Document X7yB0r373BpR5GLg72j9bJb8y

. ..1 mm<rn - *1 ' */ *.-''*y.#--'*-<M* 4 THE BRITISH JOURNAL OF CANCER (The official journal of the British Empire Cancer Campaign) i t * V * *if?$t >*;* & A<.; EDITOR R. \V. Scarff ASSISTANT EDITOR F. R. Selbie p?; ,- - L, r * V= V*V; ^-4` ADVISORY EDITORS S. P. Bedson Sir Stanford Cade E. C. Dodds Malcolm Donaldson C. E. Dukes L. H. Gray W. E. Gye A. Haddow The Lord Horder . J. P. Lockhart-Mummery J. McIntosh W. D. Newcomb Sir Heneage Ogilvie M. J. Stewart Percy Stocks B. W. Windeyer DIRECTOR F. L. Hopwood i . . - j V* >tf 3 * 4 - r *-. .,. I1 * = _v. }c jjr?*r ! \l . -: So:-.-. '*?;r;-f-c*74.'**- a l * ': rt*' h* . 'jf R > * J* 7 is"* V' Z JfS'L - *. * it - St ; - - l-'Ti VOLUME ONE 1947 WIS oocwgj I SwS5 & LONDON Jl. K. I.DVIS A; CO. LTD. 136 COWF.P. NTJELO . W.C. I fflfoSSSSU"6- ff' XI *i -s v f5 ** *% ;- r^pc:r:<~^ i^B_00 0724Q~T ITU* / GG I5Z49. sr -- * * ' I t- v l U V,V- -T ;T \-T V.; *.' * vV*. / T *'** - - - - V L .TT.*Ti" - ^ ' ^ . ---'J: .-i:\.v... ......^... , * * ;'r* '* . 'r'-**- * >*-( . r-- ' .*'*,' '!,'i.-......................j.. ... ... , ... .......... ................................... - , r, . ,V ra. T-; iv-.i*,.. x*.,' . ...V., t.';1.' :v.i|t , iV.lk Ik' .L M'.*- .t * * *' L r> r1 5MRMT DID 2 tin A FURTHER STUDY OF THE IXP-IDEXCE Or CANCER OF THE LUNG- AX*) LARYNX. E. L. ai X- M. KEXXAWAY. (Frow> /Ae Pathological I)f.wirtrtt*>'t. S'. /*** tv -v ti,'> Lghhoh.) Hcevivcil for jmlniiM-i-ai .Jaiy 25. IfUT. MATEKiAL EXAMINED. The data given below are derived from an examination of the de->-;i ee:*':; cates: of cases of cancer of the lung and of thv larynx in malo from Engb.nd Wales for the years 1021 to lOHS inclusive. The figures for the fiist 12 y-stthis period (1921 to 1032) were dealt with in an earlier paper (Kenn-.vwty a a-1 Kennaway, 1936): the material from the subset!went six years ha* now he*-r. examined in the same wav. and the data for the whole ls-year period 1921 -:,s can now be presented together. The whole number of certificates ,-y..,<un,. individually was 36,418, while the annual total figures for cases in women hv been utilized for comparison. This total was made up as follows: ' Main ' . Cancer of lung . . Cancer of larynx . Certificate.* Examined. . JD21-32. I'tS.t-XS. ., S&os . 14.741 . 9472 . 5,397 . . Tytal. 2:i.5P* l-PSo*1 O&.tis The investigation was carried out on the general line.-, rbi Sowed in an earlier study of jthe occupational incidence of cancer of the bladder anil prostate (Heurv. Kennaway and Kennaway, 1931). The chief objects of the enquiry were: (I) to ascertain whether canter n: the lung showed any special incidence u];on particular occupations, and (2; t<* seek for evidence to show whether the increase in deaths attributed to eucesr the lung, now of the order of over lU-inld (from :;t 1 deaths of males in 1921 to 59S2 in 1946) indicates any real increase in the prevalence of tit is form of cancer (Fig. 1). The figures for cancer of the larynx ~erve a< a bads of ot-mparKm with those for cancer of the lung, in that the larynx is a part of the same Jr. st.-r:'tory) tract which is more accessible to in-p-* :hm. end S', not examined la uujnostie methods \'hich have changed giv.tly in re-onr V"i.rs. The dc.n h i.eir:::cates of persons under 2n years of age were omitted. ,t> the invostiirarinn an. concerned primarily with the effect of occupation. -'Jilhorl of ("nli nltit,//' of J.'ir , The cumjiarativc incidence of cariem* <if the Iu:i_- and larynx open \.;r a;oeeup.ations an* estimated in the munte-r des.-rj!,. .| i:, . ij! tec *11: ;> * (Kennaway and Kciir-iway. I!*:)!), In ji;11*_:i11ot i1 .eeu|*:t` >i,al intid- e. GG IGZbO T"bT0007241_J[ ' iM NO T| VAC/'vV/!>'- f' 4 \ **is'v* i* fT U sYLt 27 -f k. l. .VXD M. KrN'.VA\V.VV incidence of cancer of the lung i' :h .-<(me in .silicotic and non-sdiro: (Table XI). The account {riven here of the literature on the relation *f sili'O'is * of the lung docs not claim to he compute (.<*? the review by Klot7, r. (C) Asbe$!<~v worker*. In the years ll^9 to 1044 in England and Wales the faral cases -,f .. and ashestosis numbered 2699 urn! 7.'. respectively. The uverag** lif employment in fatal cases teas, in silk- .-.is, 34 years, and in a.-bomds (Factories Report, 1944). In his report for 1958, the ."Senior Menn-af I: y of Factories states that " among lt):> fa-;;! cases in which asbestods or a-` with tuberculosis was present, cancer of'the lung was associated in ! (11-6 per cent)/' Table XII records the cases of cancer of the hunt in workers which have been found in the materials dealt with in this paper. Ti-BLE XII.--Cancer of Limy. Ashesta# Workers. Death Certifcrffes 1932-1938, 1935 1935 193S 1938 1938 1938 1934 1938 Asbestos weaver . ,, cloth weaver .... ,, weaver. . . . . . - Boiler and pipe asbestos corerer . . . Asbestos packer . '. Disintegrating room hand in asbestos works Departmental Manager in asbestos company Asbestos works manager , A>-. 02 54 40 5S 58 . 65 45 . 38 These eight cases of carreer of the lung occurred in the years 1934 to ]! s men of ages from 45 to 65. If one take?, the nul>er ol deaths from c.-,n*:-r the lung in these years among the general population of males of appruxim the same age groups (45-H4) one can make the following comparison : 4,068,352 inales (ages 45-64) produced 8191 deaths from canter of lung. * approximately 4 million males (ages 45-64) produced S"o.j de, from cancer of the lung. -- 4Qt males produced 8 deaths from cancer of the lung. The number of male asbestos workers in this age-group appears to bo <. ; siderably less than 4,uun hut as we have hem unable to obtain any ex.v-r ti for the workers at risk one cannot carry tie- cal-ulatiou further. 1 ''/Lynch and Smith (1935) ieport from SontIt Carolina. a hn. i. I i.i, carcinoma in a man who had been for 21 years- an ashcsto> weaver. Egbert and fb-i-'"r (1956) record a bronehiogcaie carcinoma. wi\, * characteristic palm*.nary rihrosi- and ,.J... bodii-. mu man wu*. Lu! 1 for !,s year- an a.-hc.- ,, \.v.*\er .-u Vew lia.cn. < 'm:ici-t i.-ut. 0`1'nnc (I(135) record< tv. o ca.-cs of fairly advanced ;isl....r...s, u stjuatnous carcinoui:' of (!* him:. in uumu-m w.ukcrs in Emriund. " Oa>- nine years after an eight years" exp.-mre h--to- dim:. a., a : GG lb/51 j"*b"b~ 0007242^y TN.r ''nj. i.\( i! \ i . : < <t I..* . L I.' \\v '.ft other li\*-'I for Jifteen t.-:;: two -i*-i | iii.i|-- ol i\ 1n<i;: 11v and thirteen jnontlisin tIn m.: nd upiuii.:.: d-p.u: of tie*. faeli.ry. 7,,#, h-duns u! : ' >u r. . iii e.u !i \c-jy small and Hot iwtig- dtiMM-.' !iie." Sub--- :<u : vr-;* ;i o-i. and an -cell rarciiinuw. of t ! him; in a whu had 1 u for 2n tear- foreman in ilit* stores riniartmcut of an u.,:k*s. ."7' Alrnl.S ''i*1 li.b'irm. Then- is a considerable difvrenc-t* between occupations associated with the supplv of aU-n!m|, and of to1-.- .!>: the former show a very high incidence upon me larynx, and a normal i.Mid.-nec upon the lung (Table XIJJ). The ratio for the lung i-> tin* same for licenced victuallers as for physicians and surgeons (Table XV). The occupations of barman and cellarnian show by far the highest ftrures of any in Tabic V for cancer of the 1aryns. The incidence of cancer of ..the lung upon the two occupations connected with toha cco has decreased distinctly in the later ]eriod. The increasing use of cigarettes (Fig. 10, 11) has caused the tobacconist to become more and more a vendor of closed packets which can hardly have any occupational effect. The decline of pipe-smoking makes the mixing by the tobacconist by hand of a blend to suit a customer's taste to be jess frequent . cS' 5? / s. 2 -Q" A .O 7-,f . 4 Table XII3.--Cancer of Lang and Larynx. Occupations Associated with the Hanphj of Alcohol and Tobacco. * Ratio. Lung. Larj-nx. /" f .o iiannen .... Ctllarmen . . Licensed victuallers .. . . Tobacco manufacturers . .. Tobacconists and their assistants 15*21--3-2!. 104 92 -123 19G H5 1933-3S. 1 021--32. 122 469 87 317 no. ...124 185 65 S2-5 . 142 1933-33. 275 502. 199 129 171 * *v r J , .*K*r * * i fe t -^A V * \ . ` Coal-gas anil tar. The occupations associated with coal-gas and tar are important on account of the known liability of tin.- workmen to cancer of the skin, and of the bladder :rienry, Kennnway and Kemvawny. J 931),- but they offer unsatisfactory statistic.i1 material because soil',.- c-i the most important occupations employ verv :i , ui iu.-iv .u kijcic .ire ecu occupations m vd.ich there is especial cxito coal-gas and tar. If from these ten one excludes the four which hnv- rmdnced le*s than ten deaths from cancer of tho one o1iiain<. by this qv arbitrary procedure. the results siiown in Table Xi V. Thus all thn six occnpaii- i,- :u'lieh employ about S2,nfjo men (1931 criiMis) and yield -(>7 case* ' f .-.nc-r of :! r- lung, have an increased (up to 2X4) ratio fur this disease, the lowt>t ligure being that for chimnev sweeps (J]!i). 7 T r7 T T ir#,-, lV"'WT.',r r v iu)j*. ;ifnr?ii .Jp ..v;,:.' GG 1525? 777:.-; -J .d.T'Td-i."/ l BB 002Z------ ^ 1 *. ; i t j - ,1' ^ ^ i.Vv^.7,- -1-VvV ) . *_***.*,_ ** y *s yu .j. 1 h'-j ' ^ (-*,'' i " < - 1 > 1 V'.-r.'-'V.;rr'- .Jt'C-v:'-*-",.,T. v-'J . 'r 4. * ( ` , _* '. t .. * * * ' - * b , * ' !"*****?** .1A ' Av 4 * ** * * ____ *+ir44*. W* *.* CyrUJi^J^^ (p ^"*C^sc? j.vcn.FXcn or cawei: am-' lv.w ,\n*i> lahynx 201 -- *n.v form of cniu-er il is of t/ouvse ary to ennvci for ace distribution, for an ociujuriou t!Ui|i/tn iirj u hirue proportion of older men will yield more eases of 0000 LuiiAO / /5000 / 4000f- t, AU\--' / v'"i/ v V- sooo 2000 1000 --' / * / w / / / / / / / '............. k-^'\--o Larynx i t iV : /r\\ V3) f; ViW* > V* . .r i/ 4 *. *ii f*!? i t``- . \i: t. . *'5`I tt ` *t l- tV if iI 5 : i: * Kf* :V- U: : .:. . * -. ^f * V l!2l mm J--m1 ia l'i<;. I--frvn C3ii<'i'7 *>f lu:;^ ^t\d luryux. M.ili--'. 