: Three h-mrhcil ;ni(l niiutv -of the tn(:i! tmmlu r of American male lung ia:!ai' |>mii-m^ fn'l i; 11 > Group \ (5V! ). I lir Iktnus luug-camcr pntivn'M i-l:i-w .1 p.rcent.Lgf '>1 5'*.5 in li'.v. group, cuinn.ued u i;ii 15 0% of (lie li.iim's patients v\ ill: ii`.iiii-:imvr el.cr-: !>-. Tin.- hr4Ii<-occupational iueiiknee in Group A is licit uf painter* i0.1%). Thete ;ir< .VS1/! Imt-metal workers :iiii| 4.S%- nth-.-r '>\r un t il u nrlu:*. Among those exposed to hot metal arc 27 foundry and steel-mil! workers, 0 welders. 5 smelters, and j Idark.iinithv Among lie- ml it nteg-d wo/l-vrs arc 2! mar!.isn't';. `! *-!:c<-r "i ii cr-. i ,r:u';-T-. a::-! 2 n .-..si ;-'T r- 1 ) 'i>r.i me!-.'-;). AThfn-nil workers v. hu mac he e.\| .used to some* mein!' arc electricians (l.S/t,). plumbers (1.1 e/r). lead miner-; (U.9% ;, and printers. (0.7'1 ) ; automobile mechanics t<nnl 3.2%,. Other worker.' who had hcen exposed to gasoline and c>il fumes i;icliut- oil-lieM workers (1-3%). garage 'workers (0.9%). and oil-trnck drivers, and gn.o- lme-aiid-oil handlers (0.1 'r caeli). A higlier-tlia.ii-avcrage gasoline-fume exposure may also invoke chauffeur* (2.5% ) and I ruck dr ivers (1 />% ). Carpetitc-rs (2.r>% ) and eahinet makers (0.9% ) are expired to wood dust. The latter art also exposed to varnish. One packer (0.1'0 ) was exposed 10 wood dust (excelsior). Group )!: There are 319 American male lung-cancer patients whose liistmirs reveal no significant known or suspected inhalation of irritative dusts or fume* (45.0%,). In the T.arnes lung-canccr subgroup -10.5% are in Group 1! and in the control I'.arnes chest subgroup 55.5%. The occupation* with a high percentage in Group I! are those which have a high percentage among the general population, as may he seen from the L'.arues chest control group. In the total United States cancer group there arc 0.9% clerks. 6.5%. farmers and rancheis, 5.5% executives, 5.4% salesmen, and 3.2% merchants. Physicians make up 1.0% of the total group. Statistical Analysis of the (Iccupatioual Incidence: The statistical analysis of these data teas also carried out hy .Mr. Cornfield. He concludes: Clii-Mliiare computed inr .ill '0 nccupatiuris having at least one patient ill the llarucs Hospital group was (.0. somewhat less than the expectation of <>5, and co;i;i:i|'.:ei:tly not significant. The only n np.itimi. con.-iiliTed hy il>eli, which o:cu. red with siguilicnntiy higher iTeipi- ncy among the caneer group was th.it <: painter. The' probability 01 obtaining at leas! a* large a positive difference as that nb-erved was 0.01. This calculation docs lie't lake iiltn account, h-iwever. the iart that painter.' were .'elected lor a .significance te-st because they 'lmwed Uc largest difference between the cancer and ixincanecr ltarncs Ilospilal suligr-eips. When allowance is made ior ll:e fact that 17 occupations could have shown at lead tilts large- a difference-, the probability i> iuerensed in over O.ln. In eon-dpience, the itifTerence oh-erved lor pair.ters is 110 larger than the 'arge-'t diffeieiice that entild have been obse-rved ill a series of this sire if no difference in fact existed. When all workers handling metals are combined, a higher percentage is observed among the etutcer patients than among the other chest disease patient'. A positive difii renee. of tiemagnitude cmdd have eipiahd or exceeded bv chance alone tue times out of lllli (/ is (l.ll.'.'i. A similar eon.siderctio:! of all workers \|*i-cd to oil and gasoline fumes yield' a posifier differeiiee that could have Keu ei|-i,d-.-I or exceeded by elnr.ee alone 10 times in 1(U! (/ i' 0.10). In summary, while there are several suggestive tehiti -iishii there is no decisive statistical evidence- that any of the' occupaiious itudied *jceurs wil!i greater iivipa u. y among the- cancer patients than among the other ehel di-ease patient- oi the I'.anV' Mo ; !t:d. AAV roup l!. VlltS. . in male patients I <-'iticnl> up A is ! other used to . ami .1 et-melal litioual umbels es total include I piSO' -posurc I*i IK'S in the u\\*y in ion, a< ocuuvr - ; M * ms of !')>?. ll . The HU'ju'v -.irt;e a * M|*ll. ..1 It:.- t t'*U' i*h* 1 |1Ux ' ' 1 . 1 ' * ir\'XniiN-CK.Ill.-I.U--HiiO.\'CI!IO<:iiX[C C.lh-axov.l 227 liitrnj-can Pula. -- Fifty-one patients v.cre interviewed in Europe (43 in Eng land and eight in Franco). Thirty-seven of these were interviewed lie Mr. Iconic, who obviated most of In's subjects from a highly industrial region. Thirty-one of liu: Europeans (60.S'/*,) had been exposed to some known or suspected dust and-'or tunics. Among ibcm were seven miners, six liot-mela! workers, four electrical engineers, three carpenters, two metal workers, two automobile mechanics, two chautfciirs, one rock laborer, one baker, one painter, one railroad worker, and one shoe repairer. The remainder (.Vt.2(r ). with no known or suspected occupational exposures, included six clerks, three merchants, two executives, two salesmen, two fanners, one photographer, one ship captain, one merchant, one dairyman, and one general laborer. Xonsntokcrs aiul Minimal Smokers.--Among the 7(.0 males presenting epider moid, undifferentiated, and iinclas^ified hrouchiogeiiic huig cancers there were IS iKHiMiiokers or minimal smokers. Their occupation distribution lias been tabulated in Table 5. , T s. --Occiifiiti.wtil Disliiiiiitinn of /fey.V'.Yii Male 1`iilienl.t '.i'.h l'./<:,l>n,ioiJ t.'i...!ir,ri-r'I.i.Vi/, ir I'lul.isiijirrl Hr/unhi-nonir Carei;u.uii.t. Who l/'V;v Hither X or.urohert nr Miiiuin.il Smokers innl*,r* ............................................................................. 3 ruich'M ........................................................................................................ J Hot wurt.vrji.................................................................................... liit-o!;;ie :tnt :! umkar<i........................................................,............................... Ki:\*wt'**r (imM:>i) ......................................................................................... \ ShM*t:ti*ki*r ................................................................................................... l rnijliwr .................................................................................... I lintrf ........................................................................................... 1 ............................................................................................. X SaV-'ittaii ..........................................................................................................1 Aivour-timt ........................................................................................................................ | I.hM'T ............................................................................................ 1 Nt^v^loiv ...................................................................................................... 1 Among the 11 nonsmokers two patients, a lawyer and an accountant, gave no history of having been exposed to known or suspected exogenous irritants. Among ti.e seven minimal smokers were two patients with no such exposures, a salesman anti a stevedore. lli.-toiiet ,.f Orcufiiliiuiitl F.xfosmes of Xoasiookei t.. I. K. J., a >v!me nc.ii, with ir.fut> rt!t m r*v;:!t tv^rr-M**' r ..i 'Vu j-.', VJ. Hv !:v vt it1 i. *:, .t1 *.* i. i*t* v'- it i*l *:. .!?* ! ' . :.v , i ; -..i i.-.i s- . . |,U!' I- . i .v ii., I ih tt'i nul :|*ivy ifiitv S I* . a wh!;** in.*ii, )', with an \ i-?i ,;i i iSr JcU I. i i* .`.v I: i V1 'i y m i;< vi Imijf !*<.''t-*. ff<' !':: 'im-I m I.-.itM citirx mjt ii h;-. !;:V. I ivm * !.. yi. 'I lit" . ]*.t::iUr, \Mjir>iut! iT.* Ty u .1.I ft* um ! ^ t.,*: I *t .1 !!.i* .,.* is: !'t;l Si no- th; t iii'st >*. *! -fc t -. : c t * ri :./* i* r* i;. :: a :.*?.* u-.i " 1* Mi> i tv<! 4.* *! t rf-,. -.:Iul I-* : ;: . t u v !.! i. .[ i .t -I 1 ' -J' t: .* tv "11 r. : :! i.y '|. (J. i::.r \. r. i',: U*-; *.!. k I h i */ ( i i. - ^ r* * X ~T> >K itv<;ii:\i-. .1 x/> oicrr.iuux.u. Miumixn -i. !!. H.r a wlihc in.ni, 72, v.hh t: e.i;mm i.t thi 1.; hi of the mi Ml-.- upper lobes of liit.' light lung. |'.m- a hi-p.ry of ir)vtitm>t.::i (1925) and rvpt. ti-il l.'iv r.i influi iva. lit lived i;i a rural oummuiity i:i Missouri. 1'r-iji 1911 to 1957 In; had In.n , IiI.k k -l 11 -vd to I.'il she! fim'-. .v.:d v>::l !>:!.. Suae tl at lime lit had hecii :i buyer hid. ', wools, ;ii ! 1'ir- with no speii!":.- exposures. 5. I.. \.. ;i white m.iii. 57. uidi <i:--ciII cuciiiomn of the right middle-hJit bioiicl,K. lived in a. town of .-.bo1 mniulal lit had Keen ;i ii'.riiHT until lie was 37 yr. oh'. After that he drove ;t gasoline truck fur 1J vr, IJ> r:n;_j tin. hitter period In. exposed to va-hne fumes. He stated tli..l on two occasion, lead *oni:iK developed. Attcr tl:e la-t ; tl.'.cV he left ihe joh amt liccamc street commissioner, with no futthci specific /coupatiiund exp.'-t: res. <. C. h a Y.bil" man. v.it'i ..u s:r:. ' J r- : -.i "t the light i;|mt 'o' .'.if. h:u'c:o.i ii. !l. If-- lived h, a 1 of -i. emu: !9o. I'1 i J he d._!i. et ,(| oh amt gs'oime to mighhoring farm areas., I:t some instances lie delivered the oil i.i l.r.rreU. le t in many cases hi had to transfer the oil front the barrels to iivi'iiiaitviit container- by m'-sus r,i a crude [.1111;;!. He also bandied the gas station of his father's general store. I'runt i/it to 19-17 he merely operated toe store, am! from 1947 to 1949 he tliil no particular work. 1'iom Oetoher 19!'