1021-1045, ennm* apart from any aetfolopienl fart nr. The eensus returns ^i\e the age nisi vihm ion. in a- and lo-yenLly periods, el the tv hole population of males, and re- = tym trttp *s ^ GG 15253 t* r ^ 1 BB 0007244 |  r -> ''T 1 "- rtC v- - ' - ;- * ' ; ' y 'V....^..-.. j..f, "f ?.5 ' ,r%. . * _ y-; r*0 ._ . - vj)S*' 1 ` 2d- K. c. and n. .u. kenx.vwav also of those following each on*- of the recognized occupations, at rhe time of tin census. ^ The number of deaths attributed to cancer of the limy and Inryiv occurring in the 'viado mule population in -ach uf these age groups during tlu years in question was obtained from material at the t'onernl Kegiscer (Jtticc The comparison of the various occupations with. tlie .general population is then a sum in proportion, which gives the ratio of the number of deaths in any given occupation to those, reckoned as lOo, which occurred in the same number ot males in the same age groups in the whole population. An example of this calculation is given in the earlier paper. Sources of Error in Statistical Work on Death Certificate*, These were examined in the earlier paper (Kennawav and Kennaway. 10'>*>), The use of death certificates for statistical purposes is liable to errors which are inherent in the nature of the material and cannot be wholly eliminated. One must either recognize and admit these errors and correct them in any way possible, or abandon any attempt to obtain information from these data. (1) Correction for period between census.--In order to compare the incidence of cancer upon different occupations one must- know the number of persons following each occupation. This is learned from the census returns. The longer the inter-census Interval the greater is the risk of important alteration in these numbers. The figures for populations used for the earlier period (li>2 V--22) were those of the lt>dl and the 10M1 census, which were combined by means of a 3 formula described in the earlier paper (Kennaway and Kennaway, 1 !:(>): those in the present paper are from the 10:51 census, which is the last taken. Xo census was made in l'J4l, on account of the war. j The ratios for the whole 18-year period are calculated from the sums of the registered, and the calculated, deaths for the I--year and G-vear periods as in the s.'. ^ following examples Table I.--Combination of 12-year and 6-year Periods. Cancer of the lnny. 10 51-1043. rali-ulitttti Unit hi. Total *n:utvn-vl Crtry>*ntof*, ltV) Vrmtrrs 33-7 173 til Katie of nnM to loo cftl* cuiuTH tbuitta. 775 107 1D33-I0.1*. T.*al Calculate Urnth*. Kano *f rr.tt. to !;> caj' . 77S-ti . HS-S 7 On 1 In 77 131 I!>-J|-10;!2 - 10i Oili*ol.irM rwi** t*TM . 443-t Us-3 373 ITT Karin n( f 1 t o ,*ilruLvt(**l 77-3 11.) {-) Samptiny error.--In some of the mo-t interesting occupations from the present standpoint (e.g. patcur fuel workers. t..r di-tiller*} a few thousand men only are employed, arid rhe.-*- will yield but \r,y few of eaneer of anv u organ e\eu it tiie iucidr-ricc is high ('fable XIV>. Hence the sampling error will be large even over the period studied here of Is years. The figures given in 1 ublii Will show the range of fluctuations which occurs. Kveo tin* targe group of agricultural workers, numbering nv*-~ uon.otut men. does not g:w* so smooth a curve representing deaths from cauc-r of the lung as tines the whole male population (I'ig. 2). ________ T"bb"0007245 | GG I5Z54 !, fi ` r? v,`t,'7r"ryy w n mi> > J BB 07246 GG'15255 1 14 A ! --4 iH3 M** -4 ' * 'arm .v *v ' . 7'iu i" 1 * '"' ' ' ' - 1 "; * ' i 4 204 E. L. AXD X. M. XEXX.UVAY when large numbers are concerned. The iamien.se Amount of labour involves in such enquiries can be seen in the monograph on cancer of the scrotum b\ Henry (ltUO). But as none of tho occupations included in the present study, with one exception, shows a very high incidence of cancer of the liihg. comparable to that seen in the occupational cancers of the shin and bladder, this sourco of error is not a very serious one. (4) Incorrect dinynosts is of course a source of error in these, ns in all other, medical data. In the case of death certificates received in bulk, perhaps some years after the dates of the deaths record-d. one can do nothing but exclude any certificate of which the wording sttggc'ts (l) that the cause of death did not come within the category under examination, or (2) that the diagnosis was uncertain or ill-founded (see next section : such certificates are made the subjectof individual inquiry by the General Register Office). When such exclusions have been made, one must treat the remaining certificates as correct, if any use is to l>e made of the material. Death Certificates Taken for Examination. The material utilized in this paper has heen restricted as far as possible to cases, of primary malignant growth of the lung, and of the larynx. The forms of words in the certificates .taken for examination, and in those rejected, may be stated.thus: . ' " Cancel of Iniig. (a) Detained.--Cancer, carcinoma, or sarcoma of lung, bronchus, pleura, root of lung, hilum of lung, lung and mediastinum, or lung and pleura. Pul monary, or bronchial cancer, carcinoma or sarcoma. Cancerous pleurisy. (b) Dejected.--Any new growth of mediastinum, of mediastinal or of bronchial glands. New growths of chest- or thorax. Peribronchial .new growth. Any new growth qualified by " probable." " doubtful/* or query.'' . Where another organ is mentioned, in addition to the lung, as the site of new growth, the practice lias been to retain those cases where this organ is uuUkelv to he the primary site (e.g. cancer of lung*anti brain, or of lung and liver) and to reject the rest (e.g. sarcoma of arm and lung, sarcoma oflung and testicle, cancer of lung and oesophagus). Cancer of larynx, (a) Ttdain)l,~ -The category of earner of the larynx in the tabulation li.-ed i;i the General Register Office include.' malignant growths of which the situation U described hy the following terms : Aryteno-eniglottidean f->!!>. Arytenoid glands and curtilage, < 'ricoid. KpigloUis. (11' i-.sti-ej >t t ie f,,M. Glottis. IJi -t cricoid. re, ro-crieoid. Pyriform fo.-sn. Sinus pyriforuus. Thyroid carrilaje. Vallecula epi'jlotl irn. \ ' *-:d eonG. Ti u.hea, windpipe. All tlip-e were retained with the exception ol'\ allecula. r,r, 15255 J BB 0007247"|  I * . `i> i..\Y.\* .'7 if; . * ..lilif.: !t\ i.mli,)!,].: : d.nih:f::l." nr of So if m.-*s of which tin* nut up- i.- doubtful (e.g. t amour of cricoid cartilage and thyroid gland "). Tin* opinion is sometimes cxp:eSM*d that statistics of lung cancer are of no Value which comprise cases where no autopsy has been made, and some authoriti*.*.* (s**<* In-low. p. 2*!li maintain further that, e\e;i when autopsies are performed, many cancers of the- lung escape notice. Table II shows the numbers of autopsies recorded in the death certificates for cancer of the lung* discussed here (i.c. after the exclusions stated in the preceding section). Similar data for 1921-32 are given in the earlier paper (Kennaway and Ivennaway, 193G). These cases are classified as follow- : (3) Xo P.M. (2) Inquest. P.1I. (3) P..U (4) Inquest and P,M. (5) Coroner's P.M. without inquest. : ' Tahle II:--Autopsies. Cancer of Lung. (Males, 1933-3S.) Y*kj. I ?I33 J!*34 1 M3ft IMali IM3T 1 !*.'{* I. IL 1IL xo rji. Xo PAI. 1imuici oIIf. TV. PAT. V. Inqiirrt and PAI. CorVonI.er.* ]\inMq.uesVt.o SVuImL of and VI. . 1,247 . 0 . 1.233 . 439 . 34 . 1,784 . 3 . 1.487 , _494 . . 28 . 501 . 39 . 555 . . J.C4G . -- . 1.040 574 . 30 . 34 644 . . i.tias . 4 . l.e*i2 .* 539 . 37 . 34 ,, 010 . . 2.233 . 5 . 2.240 . 522 . 01 40 023 . . 2.324 . 5 . 2..T-2f' . ,, sys . 42 53 . 093* . Total. 1,754 2.042 2.290 2.572 2.Sr.3 3,222 Te! ill . 11,034 . 23 . 11.117 . 3100 . 232 0.5I.U . 34 . fi.C.113 . 2005 . 132 22S . 3020 . 14.743 OS . 2205 . S.sas 1M21-3S . . 17,303 . 37 - . 17,720 . 5171 . 304 290 5831 . 23,551 * T.vr.nc TII --JL'jp*:rli'yii of Autopsies (Males , 1921--33.) ` - ......... . Mean mitopiies. deaths. Autopsies. crxnmn* Per i-enf of (Imt)la. 1921-.12 S.St'3 2205 134 25 * 0 1933-3S 192!-32 1933-3S 14.743 n.472 39S 3026 (504 995 50 44i> 7t" 24*9 G*3 v*3 Table III shows (1) that tic ;.\mbrr of autopsies has incrca-ed much more in tiie lung series tiir.n in the b.rvij.v series : and (2) that tho average proportion of eases of cancer of the lung examined po<f mortem is (he same in the earlier * A vufTcfrviniiiii! lanle if..- i- ;.vtr cf t)if larynx ir oiaiu.'il to uu space. -- --kl \ *. ' "A ' 1 >3 f* ,5 Tt*****1**^: *-- k. (.V^rrvx'. >;v. "~ - ^'-1 - /- - .1,'.... '* vr,." .^`a i'p.; .v-TT.V'" '/s V-.`r* - * - * -* .. . -%* s*T' . " . GG I525f V 1 bb 000724 - .*i'"ric ' * ' ' * " ' # \ " * . ''*J h *, :/* .' ` / , 1 '. V1 , 1 < #'"a*. * r-'-M ' '.'.v . i 11 i -VI- '. i !'. - ; .. , .'T-.f-*'- M * *- s a!, ',+*' >I t > . ,` % \ ^ 1 ,1 I , t ,., . I. > j,v ,I , l| |. I *.{'',i ",i `'LV* i' *' * ' . ' V* ' > t'f * -Vs. *p^.rrT,y jo/7mr)ATTTn.. * r, \sii' 72 .j-~ .a . .. if. IcIc n ICl ' ) I o I c/l I to I 1 -t t Ii tI I-- t Tauui IV.