/ to May 1950 he was an oil-tank driver. 7. C. (.. :t v.hite loan, 59, with a squanioits-rcK carcinoma tit the tight lower-ioiie bronchus, lived in I.o> Angeles and pave no history of previous lm:g diseases. Throughout his adult lif-- he had keen a cahioct maker. In this (eeupatinn he was ex|K>'cd to saw iltisl as well a- to vruni.li ami rvcasiomd paints. h. C. R.. a white man. 55, with a stiaamnti--cell earcinoma of the right upper lolie. lived ill a town of 50.1X10. He pave no history of previous lung diseases. He had been a telephone engineer and hail not undergone any occupational exposures. However, he raised Mowers as a liohhy. In l!ii> eoimeelioii he had lieen exposed to a variety of insecticide sprays for the past 14 yr. These ii.elndrd priitiarily l.erosctte.. nicotine, and arsenical spra.. s. Might years prinr the development of symptoms of lung tumor, tiic patient noted the appearance of multiple skin tumors our the extremities and the trunk. These turners were shown to he lieliii'.n ha-.dcell epitheliomas. No determination of the arsenic content of these tumors was made. The lesion ni the lung was regarded as a primary epidermoid eareiiMiua 'I lie patient never tied a mask while spraying. 9. II. H., a white man. 72, with a *<;i:a:i:ou--cell carcinoma of the right upper lobe. li-.e.I ia a small village in Missouri, lie had pneumonia in 1919. In 1927 he fractured his lower ribs tCa..- bilaterally. He. h id hccii an accountant, with no occupational exposures. AUmt once a yi.ir during the seven years prior to the interview he had sprayed his flow its with nicotine. 10. 1*. S.. a white man. 52. with an undifferentiated caiciiioma of the lcii huig. lived in Cleveland. There is im history of previous lung diseases. In his youth the patient had worked lor cieht years in newspaper plants where, la: staled, lie was cx;a>'ed to excessive paper dust, .since !f,23 he had practised law. with no further history of -'c'n;t11 m` huhby exposin' s."1 11. T. S., a white man, X'l. with a stpumous-cell eareitu'tiia of the left lowcr-lohc hrrmclm.;. lived in New York ami gave no history of previous Imig disease. He had liven a sail maker and canvas rigger hy trade. During the war vents lie vvnrkid iti a joh where he had in cover pipes with asbestos.' " ' ''sltit'iiocarciiwut,: in Males.--.Amr.iijj the- -5.1 iivtle I'atients with adcitoearc-iiioiiiu of the Itttios are 22 with known or .su>|itTled M'ctij)ritt<ui:il ihi-! or funte extiosiwex (51.2^c): three h'd-iiictn! worker- toller.), two ]'aiiUi-rs, two'chaulTettrs. iw-' trvwl: drivers, and two railroad winkers (-1.7'/ i-aehj; the ;gvmip also iiwltule- a Diesel-engine driver, a shoe-factory worker, a hi;:.her-mi!l worker, a tailor, a 14. This case was contributed hy Dr. C. T. Suringh-'i. Ciile Veterans lhispital, Cleveland 15. Tis case was Contiil-ut-.d !*y l-'r. ii. (. 'liutier, Ct'tuuihia (.ties* Service. Iltnleoir lh -pital. New York. - j. i a*.ui.iM--twoxi uiou-sic c.iucixnu.t >ij !.t*fKci-. ;i gas-station attendant, ;i construction worker, :i long-ln iremau. a hakcr, a tn.i'Oii, and a plumber (2.3/fc each). Among tlic patients with no suspected occupational exposures (4>\.S;<) are four executives nfid lour clerks (9Ar/n each), tliree salesmen an<l three farmers ('i.'.''' each), and a pnolrooni operator, an army officer, a draftsman, a collector, a pli\>ician, a minister, and an editor (2..V/c each). . The four nou-innhcrs are a 3 l-year-nld clerk, a 50-year-"ld jeweler. :e 73-year- old minister, and a 59-year-old merchant. The tw o minimal smokers are a fo-year-" Id tanner and a CO-year-old truck elriver. .Amour; these six patients only the truck driver had souse occupational exposure. The jeweler wmked cltielly in the executive hr.mcli of his profession. Two of the. nonsmokers (the jeweler and the merchant) had terminal hronchiolar carcinoma. lil'ulcnuoul Carcinoma in If'omcn.--Anion" IS women with a smoking history are six- with some occupational exposure (3.i.3^b): a cigar-factory worker, a weaver, a gunpowder-factory winker, a laundry worker, a shoe-factory worker, and a seam.slrcss. The other 12 patients include live housewives, three clerks, two salesgirls. one waitress, and one writer. The sl.oc-faclmy worker was exposed to leather dusts Imt not to dyes. The cigar-factory worker had liven a heavy smoker for many years. .. I l.c 12 nonsmokers include six housewives, two clerks and a secretary, a teacher, a weaver, and a .seamstress. Adenocarcinoma in li'onmt.