--Cancer of Lung. .1021--10:12 and Tim omijmtions nro nhaugud *m (lescunding order of tlto ratio of rogisturod to 100 calculated iloatlw, 1921-:J8. It's U|Nil hill. I'lilinlalliHi. T-nlmitivrs, fiiit.iit fin-1 ivuiK-t (Jn-t t-l.'kiis unit I'nkii-tiviii i-luugum I in . f inuluciT in.'ii M> tut V'iiiilcis . In-'- wntk* li.i'i-iiii-ii anil iriN|>i-i-t,)[-H ri-u-i*' 'mil iirkiir*; >ii|i timkoi-* .n-i| int.im-n .ituuily i-uiiiti-il In 1 in 11 rt., i'i 11 1 -.Hi-t`|n-I* all-1 ill..tin' l in- lit li-t* I'm I'-IHs. slti-i-l tna.KillH. (Dlli-tlitlirS, n .j 'Inill i'i -i .V"i..r itm-. 11, yiniils flii'l |uin*.'naf-r.`i Itl.i i l.ii'ii.n i-.-ii^iiii'mi'ii . , Ikll.'lli'l fllliki'j-s , . . T.il-1,i-i-i. iiiniiiitiii lutvis k I * Ill lllil-'i.liN, i ill l.-l > mill ih'i-M-tiT* 'I'utii.i-i*, Ii-.iiIi.t iln-.'.i r.i, i-iirricr*, *i.itti il U'uit; is ]'iil.-is; iwirr-i nullits, 1-nstiT* anil Iml-li.ii .... I in. uniks t-iinjii.i nmt cniiH. ili ivtT* kkii.ilM.i-t, i* .... < in . .i i ri k* jii.ii!iiP:i-r* ., I *r ii. iii nf li.n-.-,ii . Imu ii voliitti-* . ttus ii.uk* lrl.-.iviu-rs ,, l-'ri'iirli ]mii.l.i-js ... I'.iiiilils ..... l.li-. i.si-il vi. Ittalli I* . I'i `M is . l 'tiiniin-y IJls I 'J*:i i .In Is 1 -III I III It , . . , . 'rul..ii i iiiii.-l* mi l llii-ir insistiiiit* 847 118 IN J, III5 1r5.,,422t.0i 1,-INII 39.155 15,079 7,41`J 2r,4. titif. 21, (.7.7 7.litis :i7,177 18.001 7,723 l ,s:.i iijii in t,.'..*> i 17,78;t 178,837 75,832 83,189 5.900 Itl.urill 21,059 1 t,tt,t| 1WM0K. ChIcuI'iIikI llisil It*. il'uti-'-..iiiltlilildi.i. 5-1 itatlu nr Ii-imI. tu 100 cul-ailitliil itiu It i*. 4:13 ' 34 3 1(13 22(1 107 J'liimliitliiti. 110 13,03(1 2,451 17,(HI!) 0,1178 1-04 311-2 8-e 1 U8* ` 111 ' till 173 182 r,7tm 4U.1H4 19,378 0-7 90 0-7-4 21-7 4-tl 35-5 M-2 12 209 130 112 1 131 34 138 11 . no*, 53 1 III' \ 'l 21 I4t*` 8,915 305,908 198 41,110 8. |!J2 10,087 ' 18,580 8-0 9. 152 ' 8.511 l ,809 1.285 1,010 138,550 :i:t,t)iio ' 22,072. 2U2.710 711,4 111 82,147 Ii. 1110 till,'.till 27,1111 11.U75 Cilliuti ti-il it'-llllH. 0-005 1111 3-4 13-9 tl-3 18 01 8 15 8 HI * 190 9 0 on 59 i 7 it Oil s 22 99 I03J 'J'utut WMil, ili-utli*. ltiillu nf rii:'iialtt..'IiIlniiliIl>K1 I ill Hll'S, 1.520 251 232 Ml 101 218 30 130 1921-iW. lintto nf n-tiil. to luD I'Jili i|la list it.'.lllis, 571 2S4 2112 170 171 174 109 107 lit 21-2 i- f v- c r-t. - L; tr- tv. m ti-. r ; . it o i Vi ! /i j 1 : ! i j * , "r * > \ i -*(r i < I-- I ./ IPil- li':i'.`. lit hi|m1 imi. I'litMlInlhm. tlrntli*. 1 titinln--'i m ..... It i'u-iv im:l piiNlry roiili* . . )`iiifr">ii>mil men .... I'ntleiv, i'!c. i l.iln imiiI itvenitieu, It j Jr n-lli-ii- nml jilmuMrf Cironuw, *,. l>ii> U ktlu itii'l ............... . . . . 'Sluli-.pirir v in-iiii- mi.) mum driver* . (V'ltim grinder* mid rnnl- riH-m ... * ]hm*i>iiioJh n iirij'jfii* ilrivott*. rind .... f 'tn , . * , . hillin' miiirr-t mu) i|imiTH>i'ri . (Vml iitini'r, firtvt'iH #nd |S*tl*w l.ill>i!i.i|itui- nml |ihhtss t'lij-riiverx . >1 tintnii-r iiirii itjul Inle-iimn finn fl'IH`1 N . . . * * * Cotluti mnl jiineorfl (mule. rinjj <.!] t>r ftjvil .... I'oil HlijIPlM'- Kiri Url* hIkiVII priHillil . Tdi up Iv i-i :i inid wikii-uvili 111 III 1-H Itrii li Htc) (iJniit lito nmkors Co;il iiiim-rii, oilier workorn liutow praiiml ..... (.`(ml minr'in, ('(invcytng laiitcrint to Un *4mil , . , * t'liiil mini'iK, milking ioiuIm ('hiInn i'men* .... FiinmiK ,.* .tgi'irnllurnl lubtiiiivrs, im'lmling ulir|>- lien 1,-t ...... J'urm lm ilttTrf. anil foremen . 113.517 toi.o'.n it.:t:i:t I2.IW 51,1118 li.22fi t`2.H".ri 5.212 87,5 II 2111.131 28.17 1 1 ltl.:t 11 5,7111 (1.3(11 20(1,071 38.817 B3,H71 I,0'.I7 0,325 81,403 1)1.551 02.155 -111,(178 253,1811 431,311(1 20,270 Tnlul 00 .23 0 43-7 ` 110-3 13 H-2 2H-4 4-3 58-11 3-4 r.n 1 no' 21 275 3>fl 7-2\ 204 , 215 05 1 08 0-2 5i2 31-4 54 B 27-8 *28(1 351 IS-ft * 'JV.I.il l|lVI flirt 20 37 HU 1 8 311 1 12 1 H 123 ` 4-1 174 3 5 118 7 48 2 3 28 12 20 13 153 5111) 2,24 a finlfr# t,r ! HKl riifrtrliilrst rfnillik. 84 85 01 02 (trt Kill 23 71 30 7fi 73 11)5 H3 83 . 54 58 32 71 ` 20 49 44 38 53 47 83 31 28 4 4,430 75.0)0 108.012 7,U.Vl 11.112 20,521 7,112 08.880 5.312 87.812 2 i:i.t'28 32.380 418,8(3 7.28(1 . (1.135 223,310 43,001 110,1155 .7,824 12,403 80,247 127,17(1 80.512 41.015 200,002 453,221 17,083 um IflH. ilinfli*. 43 ' 73-5 181-3 II-!) T< -IjI rcj-l, ilmHik, 47 70 170 li 14-5 42-5 7-1 01 (I 12 30 0 75 5-8 0 (tl-l 275-5 3 Ml 442-7 00 7-0 317-li 30-1 into (W 200 17 ` 31(1 4 4 253 27 4(1 8-5 105 II 5 112-4 52 HD-2 HKl 48-2 4110-5 28 37 17 143 C32- 7 27*1 137 (i 3,550 it'.ti h* *r' rvl n |m,i *h` rfJii*, ) 0(1 K'3 07 87 82-5 71 121 yi tWI .18, ttnll** -r Ill HM rah id di'it ih .itlrf. 101 Slcl 05 S!l ss 33 hft 7H x w FI n lot 72-B 72 111 72 58 50 01 73 47 70 47 40 "li 71 72-3 70 fill 57 oil 50 ' ft* 50 52 43 15 n % r. ** o * nr Si V4 o T -* 17 II a 37 * 43 `S, 37 -111-5 32 40 20 2(1 D4 21 7i ''."-``I ; i TUtiftf-'J V .' '``.'''v1 x '-i - . ' " - - ' vc* * . K" \\ . , .: j , ,- > W. *. i. / -j '',* i- v.v,. r.*,,i.v r..-Mil- . *;-tV--ii V-r f* "^-' V f * f ^ s' f - }' \ t *; *Ay ,. ***. .* ! :*V j ,> t* >>'. `t * -.;' > V: ; ` .\: .; f.; V^tT'JSrT K'&TfPAWV'..: >i->> * *' * : ;.*S Vi-. ;i; C. > ` * ' * ., , , . , * -v ^ v r , v. * ' 4 . 5''? r : 1 *.1' >V..iiy; * ` * t ": v" .*>..; Ha'w?.:;>;:<*;iiv --; ffrijuWrto Hj.; r * -.3 i .1 Table V.--Cancer of Larynx. 1021-1032 and 1033-1038. Tho occupations are arranged in doscoiiding order of the ratio of rogistorod to 100 calculated doaths, 1021-38. Iturniiii (Vll.nmcn . . , * (iix-umLi rn;'Irn` mill crnno ilrivnra Chh MtiUt'in uml iaiiUt!*ivni rlmifrora M.ut*l> <**tnn*il l.ilumivrH, iwl awerporo untl tu^inini ., MHmI (Ipli'I'N . . tlmi-r* urinHM- .I.Mvui vrliit'lcH . ( *|< till I11 'V Ml tVf'* . . . J'off.-r;; u iihwimIkth, t'UJ'iti'H mid ... * * l'<Eu*iy. i-t<- ; t-iln ami nniimafi* lain M llt l * llllil ]till** I <4 . * T H nial I la ir iis.-'isImmIh t 'itlatu I tji.tWi ... I'nv ..... . hi ivl Ml.lSollH, It'lK'lolorH, I'J'l-.illMI ;l .... ) !**!:*'ll |Hi)Ir IliT-i . . . t.ti)i'ami (JiottL-a rn^mvar* J'jiintiu-s .... Culaiii ^ijniiar* iiinl pillars {uilllo, lint!. nr Myri*) . . 4 It* nil i >, I*ni`*i , J`llMiJa'I s I'n'iiii'H . t-'d- (iUcrn .. . , . .- .... Maliir *lin*rr'. "tmU isntl JJuifJi* aciv .... t lit<.r l;s imuat^ri'^ ' * . i I.iJ.r; s mal jm`*try * i*Uh 21.050 o,:i:i:i 1,054 12,mu 30,155 75.S-.I2 15,220 151.551 5.000 1.725 12. IKS n,o:it .71.455 7,410 J7,7s:i 5,701 17s,s:i7 3S.S17 31.010 10.071) k:i, iso 15.070 251.350 30,407 l.:lo:t 00,7,47 1921-1932. Cnkulntcil sU-iilti'i. Tt(il n*K*l. ' s :i 4-4 1*7 10-7 30 It -1 20 45*3 03*4 7*1 132 . 7*8 78 173 10 212 15 (1 11 7*7 0 III* 1 10 28 40 5*8 111 :>*u J5U 0 15 3 105 20-0 .32-1 31 *1 01-2 : 1 8-3 04-8 22-U 1*3 40-H 31 13 30 71 8 05 28 1 40 ItiilJn of ivuiL to 100 L'ttlmliilri) I'utmliUton. 4(10 . 317 233 lHd 27.101 7.050 1,800 13,020 172 40,181 18.1 7(1.4 10 14) 17,000 184 138.050 102 ^ 0.400 184 * 8.51 [ no 112 \ 101 L 14.44 2 11.075 ti.no 154 ' 8.015 135 22.072 84 7.280 130 ' 202,740 148 m 111! no tm ' 100 121 70 105 43.001 g 20,521 lUJ.OOI 82.1 17 10,375 . 305.80.7 4 1.430 l.ulo 75,(110 1933-1 U:H. Ciili'iOiilRit iti'alli-. 47 2-4 0*03 0*7 1m7iut.ii.l (Ifiitlm. 13 12 i 17 ItrvIisiitllntl'.uitllf(lnalumhnI,f-fHl I W* 2U *r*3 23*0 51*2 3'8 110-8 441 03 102 0 10(1 11 3 1 4 ns 4*5 10 8*2 14 15*7 20 3*4 4 0*4 !) 2* 3 5 87 lift 12*1 17 18-3 3(1-3 3 42-5 13-5 11-03 27-0 11 1|,7 33 0 48 Id 1 d| llntln af iCviJilitle,lull.yil iliHf t ilimtJi*. :l!Jfl :\ i82-5 2:27 il:) I do i mi ir>:i 151 f &i* < ft'- : ** t'l: !iV - . U\<:h 1^' fil i / 1- I . <c .w. i. J . itj'r IXCWUXCE OF VAXl.En o f l u x g AXD LA11VXX Ilfrillnlliill, I'lJlilllnil'Hl. rnttrri* nml ilrcswem TIipc< iitmnirm-lMnin Itin-U Kiln iiii'l iivi-nineii . . (in-,mil!;*. l.dwHiieii. . .. C.iijii'iiliip . HIniif inini r i mill t|Linrriri'it . I'.illnii i-1 ri|-|vt*, f;iiinliT unit curd* ii'i'in inlil i i.i .... H'inl inu.iry i'ii;;inc nml venue ilrivviv . lilllill ll"|1 ..... I'i.l tun ut-ilivui . ... . l'i,mil uv ii .... <Ini miiiL.n 1.h-iiivsi nml irin|j<*rti*i'H . I'.I.i.I liiniin mnrii him) tiiliniiri'rs . Hi il l: nml lilniii I i|i`innlii rn . . 'I niim in. tinilln-r ili rhith, t'lirririM. ol.'illi'il v. nrlii-1 it , . /. I ',*nl miimi *i, In iii'Iii . . .. ( V.nl inini'i i. nnikcin ubnve grim ml (Itn |ir'"Im'i itiK'n . . .. J.iuMfimlH c erir'ino drivers!, firemen unci rtiMiii'is . . ., ( ..ill iiiini i^. nullum; ruin In Aern'iillimil Inlnnireiv. UH-lud'mj; tilicp- Iserils . ... .. foul ininrrs.. oilier work cm lielim* eriutiiil ..... foul mint ih. j i'iwmaconvoyinginiitcriul III till' sjlllfl ..... ('llllWL-* ..... I'm us hsiilillV null foremen .. Tnc distillery *norkcin nml coko-ovrn ivtnker.-t ..... 37,177 7,liJ>3 0,225 33,.'Ill I 2111,131 23,171 6.212 72.Hi 3 200.071 I0.07H ft, I 12 11.3111 ll, 32:1 13,01)1 4-111,3 11 83,071 3,135 87,514 112,156 434,31m 81,403 '01,501 203,130 `20,270 I),DI)7 Tot nl 52 tuu.ii V IIJ2I III <2. Vi li-nlril'il itialln. 4ft-7 40' 1-2 30-8 101 21*8 T.vt,{ *li iM. tlcnlli* 31 3 :t 32 . 150 10 :i:i * im-Hi . 411 258 * l 20*4 ^ ` 131 1 101 |H if 2 5*3 4 7*4 \0*1) 7 15*0 200 7o*r> 2*3 'u 150 30 JJ 54*3 00 30 27 4 ill 174 08*5 30 25*1 354 20 `3 11 143 _0 0*0 3 2,508 ' Il:tl In <r r. L*.|, tn 1 m) t'Alrnhli'il ilrnftm. 125 05 71 104 82 73 1U.U IW, t`i>|iiiliiiluii. r.ih'niniAii . ilcnllin. 40,087 8,102 7,112 33,000 213,028 32.380 25*1 3*1 2*4 10-H 111) 12*2 Tulnl ni), di'itlli*. 12 4 3 11 07 12 lill HI 75 75 84 7(1 . 41) loo 5.312 OK,080 223,310 11,015 108,012 0,075 11,135 12.103 1*7 32*3 151!) 10*7 77*2 3*2 2*0 3*0 |> i'l 123 12 3!) 1 4 0 00. IR.BHi) 8*7 5 BH 41H.H13 III! 107 55 00.055 38*2 20 88 2,451 11 II 55 87,812 31*8 18 45 00,512 30-0 21 41 453,221 226*8 135 44 80,247 t 40 44 127,170 40 200,002 44 . 17.085 18*0 11)8,4 10-1 )H 7 81 3 00 7,824 \ 2*7 (1 1,451 iiiiiiti.ir' rnul. i*i lun faViil-iti-d is 120 123 05 *5 SH i.M- 0 Its 71 7!) 72 :.0*5 02*5 138 " 57*5 73 08 -- 5(1*6 l>5 00 45 42*5 41 30 *- l"2l-:H. ft fl1l 4jf inul. In Hill CilU lllllt'tl i|in4U. HO 01 00 SI H2 sn 7S ;? 74 71-5 71 OS 07 05 03 00 30 53 48 41 ' 43 40-5 33*5 32 C"} J~! ro cn 2G9 1rnr?7t'K.'-t *?cv^-'*y "nrrvT. ,1 .-4 ' -i >;r.B!0r? 'i)C: ^fVr-r.' ! V * i '*; C V' V1 -' mot COME FROM FPGFlCSr *270 B. l! axu n*. m. kkxnww.w i\acl later periods. Hence the continuing increase iti deaths attributed to cancer of thu lung is not duo to any increase in thU proportion. COMPARATIVE JNCinEN'CE WON VW.IOCS OCCI'P.VTIOX'S. In the sections Itelow, the periods 1021-32, 1033-3$ end 1021--38 arc reforroil to as A, B and C respectively. The 56 occupations named in Table IV employed during the period B 3,s$o/*n l out of the 13,305,668 males aged 2o and upwards (census of 1031), and they include most of the men engaged in the two largest industries in th- country, namely agriculture and coal mining. The tables include 3350 out. of the 1 V.741 cases of cancer of the lung, and 1431 our of tho 5307 cases of cancer of the larynx, occurring in period B, in the whole population in question. Tables IV and V show the data referring to tiie occupations which have been studied in detail. In Table IV the occupations are arranged in the order of magnitude of the ratio for cancer of the lung, and in Table V in the corresponding order for cancer of the larynx.** The population engage'! in each occupation, and the numbers of calculated, and of actual, deaths which are required for the estimation of the ratios are included. The number of deaths in each year of period B in each of these occupations is given in Table XVIII. (1) Agriculture. - A group of open-air. occupations (gardeners, farmers, agricultural labourers, including, shephertls,- farm bailiffs and foremen), which together include about 054,000 men, has 505 cancers of the lung and 342 cancers of the larynx in B. This group shows very low ratios for lung (from 20 to 58 in A and from 22 to 61 in B) and low' ratios for larynx (from 41 to 75 in A and 20 to 70 in B). In this open-air class the' highest figure for both lung and larynx is given by gardeners, of whom many live in or near large towns. (2) Coal mining. The chief coal-mining occupations (workers above ground, hewers, roadmakers, persons conveying material to the shaft, other workers below ground), which employed nearly 770,000 men, show low ratios (lung, 38 to 71 in A and 37 to 72 in B ; larynx, 44 to 58 in A and 42 to 73 in B), which are very like those of the open-air group considered, in the preceding paragraph. The air in a coal mine is pumped in from outside, and collieries are not always situated in urban districts (e.g. the Kent coalfield). The close agreement in the ratios given in A and B by the agricultural and coal mining groups is noteworthy. These two industries (agriculture and coal mining) have also a low incidence of cancer of the bladder (Henry. Ken no way and Kcnnuwav, 1051), The rate of increase of deaths attributed to cancer of the lung in tlie.ic two groups is shown in 1'ig, 2. * Tilt* b-iwi*f ih tntul munli'.rs <>f o. 'i.palwri.-. in Tjlilt- IV tt*) ,in.l Vj is rtu, to lour i>,'i"ii;mit<ins (piio-nt fuol workers. ]t--r-* mill worker*. III., .t liini.io,* -neiuc* men. *.U4iitjliTersj iu whiuii no ik'iitlis l'rom cmu.er . it l lie kiry.vi 'eiirre.t in riflirr pern A. GC 15262 ............... ---- 0007253 > NOT DID NOT COME FROM PPG FiLES 1 i- : i > i 1* : *i tin- 1;i.-: *1 1 ! . |h* *. i` ! :r;*. **. butc m'isjly in-::;...* Iiu!ii -h u - a Inch incidence t-;;rn- -.:; - n.'u! ssph;.lt*-iy. s!n>V .1 0 >ks v.v. 1 lit.- 1 i.i.it in* tier . (T;:*l* Vi). Xcm*. of the*? ovvtipu- if tht- lung. anil the put hums. street iiuimisis inct fall in i'.i> l.-.ter ju rind. (4) Oitx'iM'. hnrstX'Vjitrx. rarjitnhf-s. (br-.< m.-* and linr.-i-Ia-i-pi-r.'!. who art* cxpo-ed 1.1 various forms of dust arising from li'iMt and foddvr. have an im-idem-e of cancer of the lung (A 100, B 71) mid larynx (A 134, B !<) which is not wry far from normal. Carpenters (T-' lv T an-.i Fig. 7) ai.-o .show low ratios (lung A 73, B 72 ; larynx A 4*2, B S8). Thc-e butane*-? suggest that exposm e to dust per sc, irrespective of its chemical nature, dor- nm conduce to cancer of the lung. T.-urnt: VJ.--Cancer of Lung and Larynx. Occupations with Exposure to Rood Dust. Ratio. T-ur.e. Lareiuc. 1021-32. Paviunrs. street masons, concretors til OO and usphnltcrs .... Council labourers, road sweepers, dust- men ...... 173 Drivers of hor.-o-drawa vehicles . ; 144 Motor drivers (goods ami passengers) . 3 42 (5) SlUcosit. ., " 1933-3S. 1921-32. 137 . 154 167 172 131 liS-i 153 .* 100 __ 1935-38. 11G 207 143 113 . iu-T;'..le YU. Of these oveuparions', those mentioned in Table VIII, and the various subdivisions of coal-mining. were included in the present study. Table VIII .-hows that- in the period it!S3-3S, the highest incidence of cancer of the lung is in potters" mill workers, slip makers and arkmen (ratio 21S), but in this occupation the numbers are small (see Table IT), and hence the sampling error is considerable. In the other occupations in Tabic* VIII the tendency is towards a decrease in the ratio. The s* onenia-and -'torn- miners and quarriers of course include many workers with non-silk eons rocks. The figures for deaths from siiicosis in occupations- c.f this class are fulling : in the metal grinders this is duo to the adoption of non-siliceous abrasive wheels. v;ueh has been advocated by the .Senior MecbYui Inspector of Facioiies (Factories Report, 193S). In the v.ii' -u.' groups of '.-.-a; miner- Table IV) th- low ratios show no uniform U-.tdeiic;. to .isc. **r fall/' The gei:'-;.:' indication of - kcse results is that the factors which to siliec-'i-- are not very active in producing cancer cf the lung or Lryi.x. Ti.eie an*. however. in he ii`- raturc various accounts of cases in which 0 4\ .? i*;. *Jin*a* ivl'*, i\t * -ui'.iv c.f in Sunth 'Wa)^ #riihrnaiio :yAu* t*. if u::i jv t/-*'***. *f p;tiiot*r rf i!.* m on wr'.iiVrJ tilrjoiicy, arui oiif i w;'vi. jn n fnrrh^r marling iirnrJy *if" iivciop-tr* in ll. -. .- - f*' *t *t bs ^3 ; .3* 4 ! i * V** *. *\< ';Sr j*7v`T*'T'r - i "v ^ GG 15263 1 DB 0007254 | k j r "A ,^* *'* .' f^f '* ` ",M`*i -- - *>'** *+'' '.* ' ;**' ' '*', '%'a ** * V*vy nj-, . >;f-j y -3 :,>:f . :. ir 'I K. !. AX!> X. M. KKN.VAtt* W cancer nf (If lung M us annia-i.tM-il. wit!i nilico-.s. Such iiclividual ob.-e*-various-a: dilricu't t<* ,!>((>.- -* nii-fic:.-\;y as fit*- tv.-t condil'i-ms must noun.'.Caen ncct tou'-tliiT, ami tin; c-Imm* examination of silk-uric lungs in special invest ignt ici favours the detect inn of a high proportion of etueiuunKU. Talitre vrr.--Iini'!)* from FiUrn.<it< hi Eughnot iiw! UI".:>*. /., 1945 iti<:lu.irc. (From the `Annual Jirp'-ii of the f.'bhf Inypertor of Factories for tin: Fear 1114.',' p, 70.) 1. Refractories industries . * . 2. Pottery, manufacture of . 3. SamUtone quarrying and dressing 4. Sandstone masons . . . 5. Metal grinding ...... 6. Sandblasting ....... 7. Steel dressing and cleaning of castings 8. Stone, pebble, Hint and sand crushing 9. Scouring powders, manufacture of 10, Abrasive wheel manufacture .... H. Glass cutting and bevelling .... 12. Millstone dressing ...... 13. Slate quarrying and dressing .... 14. Granite quarrying and dressing 15. Tunnel mining (sewage works, etc.) . ' . Kb Coal mining . . '. Table VTII.--Cancer of Lung in OccujuUions with' Liability to Siiicosi*. Patios of roiistfn.il to cakiilAtetl (loaths. Potters' mill'workers ; slip makers ,, and arkmen ; Potters ; ware-makers, casters and finishers ..... Metal grinders .... Stonemasons, cutters and dressers . Stone miners and qnarriers Sand-blasters .... Conl-miners (see Table TV) 1021-32. 90 152 229 149 105 201 ' oS-71 1933-38. 218 132 144 140 40 103 37-72 1921-38. 174 139-3 170 143 70 136 43-09 Xmnb^r Of (l-'iltlis. 1921-:' o 22 39 SO 39 a . 774 Some of the literature on the relation of silicosis to cancer of rite lum* is summarized below. Dihl* (1934), in the course of 14 autopsies upon per.-ons of bnrh sews suffering from silicosis, found malignant di.-'-a.-t- in three eases in -touemosons, an follows : Case I, Carcinoma of bi!(vduvt. .''nb.rmirinl-i-cll vur'-inottia of prostate. ,, 2. Oat-cell carcinoma of lung. Columnar-cell carcinoma o: colon. ,, 3. Anaplastic carcinoma of lung. ` r- 1.1 * Fi: : . :'r'' ' . * '*J w i V i ^ r^m -; Lnu 'n ctm TMorv'-.ra | 0B 0007255 J M l I **/ .1.1 (!;:* ; ... ti ; I; J j.*unts t)u* Mean inni'.H i.; t !,<--" o.-iuij iicnrh1 in lime.* iL::t of A. * 1 r i* * tin* of i!k- iis'il'tii'u *,N iP) of J' v.m-; tin* .-.ime as that of A. t, ;%ic...-J.lil\v.. CV. MU d il n.MIM'I.UII* il *s i li iV* Hi t % ill i*u> i i il..;-. ,~ iij 3. ;iiit 1 librori* net h.->irii.-.n sugg.-.-tivc ol riliccri.- in - oft!.*- 12 ca-ics. / in A and D " ii:<! :' !. siy :-on*e x-pi-, duce tln> picture found in iho-e :n M'lucli silica a present in excess."' The authors conclude that " a3 group of cases of pulmonary carcinoma exists in which the organs contain an I'V1" '* 'i'ica and show bisi-h-gicai evidence of silicutic fihmsis. Tilt* coinncclluussiion. *M e -th inkl*. ?is. jthi ait itihe rolse orf t. hi e silicosis i*s ac.t*iolog-icails."i Table IX.--Silicosis and Cancer of Lung (Klolz, 1939). Xurnlar of autopsies. Carcinoma of lung. Xumber. Per rent of *u(op>ie*. Ciises of silicosis 50 4 8-0 Cnselccted cases 4500 53 1 -17 . KJotz (Jn.30) gives some data from Toronto (Table IX) of which the.' stati.