--Among the 22 patients in this group, which includes two light smokers, there are two women with s nne occupational exposure, one an egg-case maker and one a shoe assembler. Among the remainder are 13 Iio.im-w ices, including three, fanners' wives, three eierks. two sale-girls, and one stenographer. ' Hide nf Locality.--In general an cvaluation of locality distribution depends largely oif the locality of the hospital at which the patients arc seen. The patients at I kit net Hospital come from many widely separated cities and rural communities, UHI-.1 of which are in the Midwest and Southwest. The data from Karev- Hospital seem to indicate that city life plays no significant role in the induction of primnrv carcinoma of the lung. The remaining locality data -how a suggesti\e higher iie.juency of lung cancer among city patients. This, however, may l;e at least partly due to the fact that this survey lias liven conducted primarily in hospitals j;> large 11 iii*.:. Ilritisli .studies have indicated a hig her ine'ideuee of lung cnik'v.r iti :.r city I'oi'uk.t ion In this :uvtk:i V.C puj.s* CO'lsidli- llv t eit-. 1 . .1 1 . 1 1 ... .11 1 !. igc ho: j * \\ Ik*J,v i . *. ii-r '.iivau- >! iti..::;;i'- i : <. . 1 -m.'. 1 )i:r l .1 111. u role oat the po* sihiliiy, however, ik. at city hie pk :y:- 1-.1 ri i:i t'l.i* :r.i AW\l 'll III!.- cancer in iu.!i\ Mua! 0>]j-s-eial! v in vii w ot the fact llu:t ihy .!i iil> rit low n expel mici: h> Ik* \U` il.ly . arcin' 'gvnv.1 Vvl. ci'y !iiV. tn V*. v;i e>.].o-ed a-. Ilk M, (. oul.l no! e\| 1 tin il:e gre.i-e r *:v itViUt; ( i !i:ny V.l ik i r a'uniig men. * , V * - I.-. 1 : 1 i .*111*' a. \. ; 1 11 ..f 1 ! til e.i-'l ! l.e. in Ci.- I (*:.t is . : l ` ' l Si'i : - . t. . 1: : 1. v 1 1; 1 ' '!!. ). V 1'. e.. 11 1 S' i:l 1 . 1 . . ... !*;'. , ..1 !* ,r \ ! : . ! i 1 to ! l i .1 1 ..| 1,. i . !- 1 1 it- t !` i i ' ! i.r ;: t : . .' .i- I `. \ s! m l! ' * i:.` *: r.i n ; t I ii't nil**' ! I 1 <v( !' i ' ti. V , !'!.1, I *v .,1 1 V f* u: t* / C* r((.ir.m<>.\.u. mi-hu is a _ AV.V u/ Ofv;r/V/i'/>u.~-W j:|i rf.-'j> l!if lung,. ihr c!::<,ic reports are llto-.c based on tin: Sclr.:; cir.-ig " and Jn;n.liim.,l::l i:i:i.v.-j . ''' Marble and (irog'>: ius. in Ihi., country, lane the high it ifidrnce o; king cancer ami.u;.. idir.- mate workers,while Lynch and Smith -" found carcinoma of the Inn;; more commonly than expected among wnrkt rs exposed to a?hr.-to.;, fn r.ngltmd I'.rad- lord, iiiil and his co-vnrkcr, have ptesetitcd good evidence that lung cancer is higher among ar>cni(.a! workers than among the general population. Antony tin; occupational hazards possible expo,mg the worker to carebiogenic. sub,lance, J Ie.ctcr lists t;:r fume, mineral-oil mi-ds. chromium dusts, wirkel-carbouyl vapors, arsenic de.-ls ar.d fumes, ashe'los dust, isopiopyl-oi! vapors, aur! radmaclive gases and du.'t.-1- Mr.ell'T :i felt that lead may he carcinogenic in the lungs. The increase of the incidence of lung cancer has been too universal to he explained by any or by all of the above-mentioned exposures. This conclusion was also reached by the Kcmiawavs."1 vlto. alter studying the death certi'icatr, of all lung-cancer patients dying in Kuglaud and W ales from 1921 to IbMS. stated, "No special occupation, have been found among the C>3 examined tu which the increase in the total number of cases of cancer of the lung could lie attributed." Most oi the industries so far emphasized in the literature as having a high incidence of lung cancer arc limited to a small group of people, so that they would not appear signifi cant in a countrywide survey oi lung-cancer incidence. It is not surprising, therefore, that these occupations do not stand in the foreground in our results. As 86 ditferem occupations have been encountered among patients with, cancer of the lungs, indeed a good cro,s section of occupation, generally found in this connItv, it appear., clear that a statistical evaluation oi each given occupation would net show very significant results. The data, however, are suggestive that certain occupations cxjif.se the worker to cancer-inducing substances. The occupations most suggestive in this regard arc those that fulfill the follow ing riiicria: 1. The occupation should have a markedly higher incidence, among lung-canccr patients than among other patients. 2. The occupations must have a IS. Ko-to.-ki. Sailin', aait Smnrl: I.'ic Pcryl.raukhvit der Hr/bcruleute i'.i Sflmccheri' in Savli-iii. '/.l-chr. Kreiwiur'di. 23:110 1S4, 1920. It/. I'iicliaii. A., and Sikl, H.: C'anter uf the l.ung in the Miners of J.'iclnmov, Am. J. Cancer lf>:',SI-722 (July) 1912. ' 2d. MatFle, \V, and Crcjtniiii.,. I'.: Cniircr of Kopir.itury System in V. S, Chrom.itrI'r.iduciiig Industry, rule llejllii Kt-ji. C3:1111-1127 (Any. 27) 19-18. 21. f.vi'.ch, K. If, and Smith. IV. A.: Pulmonary Ashc-to.-is: Iff. Carcinoma of the I .liny in Asbestos-Silicosis, Am. .1. Cancer 2):?6-f>4 (May) 19.il. 22. Hill, C. A, and others: Studies i:i Incidence of Cancer in Factories Handling Inorganic Compounds oi Ar entc. Mortality F.v.ieriviiie in Factory: Clinical and F'nviroiunrntal lntestigati..n. Itrit. J. Indust. Med. S; 1-15 (Jan.l 19IS. 21. 1 flicker, W. C.: A Melhial-for l.neir.ii'inent.r: .miJ O;cui>ational Canter Survey. Technical M"imyra|!i Xc*. 1. Fhdtral Security Ayeuey, hup,,! Slat*-, l'uFFc Health Serie.e. 1942; Occupational Tumors and .\I>i-..1 1 >b.t'e.<cs. Siuinyueld. III. CF.arle, C Thomas, ruhlisher, 1942; personal iaiiimiuiiicali.>n to the author.,. 24. Mueller, F'. If.: Tahaloiii^'Siranch mid l.iinja-i.aieinor.i, Zteehr. !\reF,inisvh. -ll:?/ S;, PoV-. 21. Kemiawav. N. M, and kt:maw..>. F. I..: A Sle.dv oi l*u luci.F.-n.e oi ('aneer of t : Lu iy :c.d J. b..!u,i. l!>c. 10;.'.7 tjulyl lvlou Uen.ua-,y. A I'mther Study oi the I:-, ill. nee : the hunt; and baiyns. l'.rit. J C.usvr X:.'o,I 2'-:S i.Se|.: ) l'i!7. > Ml * ! I, * 1 M -1 r .el i ix till- M'V. I .rx 1.1* l' n > *! N*. .IM` Ml^ till tv. hi > i\ 'U' \* tilt :i ll'VXnfiK-Glt.ULlU--rkOXClIlOiJIiXtC cVi: iXoH.l 2.U li::;li-.f than expected incidence aiiiur." tin- total numher u: cases of hux; e.'.ucer. 3. The oecti[>alioii should In' found aiiiM!;.; those htnp'v.auaT ] : touts who have heat cither uotisninkers or minima! smokers. It seem.-. that if a u>v. n neeupr.;i"U qualifies i,ii all ;IiTli- points, "nod ciraniistat.t'.il evidence '.'.a* lict-n emahlislud that this par ticular occupation exposes the Worker to substances that arc eatcii!.r_rciiic. The tlir-e occupations tliat stand out in litis rc;;rud are those c.\posir,k' tl-.f: weaker to hoi-melal fumes and metal dust, to [trout, and to lubricating .ils and uau.-nline fumes. The occupations occurring with greatest f'cijurnev were those in which workers were exposed to metal fumes or dust, fn of the hmjj-cr.a.rcr patients. inhalation of hot-metal fumes was noted, and 5.5r/c were exposed to cold in. One n.at- stinker had a lifclon;; exposure to hot-met,-d fumes as a smelter. anil ..uc had hten a blacksmith for 17 rears. * i Tlte data oti painters seem particulaily striking. A mono -1.1 painters (fi.1%) there were two nousmokers. Alton: iaie-h.alf of the painters used spray ^ttts. They all mixed their own paints. Cabinet makers with exposure- to varni-li and some paint, as well as to wood dit-a, may fall into a similar occupational rr.te;.'orv. (t is initewott!tv that in spile of the comparative rarity of this occupation wc found one hominukcr and two minimal smokers with lun^' cancer atnono cr.hir.c: makers. Automobile mechanics (.5.2^1) arc cx]>oscd to a variety of irritative fv.m.is, includit:^' tli- .se from j;n<oliue, wchliuq. and luhiicatiuo oils. The fact that otte nonstuoker with htttjj cancer was a gasoline-and oil handler, and tl'at mother irv.mtohcr laid been an oil-tank truck driver, lends suspicion to a po^.ible ti.rcittoj'ciri: imtucttcc of the inhalation of gasoline and oil fumes. In one worker exposed to a.-boros no cvidcttci: ot ashestosis could be established. Xu chromate workers were encountered in this survey. Mueller21 has recorded a hilts' cancer that occurred it: a chromate winker who was a iiotisntoker. Of special si"iiil*'V.;:ee may l..- arsenic exposure of workers. Smelt in:; w orkers are exposed to serine arsenic, J-'.-ttr of 25 patients with hint: cancer seen in L'lalt were snicIsiiiT workers. These workers, however, are also exposed to hot-metal liuttes and metal dust. One tiottsinol.er had been exposed to arsenical insecticide. Xo others uere encountered who had underline excessive exjtosure to arsenical inseeticides. It must lie considered. however, that must hint;-cancer patients have hcen exposed to arsenic, because of its presence in ciyaret paper and because tobacco itself is sprayed with arscr.ic.il insecticides during its period of growth. (If some .significance may be carpenters > !.'?'"< ) : ib.e-v. like cabinet makers, are exposed to wood'dust. 1 here arc some other occupations that set-.n to .appear i... "c freo.a : t!v amon:; hiinj-c.uvcr rases which have Ihxmi listed previously. It seen;.- e-vidif.t that because ol tlii ir relative specialization. the hmy-cancrr ineidenee of the.-e occuptr- ns can he Sr:liy a [ pi t ei.iled oulv hv n survey ;\ IU`- 12 ^ Vankers, th .ectl'.c ittdtts- triv';. (): A.a fnimi.!/ <u atpfill inns! .S' i * ' ,V V'.- lit - add v: 1 ' ' a ] a -- a uk, i i: 11 . **t \ < 11 , . r. ! v.