-ticni character, and indications, arc similar to those of the material of Anderson and I)ible. . In the report for 1038 of the Chief Inspector of Factories (p. 81) the Senior Medical Inspector (Dr. J. C. Bridge) gave the following data derived from 1290 autop-io. carried out to ascertain whether silicosis was present (Table X). Hence presumably the subjects had shown in life some respiratory symptoms. T.-Mile X.--Silicosis r:r,d Cancer -of Lung (J. C. Bridge). Xun.brr of nilup-ipK, 943 347 *. Prerent Absent Cancer of Tung. Xumlrfr of cases. 23 17 Per rent of am-opsies. 2-4 4-9 1290 r-.-.m). 1.* l Taule XI.--Cancer of ihe Lung in IVilirafcrsrand Miners (Miners' Pi-fists Medical Bureau). 'wim !iaI hiiT ___- - (`"`ivral !hk] ;tnJV ly^'.icjil Dinruu), (McUic:il I'lirctll). of * ry r *l !i:viC. 13 iVrvi iitatf .fiii hm.~. !!,* i>;::i of ; rijtiurv i% JVfrrtf.nt:* af all tni<rt *>*!, 0-71 -- V.**t MU5 r.**t* r V*. *,lnstr% <*nnr i-f lime. 10 -. n?i* .if ;si! JVlM in*.*rt 0-7 am The data obtained during 15 years from 3117 post-mortems on`European miners on the M'itM'atcrsiami (Miners Phthisis jhiiouu. 1930) indicate thnl tlie 5? f'0) tZ.) ^4 "J 'b rr -- k. f GC Jb2b5 rWtt* i`Tyn- NOTE: THIS DOCUMENT DID NOT COME FROM PPG FILES 270 r,. L, . A..X..D. X. -M. ,fC-eEvX---XAW'AV T.vr.f.K XIV,--Cunrer nf Luhj. Occuitatinns Associated With Co/d fin/. <ti>l T>ir. Ohs stokers and coke-oven chargors . (las producermen .... Gus-works foremen and inspectors Gas fitters ..... Gas-works' labourers Chimney sweeps . - . tagi :.s. I# nv,e. 12 25 41 no 21 lwji-ag. 342 lw2 197 1*2 162 170 litXl-Js. 251 232 IGl 15$ lot) 90 ItcH-a 2S4 2u2 174 167 12'. 110 Excluded: Labourers, patent fuel works . Gas-works engine and crane drivers . Gas-works managers Tar distillery workers and coke-oven workers ..... 267 3 6 4 S . 433 GO 244 29 1529 ISO 5-S 70 571 13$ - 136 32 21 .In five of the six cases, and especially in sweeps, the ratio has fallen in the later period. The ratios for cancer of the larynx are irregular throughout .this class. i* (9) Professional oncvjxtlinnx. A group of professional workers (stockbrokers and stockjobbers ; clergymen ; Roman Catholic priests and monks ; ministers of other religious bodies ; judges, stipendiary magistrates and barristers ; solicitors ; physicians, surgeons and registered medical practitioners ; dental practitioners) numbering over los.ouu men and showing 178 deaths from cancer of the lung and 39 from cancer of the larynx, give altogether ratios rather below the average (lung A 94-, B 97 : larynx A S4, B 50 ; Tables IV, V and XV). These ratios for cancer of the lung, being near 100, are in accordance with Stevenson's (1923) discovery of the absence of social gradient in this font) of cancer. When the individual occupa tions are examined considerable variations are found. In the earlier paper attention was drawn to the high ratio for cancer of the lung in judges, stipendiary magistrates and barristers (173) and in stockbrokers and stockjobbers (1ST) ; in the later period (1933-OS) the former fell to 112 and the latter rose to 253. The .stockbrokers and jobbers also have the highest ratio among the professional workers for cancer of the larynx. The figures for Homan Catholic priest.-. and monk.'* are too small to he significant. The ratio fbr ministers of other religious bodies has.risen (Table XX). In regard to th*' view tii.it the rapid increase in recorded deaths from cancer of rhe hi/tg h d ie to the detection of more c.i.-es by improved diugrin-is. the very modvrite ,;vi eoe..-i.-tent iv.tin (A 129. II 125) for cancer of the lung in medical men is nomv.-nrthy. for this is an occupation where the availability of the existing > i- for the defection of cancer is presumably at a maximum. Rental practitioners give very similar figures (A in;'.. 11 124). j BB 0007257 CC 15266 ,1 i. i l- LC.V: V.\- :V.i.V i ii-` tartar c.e-CK tama i c-1 the lar. ms, in those oeeupatinus are ; -'mo, and in l a !( v below-. except in stockbrokers and sinekjobbers 1* * * * Tauu: XY.~ -('<u'iv (if l.nD'j. J`i'fii'ioii<il Orci(jinilons, \Um. m*k-Lbroker* and ti.saa }tomAn C*:JioJie IViV*-'* d Moult* 3.rt4 Clerptnen (Anjlic&tt Cmin-lil 33.422 V ims.a.-.'.' of other He- lipious Jtodies 1 .ludsr.--. Stipendiaiy AIiiristratM and TUrrtfters . 3,S8 Solicitors 17.300 Khv^ciiijis, Surprons ouu Rr^risteri'd Mr ili cut Praf-ti. tiourrs 27,`lal 1 K-ntol Practitioners 10,494 l-.i-.O-ttL i u'ti* 14 l 15 3 7 1!) 33 S K->: to of r-jJ. I-* !* *aU Kirill. 1S7 . 31 . * 33 . 3$ . 173 . 100 . 120 . 103 . niiaww. _ > ion* Tiii-il. rail. Ui TfeU dciiili-. JWI-3S. JUl lo of r^ptL lo }<*) tal* deallttf. IPil I'alin t of lal-vici. lu-alln. )Uil 1. 7,122 32 233 . 229 . s 15S 4.030 -- -- . 11 . 0 24 22,734 *2 40 50 . 1 45-5 11,000 13 09. . 57 . c 04 f1 3,032 7 112 . 136 1 34-5 17,853 20 S4 . 90 . 9 ,05-5 * 2!,90S 56 123 . 127 . 7 38 11,033 IS 124-5 . 117 . o 44 (10) CuUon iror/.crs. 3D . Colton strippers, grinders and card-room jobbers, among whom severe bronchitic and asthmatic affections occur, show a very low ratio (30) for cancer of the'lung in A. which rose to the normal level (104) iu B (see p. 2S6). Cotton spinners and piecers have a low but increasing ratio for lung (A 32, T> 7n) and medium ratio for'larynx (A 14S, B 01). The toul population of 4*3.001 filial census) includes ring spinners*as well as mule spinners, but the laner occupation certainly makes up a very large proportion of the total, for the number of mule spinners aged 2.' and over was estimated in 192(3 as 41,ouO by the Departmental Committee appointed to consider evidence as to the Occurrence of Dpiihcliomatous Ulceration among Mule Spinners. Jn view' of the exposure to tid< which may be carcinogenic the low incidence of cancer of the lung is remarksdi'o, but the very high incidence of cancer of the skin, and the increased liability io cancer of the bladder i Henry. Konnawav and Kennaway, 1931) in this occupation, must he taken into account. The question of the penetration into the lung of oil droplets in the air of the mule room will be dealt with in *not her p u h!i eat ion. O CO UJ ; CD - O. .; ^ : 3? *o ~ or , */ - Wj O v.i O yO ----j ? s- T> * r.r.Tu <-k iNcuEosr ok tv.nosh e-r thj: lkxg axi< lalynx ;x mkn axu womiix. (7:i,<cr of lung. Cancer of the lung hn> ii;cre!,~*<! from Mi'W io ".9t-2 cases wor aymuin in men llvg. i) between 1921 .Did Ip4"*. a:vl Hum 1s<; *o 1mi ra-t-s in women, These figures are in the ratio of 1 : h;-d (men) and 1 : s (women). The incu-ase became more rapid iu 192r. and hi l!'3o in men (J'ig. I) ami about in women. Tne annual increase, i.u n.cn, hciwveij !(*32 ;t:.1 ;!*.*!" v.n*. at i!,i* rate of fn>m 200 to 3of* (-.w-s per aim;.in ; since il;cn it lain been w ry irregular ** .. .;`a v'. "*?' .'V V#*-" '* * ** '. V' ,m ' ^ GG !526f -* , * '* -1 ; "'.v ijF0^"2"8' i - % * #* .;;* i'.v" vd" ;i?rvrc::-; :r~"' *'** jr!-*'j>-v;* v;. 1- * *4- : -- *-' -./.v* ^ - *-. ' r .'V -v-*'5r ' %-*>* - ' r* '*$ - "; -hrtJj , -t *"T . 1. - " ->-"(1 ..'djy-* 5-.^ . ; ` ".'.Asi j -'c: r * ' o^c E. L. MTD X. M. KEXXAKAV (Table XVI). The ratio between deaths from cancer of the lung in men. and in women, is now (i.o. in 1945, the latest year for which figures are available) 1 : 4*0, which is approaching the latest available (10:;!)) ratio for cancer of the mouth (Table XVII). Cancer of tie lung differs from the other forms of cancer in Table XVII'in that the proportion of males is increasing. During the whole G000, Males 5000 * / avN 4000 / / :<<r <&y .... /y* 3000 / / SS` .<CS"Sv. ' W. 2000 Females k ( iooo: 1935 1910 1315 Fio. 3.--OentUs from cancer of lung. Males anO FenmtiM. HWa-l'M.". ' ------- period under consideration here (I0gi-I04n) the ratio of female to male death* from cancer of the.lung has changed from l : 1-t* to 1 : 4-n. A similar ch.irr.rc has occurred in the thiired States ; the ratio of ri - ..rmid udi/i d death rates for cancer of tin* lung and pleura in white men amt women was 3 ; I in ami 2u jears earlier was less than 1-3 : i ^Statistical 'ihdletim |*. Dig. 3 shows that the rate of increase in reem* years of deaths attributed to cancer ol the lung is much greater in men titan in women for the curvo of deaf ns rri T *'11 W- V* C-G 15268 1 BB 0007259 7 1 i A' t ..f male.-. ri"- in :-i li !. than ..f death.' t*i ; *. !' ihis aiiijjieiit tin-in u*t* lnr.u-('n tin* m \e> i> uuc in large par! u* the met that, iu a graph of 1 his lype. a given increase in <1 larger quantit.v is much mnre enasnicuous than i* the1 '..me j 1^.-1 ovifiti?.* incieu'O in a smaller quantity. If one ivfhuns the annual mini! of 'lenthe- ns a nerecntage of those in any given initial tcar (Table VI). the diderenec between the two sexes is not nearly so conspicuous (Fig. -J). 250] 200 150 Males / / // / Females / . * aw. V .A j ' aw' . *> - <t** V 100 # -i .. J y35 ' 1- ' * 1 1940 1945 Fig. 4.--Cancer of lung. Males and Females. 1035-2943. Deaths jvr annum as percentage of deaths in 1035. Taele XVI.--71qtah of DratL' Certificates {England and IVales) and 'Percentage Increase in Cancer of the Lung. C,.ut-fT ;f lung. C-ancer of larynx. : Men. tt'oiuon. Men. Women, 1035 2337 = lot* S5S = lfO 903 224 193 Is.*3" 2Gu6 = 112 2014 = 126 ..017 = 107 027 = 10? 016 91S ow - sO 232 193$ "273 = Ut 1040 = 122 $$7 259 1030 31101 = 145 1 140 = 134 029 2$0 loin --= uu 11$0 = 137 0n3 2G7 .11M I 4t)G9 = 174 135G = 135 020 2G9 .5'. 1042 . ' 4570 =. 10G 1207 .-=? 14$ S57 255 1 !M 3 5001 = 217 1290 =1 151 972 2S1 1044 10-15 3491 = 235 13G0 = 15$ $52 2$0 59S2 = 25G 14 SO = 172 S41 27!) GG I526H p?tpr^iS^. Zx!O^H*b700072^0.1 N -V> * * * *', r << * * ', .m im\ *1` /-* r >V*-*-i-V--* ~'*?sa Ii ft* m--^n ;&4~ c-:i :; ; g-^: *..