-i'u 1*7 ; :.ti- nts 1 \'V 11 i" V n cat tied i \W. Mi si of ; n. j!i' ' t. cot ds. T!hi 111":! ex't t.s i. v .' t hem !.: v ' ' >/ V. i ;i i 1 e*. U \ II '" upatim 2 ' .1 ?.ii.5 r* tr! V,. .i!o, CO*. IT! m; S' . | re -d l;a i it i r.. h'k . . ^ ;r. :] s. the IS. 1 1 ' Ma*, av - ; ' 11 ia ? *i .V t a ! .1 fc J i~I V*i / ( I 1 Q i.- t -i rn vr ^ t`^-1 e'l *-U ., -T - i t ! 1 j I ) ixin.siki.u nrcir.xr. ,i\n ihst/'.ir/ox.u. M/:/>/<fx/-: ratio of rcgL'nivd to K/) calculated <'- ii!i-. 2 lla-l-fm n.cc nun (`ratio (if \ 4.57 motor drivers (ratio of 14`>), 94 c.i'niuel toal.i is (ratio of 147), and -V"i painters (ratio of 129). Tlicir highest ratio is that of fuel worhcMs willi three eases ami a ratio oi 517, ami g,:.s stoker.-. attd .u!;e-o\cu chargers v.itli 8.5 eases and a ratio of 28-1. A study of lancer nmi tality in SluUield. Lngland ( 1926 to 19.55), he I timer and Grace.-" showed a *ig!iii,'v:vjr!c high mortality ol cattcrr of the rc'pira- II IV sVs|.'!M ill'l'oltfntry -.f tVC-:'? -1 m:g*:'V-i\ at| of wl'oin aiY to either hot or eo!<l met.i!'. f;i the >t.r.(;. (.inters \e:v not fout.o to have . .ngm.i- cnntly tii^li incidence of lung cancer. . The Clinical I'c.-carch Committee o; the I'.iitidi Kmpire Campaign."1 in 1''44, analyzing more than 1,OX) cases of primary Carcinoma of the lungs, found that engi neers. meeltanics, painters, ami decorators are more liable to the development <>! cancer of the lung than oilier occupational groups. I'ulton,"1 analyzing f.610 eases easts of lung cancer from the register of the Liverpool Cancer Control Organization (1944 to 194S), called attention to the apparently high rmtnhvr of cases occurring among furnace men and painters. A Dutch survey hy Vcr.sluys,"' based oil mortality records (19.51 to 19.55) rml covering 1,291 lung-cancer ease.', shows a high incidence especially among "white collar" workers, diamond cutters, drapers, barmen, ha!! porters, cigar makers and tobacconists. In Germany among 86 lung-cancer patients, about all of whom information was obtained by special forms. Mm.-Her 11 found that 8.1 )v were painters, 5.8/7 lead workers. .5.5)7 plumbers, 2.5C- wire makers, 1.2)7 fmimlry workers and 1.2)7 tool and die makers. ,\n .American survey by the Metropolitan Life Insurance Company J" ( 19.57 to 19.49) includes 1.682 lung-cancer cases and covers white mate wage earners insured under its industrial policy. Il lists occupations with, probably higher than average death ra.le from cancer oi the lungs. In du se data the percentages indicate number of deaths from cancer of the lungs jx:r 100 deaths from all cause:,. The list iueluors 5 engravers (6)7). 7 welders (.4.2)7). ><2 painters (2.2'/). and 9 copper smiths (2.29c), a> Veil as blacksmiths, plumbers, steam litters, masons, cooks, laundry workers, mail carriers. im tiers (excluding coal miners), plasterers, slanghtcr-am!packing-housc workers, street cleaners, tannery workers. Iadovs, and traveling salesmen. In this study painters make up .4.9)7 of the total lung-cancer group. The best agreement among these general occupational surveys oi lung-cancer patients concerns the high proportion of metal workers and ol painters among lungcancer patients, h must be realized, of course, that data based on mortality recoil's mav conceal occupational exposures that workers may have bad in their earlier life. l'or tin's reason, complete occupational histories apfu-ar essential if one is to evaluate tullv the imjMjrtancc of industrial exposures in the production of lung cancer. Sectional Differences.--With the great variety of occupations encountered in life it become.' evident llial thousands of control eases would be necessary to evaluate 2<>. Turner, H. M.. ami tirnce. 11. : An hive-ligatiou into Cancer Mortality Am'-m: Males in Ceitaiii Sheflicld Trades. ) llyg. 1`z.tS. 27. Cliniejl llesearrli Committee of the lliilish Kinpire Camiiiicn, i,'iUi.ii.d, Cait. M. ,1. 1:122. 1*744. ' 2K. Fulton, J. S.: Carcinoma 4 the 1 .iii-.s. l'fis\ lew. Sis. Med. 42:77.s-7S2 ((), t.) I'll'.1 29. Vci'luys. h J-: Cancer and Occur- n!w. in tin.* Netherlands, l:r:<. facer 3:1 *,J ls.- (,rui.c) r*4'>. ill P.V I.. I. lUiMin and t J. Vane cl the Metro|i.>'.i:au Life* ki'ur.Uiee Company. Siati-tieat Division. . i in'Xhr.K-<-;i<.ttij\i~nKo\\;iiin<.i:>:ic c.uu'ixu.u.i _\U ilu: lung-cancer (lata jirfjH-ily. These studies. furthermore, would have to he carried mu separately fur cadi country, as well as for all sections of each country. and cceii fur each given hospital. for though smoking lial.its are mure or less uniform through out a given country, occupation.-; vary markedly, depending on climate, special jpUm.. inn. -Siilit nltn'i i-y 1........ .. Mu . f. ..pr .-..jiii-.il .pjp.- 11nn--> lfu>pna1 ir;i flie-l Service nuucaneer eases. These comprise rather large mnnhers of farmers, S'll miners, railroad workers ami nit-field workers, reflecting the industries of (lie area lull mu rounding St. Louis. Similarly, v.e have noted a preponderance of heavy-nuT.I workers in the Middle West and in the industrial Eastern section, a high incidence Ml. I of restaurant workers iu California, ami a high ratio of tailors and taxicab drivi rs l|gi- in New York City. ; m Genera! h'ole of Ocelli'll!ions.--While this survey may not show a high incidence 1: fs of highly specialized and sectional industries which nitty have an influence on the ' II 'll production of lung cancer, it nevertheless gives a good indication of the prevalence r.i" t of lung cancer among general occupations r.n a nationwide basis. The great number '.bn \i of iH-cupations involved shows that the oceujiaiional exposures per so conk! not in r l have given rise to the great increase in the incidence of lung cancer. The high ilull incidence of lung cancer among "white collar" workers, loo. and the high incidence f its. among workers.who were not known or suspected to have been exposed to irritative iiUm * i v I dusts and fumes speak against this concept. There are a few oce`n>utions, however, ( listed previously, which, in addition to those already recorded in the literature, seem I In to exert some influence on the induction of lung cancer, [u contrast to the SiTr.ee- :iol lierg and Joaehimslal mines and possibly a few other specialized industries with :i'^r which exposures have '.men associated, tmift occupations listed in this report seem in he. it at all, hut weakly . arcinegcmc. It i< possible that their main eitTcl may lie in an action synergistic with that of-lohacco smoke, since the vast majority of these patients also have heen considerable smokers, fn this connection one should iceail i|t \ 1 the work of Herenhlmti.'" who showed a very definite synergistic cited of crot-.n .\'A resin in experiments in which carcinoma was produced w ith carcinogenic agents. lit.- .Uieimcareiiiairoi in Moles. --ileeause of the relatively lew patients in this group :ai m finite conclusions can fie drawn. Wc previously concluded that tobacco smok !t VT ing does not hear as clear a relationship lo this histological type as to the epidermoid : i^- / i and the undifferentiated carcinoma of the lung. Since in this group, however, v.e t do hud more excessive smokers than in the general hospital imputations, as well as !: 1 * . i;itr < an apparently high number of workers iu industries found more commonly r> ni ctated with the other types of lung cancer, it would appear that perhaps exogenous irritation also plays a (cm in the induction of adenocarcinoma in sme eases. \\ e ! in 1 seel that these factors play no significant vole iu the induction of adenoma and the i so-called alveolar-cell carcinoma. I ('urcinoimi of llte l.unt/s in 1I 'omen.--Our studies of lohacco smoking have . \ shown that among women 43.7'/ of those presenting the epidermoid and nudixcrcuiiaUd types and bM.9'1- ni those showing adenocarcinoma were iionsmoki-i s. In 'In Miter ivpc of cancer, lohacco was tound I-1 have no statistically -igumcanl '".'V.t- ^ '-`.lit!!..;iV Action -Jitl Ki'.tU'f I'Ih :t i. ''*< fe `.4 J y ( .. Vj ^4 f. s. %c ' IV, % 4 r V - 1 I i I ri 1 i i ! * i < f 1 I t i j. j1 :i\ ;t sieiMliraii.i part. At the -ni,r time, occupational (.v>M--..rv , (|u t,(,l n-ein Ayrrfli v:t hi r< kp.-ct to cither i if iht :;:r- logical types (if lung cancer in women. one p: it,rip: I exia ]>ti<>ti. in 11 li . survey. in i,i_. tin.' cancer (if'it Inhacco-faetnry worker. 'I hi.- patient. howevcr, wax ril.-u an cx.o .i v.- smoker! It is dif'lK'tili In .-tale whither tiic I. male lung vanccr path nl.- have I incidence of ri.i ;mil ccci111;11i>'al-cui`cin*f;**:* expo.-atie- bvean-e the '"cm-ile |<ijndatioii is iif'j11n11 ' i-.nin si-t! k-s ro tuc-.-.c --elix'-mre.-. or aIicIIi'T woi.iet' ether- ivith :i: L1 llivl-J ,!!,;< hi hi - r:n:r:-r : I-..-:. ;. i-.-i li,;:- m:;;. hive I';;m m itie ah-ence of .-Hong exogenous ii rii:::lun. In this c<lin-.-cti*m k'emlct and Graham r: have demonstrated that lir>"*iiic carcinoma c;m lie trims;.'ante:! from mail! patients in tin- eves of Irniii rn.'i!: and icmatc guinea pigs with eipiai facility. This would suggest th.it inherent -ex factors have little, if anythin", i . do with certain differences noted in the incidente a* well as in (lie causation <jf bronchiogciiic carcinoma in men and women. T . Academic and Clinical Aspects.--The evaluation of occupational exposures t.