*_* t e * ; ;>i j Jj.-'i/ . , -5 r ; I - .*. *\ .;,** t c|h>-^ *-5TIr,.--- - J*v i *, -- . 4 ir1!!- ` ' J : C 1 c' i v * & < K . -J i-i -:v^ \ ? Table XV11.--Cancer of Eung, Oesophagus ami Month Region in Men and Women [England and JJ'u/m'). Site of cawer. Xtimlwr of rieatlu, , Women. Meu. Ratio. 1921 . Lung 1932 * 77 * H . Oesophagus ISO * 5G5 * 601 361 1553 1774 . 1:1-9 1:2-7 1 : 2-7 f . Mouth region (lip, tongue, mouth. 1937 1939 7* tonsii, jaw, pharynx) . . Lung . . . - * , ; 77 *** * . Oesophagus # 530 927 1029 729 3040 1 : 5-7 2914 ` .*-- 1 : 3- 1 3544 1 : 3-4 1590 1 : 2-2 M Mouth region 1945 ,, Limg * * ' 585 * 1480 2538 5982 1:4-3 1 : 4-0 Cancer of larynx, ' Cancer of the larynx has increased between 1921 and 1945 from <141 to s4t cases per annum in men, with a maximum of 972 in 1943, and from 13S to 27!) cases in women (Table XVI). These figures are in the ratio of l : `1 3 in men and 1 : 2-0 in women. But the figures for men have been tiuctnating in the region between S50 and 979 since 1930, and in women there has been no uniform increase since 192S. Hence if the adoption of smoking by .women has had any effect upon their liability to the disease, this factor has reached equilibrium. . comparison- of the ratios nr the earlier and later periods. The calculation of these ratios (Tables IV and V) for the two periods 1921-32 (A) and 1933-38 (B) provides material for a comparison. Tf the data from which the ratios are derived are reliable, this comparison should show whether the incidence of cancer of the lung or larynx upon any given occupation has under gone-changes differing significantly from any which have occurred in the general population, and the general degree of agreement between the ratios for the two periods is some indication of the value of conclusions based on death certificates. In Big.. 5 the comparison is made for cancer of the lung by calculating the ratio between the earlier and later ratios (B/A X 100) and setting down the figures in order of magnitude. Occupations with not more than one death in either period are omitted here, ami are considered elsewhere (p. 2X0). The results shown in the graph may he summarized thus : Ratios below 00 ,, 00 to 133 above 184 . 11 . 35 - *>4 49 Thus 3.7/49 of t he ratios of one period, or 71 *4 jvt-r o**nt, an* within -- 33 per cent of tho>e of the other, which is p* rii.ips as cl* -e an agreement as orio could look I bB 0007261^  * w 'fc ; s<; ax!'* l.'-uYN.\' I o *: iy j \*y A* 5 '* w / A. Ratio of reri-rt-erwl jlo 100 ce.leulf.t-ed deaths. f'JJ. B. Ratio of tvgsstsivri to 100 t.-alrulaCt-d deaths, 1933-1MS.-- - Dots represent B/A A 100. .- Occujntions with not more ;!mn one death in either period axe omitted. for in such material. When the individual points on the graph are examined, the large: occupations are found to lie chiefly in the1 middle, part of the series, as one would expect from the lower sampling error. A,similar treatment of the figures for-cancer of the larynx^ (Fig. 6) gives the following result: '` ^ ~ ^ " . . Ratios below (>G *' ,, 0C to 133* ,, above 144 7 . 2S 14 49 In tlii*- case 2R/49 or 57 per cer.t of the earlier ratios are within -- 33 per cent <>f the later ones. There arc thus more occupations in which the ratio has increased than in the case of cancer cf the lung. ocrrr.ATJoxAt. ixcjDr.se:;:. of tbs i'schease <<f cancer or the lcnc,. If tht-rc is a real increase in cancer of the lung, and if this is due to some extern;.] factor, one might find clirfcrences in the rate of increase in classes of lK*r.e;i.> exposed to different e::\uonmeuts. Ti:c annual numbers of fivathx from cancer of the lung, and of the larynx, in each one of tho occupations studied in detail in. this paper can he ?ccn in Table XYII1. The increase in the total of recorded c-r.se< )as been so great (Fig. I) that, if tiii increase were due to a con tribution from any of the smaller occupations, the incidence upon these wvtld have to-be very high indeed. 'J.- ** -- * J CG 1-5271 T*^eT0007262_7 *v: -*`W'1 " 'Jf\ 5` 'r -. 4 ' 'ij ` -3 :-J 3 - , < 'i f -= * -J ' - ` -* *. - '* ,1 { 1 S . J c. -! . P '*- -i * *. .' y w% V. ,v : l*lr<f >* : 1.4 , yi ' C:` -j.- * - j & ' lI *. A ** Jl * - 1 :a 4 9 -* . :i} J j . 14 4 1 .1 7 ? .1 - * 2S2 k. L. axd N\ M. KE27N\YWAY. WJit:&n75: ~ `j ! ^ "1 , 1 ` ' " i"'>' ' Jt_* ? `xvn #3t.Tabus Oit*"' "^'VJ <i'^, i-i (- "."i?, `r ^ I.--AW*r itfi&lttfV' .3.. Lu*ty /ia<L iLKJjf in oC> Occupations in (ttcf Year I'.b'Ll-LUdiL ._ - - The occupations are placutl in the si oe order AM in Titbie XV. L-t.4 1044. 10:;:. 1040. 1047. IW\ Total. Labourer)!, patent fuel works . *" Lung Larynx ------ --1 1 Cm stoker* and coke-oven chargers . Gas producer men .... Lung Larvnx Lung Lurvnx <1 5 3 4 3 4 - 11d 11 3 l-- 4 __ -- -- ,,__ 3 4S 17 5 Metal minders .... Gas-works foremen and inspectors . Potters' mill workers; slip makers and nrkmen. Lung Larvnx Lung Larynx Limg Larvnx 1 > 3 2 .1 4 3 1 1 5 ,.74 6 1 3 -- <-- a--- 1 1 __ 1 1 i 1 -m ew- __ _ ` __ 20 a 15.> 4 Mainly council labourers, road Lung 1> in If. 18 . id 25 lu:i sweepers and dustmen Gas fitters............................................ Paviours, street masons, concretore and asphalters . Motor drivers, .goods, and passengers Larynx Lung Larvnx `Lung . Larvnx Lung 6 7 0 16 12 . 13 C3 _4 1 w. 4 1 s . 3 r 25 <> G 4 3 2 I 2 *> 14 -- 1 I ____ 2 --* Me 4 30 20 42 43 -*>-- *S.l 3<>1 Blast furnace engine men Larvnx * t ti 8 Lung __ 1 Larvnx -- --w ___ s s 11- * 4s __ 1 ___ _ Cabinet makers . . ... Tobacco manufacturers . . *. Lung Larvnx Lung Larvnx Id -- d2 1> 5 14 6 - M " 13 ea ! 3 2-- l . J> __ -- 3 .1. -- _ GO 20 S 4 Stone monono, cutters and dreseers . Tanners, leather dressers, curriers. ' skilled workers Potters; ware-makers, casters and finishers Gas-works engine and crane drivers . Sandblasters ..,.'. Lung Larynx Lung Larynx Lung Larynx Lung Larynx Lung Ijirynx 11 15 13. l 17 13 . So 1 1 4321 12 4 \ -- 53 1 t O1 I __ 1 .1 5 .4 -- *> 15 --1 1 3 3 > 1 .30 i 13 4 3 1 1_ .1 ---- 1 __ -1 -___ e*e ' __1-- .. Gas-works managers Drivers of horse-drawn vehicles Gas-works labourers Lung Larynx Lung Larvnx Lung -- -- _ ^ 1 -- 1 w-- _ 25 4>> 35 51 45 44 Is n 23 17 13 4 K s 0 0 12 1 1 240 I no French polishers .... Larynx Lung Lurvnx 1 ,* 1 1 2 31 442 4 __ . . 4 1 J1 21 0 Painters ..... I.ung -i* 47 43 51 7*i Li-*-tied victuallers Printers ..... Larvnx Lung Lirvnx Lung d" 24 20 11 IS 20 i- rn 21 '2'.) IIS 53 IT 21 14 Id 11 1 V 14 13 14 -lit 120 172 1>:2 1 Hi Chimney sweeps .... Plumbers ..... Barmen ..... Ijirynx Lung iirtKMX Lung J.nr\ MX l.llng Ijirynx >; 4 --- 1-- >1 10 V, \ .1 1 33 ii H 7 4 .1 1 4 11 1 13 14 17 ti .7 1 t I 4 -7 I1 > l*i 'i tits `J'i LJ nraso^iTT gq j 5372 - n,-i .. N- . !* ' W l.W iXX Ill IroiiftL). Kina. 1yd.'.. lry;. 1P1*. iws. Total. Jl.iirUrvr-i r* . . . linker? u.;>l pastry vuoki Lini; Larynx Lung Larynx - Lung Lnryn.x 1 3 4 3 1 3 a _ 3 3 3 4 5 3 3 4 4 3 _nr- ,,a 13 4 10 ft 12 15 12 IS 3 t a453 17 14 47 10 7fi 24 Kc I'l cfe^-iiuti.d men . Celluriucn , . . . 1'ottery. etc- kiln and o\ cnnicn, kiln settrrj. mid placers Grimms and liur*ekeepers . Brick kiln mid ovennien Lulltr Larynx Lui>g Larynx Lung Larynx Lung Larynx Lung Larynx 23 29 27 34 20 35 17G 3 2 3 _.j4-- 10 ll 5' 4 39 0 4 1 2 1 3 3 * T- 1 2 2 24 3.3 14 12 12 10 3 4 3 3 A _ 5l2 4-- 5 2 1. -- 7 43: O __ -- 1 --' 30 17 9 3 ' ijtji I ionary ermine uud crane driver* . Lung Larynx 9 9 15 11 14 17 ! 75 7 4 0 2 A 3; 24 C-ntton stripers, grinders and card room jo)>ln-r.' Llhohioiive .vine drivers, firemen tm.J cleaners Carpenter* ...... Lunz Larynx Lung Larynx Lung Larynx 2 1 3: ,_ _.. _- -- 1 1 11 3 G 5 10 1 13 13 2 5 13 2 25 34 35 31 35 40 21 U 17 IS. 15 12 G 2" GG IS 200 97 Si<im* miner/ and ciucrrier* Lung Larynx 2 2 1 534 G 2 2 1 1-- 17 12 On) miner*--hewers and getters Lithc.crapiuc process engravers . Htflet fiimuc'cmcn and labourers Lung Larynx Lung I-arynx Lung 51 49 51 40 G2 GG 319 20 H 24 14 20 13 .2 1 __ __ -- 1 _ _. a -1 2 -- 107 4r O fJO 5 -,u __ _ 1 1 I 1 4 / -.ri ' Larynx __ 1 1 1 4 j Gardeners , Lung 21 31 33 40 41 42 213 Larynx 10 23 11 25 20 2S 123 ** * f; Coiton ^pinn^rs and pi*"-or* (mule, ring. eiip o: liv er) Coni miners--workers above ground Tar distillery workers mid coke-oven Lung Lar.:^ Lung Larynx Lung 4 1 4o 3 a G 3 7 3 3 0 11 .5 11 7 9 7 1 ' 3a 5 3 G l a^ 11 49 20 0 workers Brick and plain till- tankers Larynx Lung LnrvVjs _^ ___ -- -- __ 2 1 2 -- - __ _ -- -- , --5 -- <r t- : C-nd miner*--it her \eorki r* below Lung G 7 10 10 7 12 52 c * ground Larynx C.\il inii.ers--onvcyir.g material to Liuig a 1 45a4 3 *> 5 3 4 11 IS 2S n the shaft C*nl miners--mailing roads I'-ittvii wciivt:? .... Larynx Lung Larynx Lung Larynx 4 i^_i ___ ___ G ii i 7 244S 3 533 3 _- 1 4 14 47 33 3 --. 24 7 37 24 17 12 y 9 jn A-.= Ls O o F.:ni"rs ..... .tnrii ulrurul labourers, including .t.* i-{o''.,!?. Kon.-i i- wild foren.en Litt-g Uiynx Lung LurvvT l.n-:j 17 24 21 29 27 30 20 12 S U JG 11 17. 21w 21 19 - 17 3? 1 31 23 1 23 44 *T 2S AA 14S SI 137 135 0 o ~\y* Lor. I-- A---- -- 3 Lung L Larynx i: _____________ _______ t-r , - GG 152/3 0007264 * *- J " 284 K. L.AXD X. M. KENNAWAY Fio. 6.--Cancer of larynx. Malts in 4'J occupations. A. Ratio of registered to Iim) calculated deaths, 1!>21-1!>32. B. Ratio of registered to Imi.!. -slated i.Wtli:., l!)3:j-ly:ls. Dots represent 11 A :< 100. Occupations with not more than one dAtth `n either p-riod are omitted. Table XIX.--Increase 'of Deatjvt Attribute/. to Cancer of Lung in Certain OrcntHition-i (1 >27--1938). 'i t i r Paviours, street masons, concre- See I tors, asphalters Council labourers, road sweepers, ''Table VT / dustmen .