*I! within obvious confines of preventive nvdicine ami public health. Keyond this it is also of academic importance, for it may po'nt onl carcinogens not yet known to he active against human tissues and tint..'expand pie.-cnt knowledge ahout arcioogenesis. Clinically it is of significance as an aid in the differential diagnosis of chest diseases. In taking the history of an ndv.lt patient witli chest symptoms one should, in addition to recording an accurate history n: smoking, pay special attention to occupations; for a patient who is att excessive smoker and who ill addition has also hcon employed in occupations that seem to have a high incidence oi cancer or the lungs appears to lie particularly prone tn live development of hronchiogenie carcinoma. On the other hand, withuut such exposures a male patient will not commonly he found to have an epidermoid carcinoma or an undifferentiated car cinoma of the lungs. -} I J Industria1 Carcinmjens.--lX. does no? lie witli;;: the scope of this comiiumicution to elaborate-on what substance or substances encountered in a given occupation may i he carcinogenic. In this report we have merely tried to outline the occupations repotted !>y lung-cancer patients, leaving for other studies the determination o: why certain industrial workers may have a higher titan expected incidence of bronchiogenic carcinoma. Special attention should he paid to arsenic, a substance generally accepted as a carcinogen for man, because it i- encountered in several occupations with a high incidence of lung cancer and because it is present in tobacco.1*11 Occu pational data also place emphasis on the need for further studies of heavy metals. Kcscarch oil the organic tractions encountered in occupations with a high incidence of lung cancer should he extended. This also applie.- to tobacco tars, which slioiil 1 be studied with the enre and resourcefulness that have been applied to the study of coal . 32. Kcmlcr. R 1... atiil ftrahsm. K. A.: St.'/.u- <*:i llu- Iuflueiii.c of Sex lloniior.i:? on Success flit lletenilnRtius Tr:.:rit:, t i' :f. of Kimut'i ilrmi, hi.i^mie Cnivinoni.i, Cancer 3:7.!.'- 7.; (Aur.) 1V?0. 33. Xeubauer. t).: Arsenicrl Cancer: Review. Urii. f. Cancer t:192-J?l (June) lri-l7. Thomas, M. 13., an;l Collitr. T. K.: Coin'i,i,tr;.::.i:i o'" Ar.-.-iie in Tobacco Smoke Ditcrmiued by Rapid Titrinietrie Method. J. Ind.ot. fl>ti- & Toxicol. -3>'. (Sejit.) t"45. IJ.vtT. M. ly. and Kennavvav. If. 1..: The Ar-e:iic Content oi Tot-.icco ami Toti.iceo Sinnkc, lti it. J. C.iucer 3:17.5 (June) PdC. ' ' ' j i ii y.\ni:M~ch'.uuu-Hiinsntloansu: c.-wcisou.i !u!\ Specific carcinogenic substances mav remain to Ik- identified, and Iic data of out invest:ga!Ion may give us the ucccssarv tools with which lo approach this problem. Chief Factor in I.MHj-Ctiiicer Increase.--We know that several factors may lie responsible Ini' the induction of primary carcinoma ol the lungs. Undoubtedly, one oi I licso factors is intrinsic, since not every pe rson exposed to carcinogenic sub stances contracts cancer of the lungs. The nature c-f this intrinsic factor remains unknown tor the present. Kaclors n[ exogenous nature, however, seem to he of similar importance in the development of lime cancer. While a few occupations eeni to play a role in this regard, we believe that the most im|'Orrml factor, which can explain the universal and predominantly iiui'e; increase in lung-cancer incidence, is tobacco smoking. The data presented in this, as well as in other recent investiga tions. should lead research to concentrate its efforts in an attempt'to identify anti isissililv isolate carcinogenic agents in tobacco smoke and in certain industrial sub stances with the hope that hy their possible removal, or at least reduction, the incidence of primary cancer of the lungs may he decreased. UiNCl.I.-StONS AXI> SI'M M ,\[(V Add:!tonal data o;i lolsuco smoking eoultiiitc t-< mda-.ite that tobacco plavs a major role in the induction of primary carcinoma of the lungs. Wry similar data and conclusions have been presented from a remit large-scale l'.riti.di study by Doll and Itradford Hill. C ity dusts and fumes cannot account for the increased incidence of long cancer. A few ocer.paii'-us appear with grcater-lhaw-expvvtvd frcijuvitcy among the laugi.nicer group '.veil though decisive statistical evidence is lacking. Among those of the most genera! importance arc the occupations of metal workeis. painters, and workers exposed lo excessive ftintes of oils, gasoline, varnish, and wood dust. I he greater the amount of tobacco smoked, the greater seems the risk that primary cavernoma of the lungs may develop. J Cf fttr^ r f" - \zt> k