- . i Drivers of horse-drawn vehicles . i Motor drivers . ... i Death* from OBiiwr of hui. 137-32. l!)33-:ts. Difference. 7 14 i 47 III 102 207 103 240 301 - 60S . . 56" 120 ion __ 301 General population, males 0200 . 15,045 S740 For example, if one takes the numbers of deaths from cancer of the lung in those occupations where there is especial exposure to road dust (Table Vf) and divides them between two -ucees.-iv*. periods uf 0 years (J`.27-32 and anti compares these figures with those given by the whole male population, it Incomes <]uite dear that even rlie-t* occupations account lor only a .mall ("ruction (.".ill ca.-es or 4-5 per cent) of tin) v, hole inipat^e r.f"x7l!> cases (Table XlXl. The following example shows the cifeet of flic increase in deaths attributed to cancer of tlie lung upon the 'lata tor a .-.ingle occupation. C-G IG274 T | BB 0007265 ^ INC'IDF.NrK OF CANCER OF LVXO AND LARYNX 1S' -< r* 210.431 carpenter.* produced 123 deaths from cancer of the lung in 12 years (1021-33) or 10-2 deaths per annum, ami in the next G years (J933-3S) 243,92S up*-*; carpenters produced 2u0 such deaths, or 33*3 deaths* per annum (Table J\ ). The number of carpente:s producing 1 death in 1 year was therefore 210,431 -r- ln-2 = 2n,f.40 in the first period and 243,92S ri- 33-3 = 7324 in the second. The ratio between the two figures, namely 3*3 : 1. is reasonably near the inverse eV* cf the ratio (1 : 2*3) between the mean annual deaths (753 and 2507) in these two periods from cancer of the lung inthe whole male population. The result indicates that the increase of cancer of the lung has fallen upon carpenters, who B h undergo considerable exposure to some kinds of dust, in much the same pleasure -as it- has upon men in general (Fig. 7). j B l fw-*i fl :/ J cv* 3 B ii tj fc! a .Occupational exposure to three agents which are perhaps liablfe to induce ;.i cancer of the lung (asbestos, arsenic, nickel [Factories Report, 1938. p. 72)) occurs in employments which comprise very few workers, and hence have no appreciable .effect upon the total. Of Ihese three substances, arsenic seems to be the one to which the general population is most likely to be exposed. No attempt is made here to deal with all .the data on the carcinogenic action of arsenic, as this subject is under investigation by a Committee of the Industrial Health Board, but the following ({notations from recent Annual Reports of the Senior Medical Inspector of Factories show the possible importance of arsenic in relation to cancer of the lung, " In the can* of aisenieal poisoning due to sodium arspnite, which was fatal, the post-mortem examination revealed that in addition to pigmentation of the mini; and limbs, warty growths all over the body, and perforation of the n nn?.ri septum, there was a primary cancer of the right lung until metastatic growths in neighbouring glands and in the liver '' (Factory Report, 19.,;9, H* p. 22). "The other (case) occurred in a filling machine operator aged 57, for nI?t 43 years in a factory manufacturing sheep dip containing sodium arsenite, the r c cause of death being due to carcinoma of the right lunir." k "'I hive, similar eases of pulmonary carcinoma oc curring in arsenical sheep- J* V dip \\orkcrs have I wen notified since 1939 '' (Factory Report, 1943. p. 45). Neubaucr (1!M7) collected the literainre relating to 142 cases of w medicinal arsenical epithelioma ; in one of the^e cancer of the lung occurred (Montgomery, 1935; Muntgomci v and Y7ai>iiu.n, 1941). The patient had taken f{ ` *_'< h 4 GG 15275 1 BB 0007266 7? nr>-r^. '-*-* '1 *'#'* 4^# j- r*:, *i*#` .*,*-*v #*w -'.V ~V't **'*' .7':^.~- '-`r^Vg -*.-*/t ... :**-..,.** *. r . *^V .v.v . :.. . - >-> * - ' ,, ,, ^ - *-' \ *''.f.c. j,-. ;.;*, \^r*f ;i-?44 It-# V. f ^ w *# \w*."**^*- * r' * * '* "*T t;`, *; -* w .'^*,-'-"*f>*T * > ,f *tf * 2St; K. l: ,\vVd x. m. ke^n'aw.vv h medicine for eczema for six years in childhood. which was assumed to contain arsenic on account of the appearance from tiie aye of 42 onwards of numerous epitheliomas of the kin of the arsenical type. latter an intraurethral epithelioma developed, and dually an epithelioma of the bronchus with ** malignant dy.sfceratosuy characteristic of the arsenical type of epithelioma," and extensive metastases. Sernon (1045) records a. case of bronchial carcinoma in a man who. during a period of about 20 years, had taken large doses--up to 1 drachm 3 times daily--of Fowler's solution (equivalent to l per cent arsenic trioxide! for recurrent attacks of sevore dermatitis herpetiformis. His skin was unaffected. There is, of course, nothing to show that the bronchial carcinoma was due to the arsenic, but unless attention is drawn to such a case others'mav not be noticed. Table XX.--Cancer of (he Luny. Occu is'/ion* Shoiciny a Considerate Base in the Ratio in the Later Period. 1U21-32. A. lOM-nd. E. Xumbpr Poisihtlon. or Utath*. Potter'd mill workers, alip- JUtlo. XnniN-r ' Population. of Ratio. JUM.. miikrrs and nrkmeu Gasworks engine and crane tlrivora .... Cotton spinners and pipeers Cotton strippers anil grinders , and card room jobbers . Tar distillery workers and .coke-oven workers . Brick kiln anti ovenmeu Ministers of Other religious bodies , . . * 1.854 38,317 5,242 0.607 6,225 11,769' 1 08 . 1.786 4 218 , t 1 On . 1.300 5 186 . 310 7 32 ... 43,991 27 T.j 234 1 30 . 5,342 6 2 29 . 7.32,4 6 l 2.J -. 7.112 !) 347 *. 70 - 242 121 NOT DIO"CaaT L,, i W} H1! ! dv .SW* p * 1 r 'i. r ; '4!>r ; `'j* 4t (1) Cancer of the luny. i V- J 1 _o In 7 occupations the ratios for B are higher than those for A by more than 50 per cent (Table XX and Fig. 5). In all of these the ratios in A are lower, and in most cases much lower, than lft'i. and hence the considerable rise raises the ratio in B above 150 in two cases only (potter's mill workers, slip makers and arkmen 218 ; gas-works engine and crane drivers ISO). In 4 of the 7 occupations there is only one death in A. and hence the comparison of the two periods is liable to considerable sampling error. The fact that the rise starts from a low level does not, of course, prove that it is unimportant, and these occupations must be watched in the subsequent years to see if the rise continues. * Cases of cancer of the lung have occurred among stokers of oil-fired boilers, but no figure for the population of these worker's is available. (2) Cancer of the larynx. In 0 occupations the ratios for B arc higher than those for A by more rim;: oft per cent ('fable XXI and Fig. ft). In ft of rhese there are not more than deaths in the first period, so that the sampling error is high, and the ratiu in the first period is low. GG ior'c97i b \ BB 0007267 ^ I. * * J : t.. . : i' *. i : i X X f.--(' 11 -r ih< r *, t + i / fh* J* . #/ . .44.* Mi-ImI rj. . ]jri<-k.k:l: -m.-l .*wi nx-ii . lVticrv, etc- kiln und own men * Cotton -frij'ivrsaiid grind,-re and ram :r^.m jobbers . Tvliai-co ir...;.i;fs'-turtTs Gas works lr-simsere . Lithographic and process engravers * Blast fumaertnm nnd labourer! lyj i -r* _ .V'.rcd-r * if . '..225 I i -v !' 3 I2,lsS 9 5.242 7JS!'S 1.3U3 i l *it*04 t',391 3 A } *i *' f V.AI :.t. ni: Ul 71 no (V> 05 TO S4 40 hiurintj L "Iff /V , "-///. % K. Numla-r of Ratio. (tt-aiil*. T.O.'ft 12 501 n 34 . 7.112 3 123 ** * Wf * 15S lltli 173 * 14,442 10 220-5 . 190 5,342 . 3,102 . 1,049 2 11S . 197 4 129 l:t$-i 1 157 . 207 7.2S9 * 5 214 . 235 * 0,135 4 138 . 340 1 ERRORS IS THE DIAGNOSIS OF CANCER OF THE LUNG. Some .hold that cancer of the lung is not increasing, and that the ascent of the curve (fig. 1) is due to improved diagnosis. This statement is easy to make and dilficult, perhaps impossible; to disprove, and is apt to serve as a substitute for any investigation of the question. If one accepts it. at least one conclusion follows which is of some interest. Lei us suppose that the steeply rising line (Fig. 1) represents the detection of an increasing fraction of a pool of cases awaiting discovery. When the means of diagnosis, and their' availability, can be improved no further, the curve must flatten. We cannot- say when this will happen, so for the present we must take the latest-, and highest, figure (5932 deaths .of. males in 1945) as representing the tcftal. If the'actual number has altered little during recent years a similar number of deaths took place in, say. 192]* but only "301 of these deaths (Fig. 1) were assigned to tlie right cause. Hence in that year in at least' 5OS2 `-- 3G1 -- 5021. fatal cases of cancer of the lung the cause of death entered upon the death certificate was wrung. This is of course possible, but it would be interesting to know what were the 5021 erroneous descriptions of fatal disease. Some conditions which might give rise io false diagnoses in cases of cancer of the lung are* : O o:sr uj. - zd cr: xC " .. - *. .^ * ,> . . V '5 (1) Jtcfiastiuul hthtonr.--The increase of cases of cancer of the lung cannot depend wholly, or even largely, upon a diversion to that ealegor}' of cas*s formerly set down as mediastinal tumour because the number of these has never been sujfivicnt. Thus the death certificates for :r,.i!es show no fall in deaths attributed to cancer of the mediastinum 'iurhu. :he years following 1931 (when this form of cancer is first mentioned in the K-ri^trar-Oencntrs .Stati-rical Reviews), which would r,ci-cunt for the iucicase of T '24 in cases of cancer of the lung which took place in the years I931-:;7 (Table XXIJ). 1_ ^o o 22 I mu t-.> Prrft-i.-or ]j. \V, sc.!'.! informnticn on ihis subject. Tivfi-s*- r R. A. Willis and l>r. Eric st-ov c" for , .4 - U 'I a I!lf * GG 1527? *;-y ,, * . :*4- -V.'r? v ' * * r, '***i-.-/ ., -**m**i'f3r" . . *V ?*; tZ ;* :.v *7*r*># 4'?*^^'' * * * ' V ` w * *''* . 1 .. r * ** ' *. ** r *:? , ` ' ` * `:, ;>*>>. fy'y;v'*!7T7 NOTE: THIS DOCUMENT DID NOT COME ri"U,V( r>'i-j ;:-i! ?$ 2SS E. L. .UvVnD Xx-. vM. KEWAuWtAriY."r' -* ------- - Table XXII.--Cnnr.er of Limy ami of Mediastinum. Deaths nf mules. England ami VVuIkk. 1031 1932 * * * 1933 * m 1934 * . * 1935 . . . . 1036 1037 Cancer of lung. . 1.053 1,553 1,820 2.005 2.345 2,611 2,050 Cancer of inedioatiniun. 133 262 202 244 2-1S 222 30S Total 7 x 1055 . 14,409 . 7,385 1CSI Increase . . 7,024 These figures nrs taken from the Registrar-General's Statistical Reviews for the years i question. (2) Pulmonary infectionn.--A long list couid be compiled of infective processor and their results which might have to be! considered in the diagnosis of ennee: of the lung in the living subject, but those most likely to be named in error oi death certificates are tuberculosis, lung abscess, pneumonia, and bronchiectasis In theory, the numbers of deaths attributed to these conditions should be falling if increasing numbers of cancers of the lung are being detected among sue! cases. But actually the numbers of deaths attributed to respiratory tuber culosis, and to pneumonia, are so large, ranging from 2 to 10 times those assigned to cancer of the lung, that the proportional tiuctuarions prevent any diminution which could be due to this cause from being identified (Fig. S). In tins tiiuuc the two curves representing pulmonary infections show no uniform relationship to the third representing cancer of the lung. The numbers of death.? from abscess of the Jung (Table XXTTI) aro too small (mean llit) per annum) to be of importance, and moreover they show no continuous fall (.luring the period. Bronchiectasis is not separated from bronchitis in the Registrar-General's Statistical Reviews. Taiu.e 1032 1035 1034 1035 1030 * . , ,, - jean* .1/wc Enylaml and H "a Ifs. ''2 82 01 111 lu2 I'. 42 1037 105s 1030 19 p) 1041 l"ti af Limy. . Oil 132 lift 84 02 GG 15278 --B-B'oorn69.i NOTCOMEFROMPPGFILES FV-. .--De<uli? of Mules. Enplrjifi nd Wales. A. Ti:i>*rful'.4i. l\uirHtor%- system. JJ. PneujuoiiiA, all forms, -r 2. . C. Cirtufr of lung. * . (lJj(n from (lie Re^istnir.Generars ` $;a< istiral Review of England and Wale* for the Year -Tblw. Pure 1. MedicaJO . ..____ P' . n nt'f'jc. if trroneoua- (Untjurjiti, . '* t'ume pathologist,:} l.ave en.phasizetl the very high proportion of error in , death certificate* in general and have produced evidence that the percentage of orioneous diagnoses, as- revealed at autopsy, is considerable even iu hospitals, and must bo greater still in general practice. Thus Willis (1941) found the diagnosis to have been `'erroneous or indefinite " in 15 out of 27 cases of cancer of t be lung coming to autop-y at the Alfred Hospital, Prahram, Melbourne, and in a huger series .'private communication) of S4 autopsies performed by him m caj.es of pulmonary caicinema dying in a major teaching hospital, where CI2 E5 !,.4,? r.U'VE M XIV. -.1\>tfU of Dfarnictfcs in $4- Cus>.s of Cancer of the L itifj iiU'i at A>nnr.*y (H'j/fi's). I>iagno.-is cenc t . . . ... l/'rguois Tumour, but primary site wrong or v.ucrr air. '. . Xon-;.t op!a>{ ic di-vu-c iYm,<'!v tuberculosis, abscess, pneu 49 -- yS per cent HI >- 3.7 42 monia. bronchiectasis) . 1( C.:; c: o G) b- aa LU S4 GG 15279 * ' * ^ f * r ***""' .r ,# . -rT - Vsm*tL*iM** --*>***> -- - '-- ------ -- * * . % - | p * * - ,f ' -`v*rr* ** * 0007 270 * ` * - 1 ` ,1 , * * . 4 v - -- ' r ' '* * ------------ ---- .Y t':...' *l_7~ g.,.--:V;:V'.v'?'V1--.*'v ............ 1 7t *'. . .? .1 ,..-' . *:* ** *->^* 'i,* i. - . - */*- *.' , .................. . #;<,. . f_'- *..' *>-^**.^ '. ;" ? -V ,,-V " <*'' V :1$gie :- * *. f. ';' _*V-^ ->V` **-',. `f ' *^' '^Ts.*n''n .', - - 'V,-. 'S*rS- v. .^.>-7" * * 1 _v %- V - ^ 'W'Ai! :; :-7H: ;> -'^4 t~ cr P-i: 4 V , *- ? *r> 7?J??0 r^nr;! v:: I3--; nr j,rs |\fQT ' '. :-. 200 L. AND> Vr M. 'xXN\W V - -`; i ", ` 'j-7 there was a special sunrieat clinic dealing with lung cases, and where full X-ray and bronehoscopic investigation was practised, 42 per cent of the clinical diag- ' noses were wrong (Table XXIV). Hence the diagnosis of cancer of the lung appears to be still very incomplete, even under favourable conditions, in spite of the great improvements which are generally stated to have been made. At any rate one cannot well emphasize at the same tune both the high proportion of cases (e.g. 42 per cent) which escape detection through inaccurate diagnosis, and the adequacy of the improvements in diagnosis to explain the apparent increase in cancer of the lung, though the two statements are of course com* patible. Willis does not give any information about false positive diagnoses-of pulmonary cancer. _ Professor Willis (private communication) has recorded a very instructive example of the statistical effect of diagnostic errors. In a series of lu<>0 con secutive autopsies which showed the presence of cancer, 135 were found to be eases of cancer of the stomach, and of these. It'd, or 70 per cent, had beeudiugno^d correctly and 46 had therefore received incorrect negative diagnoses. There were also 40 cases diagnosed as cancer of the stomach in which this condition was not present. In this group of 1000 cases, therefore, 10!) -f 40 = U'.i cases had been diagnosed as cancer of the stomach, and the actual number present was 155. In so far as the total is concerned therefore the clinical answer to the statistical question--how many cases of cancer of the stomach were there in these 1000 cases \--was very nearly correct. The far greater error in the diagnoses of individuals, of whom - S6 were described wrongly, is concealed statistically #by the- approximate cancellation of the 46 false negatives by the 40 false positives. ' , . This process of attaining accuracy by the balance of positive and negative errors *i3, of`course, neither desirable nor reliable, but it is unavoidable in such material, and is bound to happen to a greater or less extent whether we like it or not. When any decisions are reached on inadequate evidence in any subject, there will be the same tendency for errors in opposite directions to cancel each other. Factors which might cause ax decrease rx tue deaths attributed ; TO CAXCER OF THE LO'C. The increase in recent years in the number of deaths attributed to cancer of the lung might be due to one. or more than one. of the following factors : .(1) An increase in the actual number of cases of the disease, it is obviously difficult to obtain any direct evidence of this factor; one is driven to seek for indirect evidence by means of enquiry how far the second and third factors can be excluded. Some possible causes of a real increase are con sidered in the next section. In the earlier paper (Kennaway and Kennaway, l!>3l>) we drew attention to the evidence afforded by cases of cancer of the lung in which an erroneous di:r*nosis was made based on nervous or mental -ympfnms due to metastases. Tims Tried and JSuekley (I!i:!u; record that mvrastuscs in tin- central iiei\-,,-is system were found in 15 of 2S proved cases of cancer of the lung. To II of the 15 a diagnosis of primary tumour of tin- brain was made anti the lung tumour overlooked; an intracranial operation was performed in II and tho m-ta.sM.^s C-G 15260 | BB 0007271 i.-'< : i; - (UNvr.r. m* lux'- i.acvxx 2ll rvuiuve:: in 10 c.i-e*. OIviou.-ly neither impro\enu*iit nor fashion in the diagnosis uf cancer of tin' lung ts-c W lew) ittmt into piny here, and hem - if it. can he shewn that .such n>is sue. as mu;-.- pi:y-tcianbelieve, increasing, a tval increase in cancer of the lung is indicated. (2) Improvement in diagnosis. whereby a larger proportion of the actual number of cases is delected. The melhnds of examination of the lungs, and the availability of apparatus for such purposes have undergone very great development in the last twenty years, and it would be remarkable if these changes had not increased the number of cases of cancer of the lung discovered. Tin's matter is discussed under " Errors in diagnosis " above. According to seme authorities (e.g. Willis) these improved methods, even when.fully available, still leave about half the cases undetected, so we may look for a further considerable increase from this source. (3) A tendency to identify as cancer of the lung cases which are really of a different nature ; that is, a fashion in diagnosis. - ' We have not. found any data which would enable one to judge whether this factor is of ant' importance ; if it is to account for the form of the curve shown in Fig. 1. two or three hundred more of such errors must occur every ye-ar. Willis (p. 2S9) does not mention such positive errors in the diagnosis of cancer of the lung. SOME POSSIBLE CAUSES Of CAXCEE OF THE LEXG IX MAX. Experimental pathology has not ridded any conclusive evidence on this question, as it has done in the case of the occupational cancers of the skin. Most- of the laboratory work, such as that of Argyll Campbell, has been done on the mouse, in which species the neoplastic factors in the Jung are certainly different from tliO'C in man. (1) In default of experimental evidence, indication* of at any rate one direction in which to seek arc derived from the material of the General Register Office. These data arc compatible with the importance of seme factor in town air, e.g. coal smoke. () Cancer of the lung differ* from that of the upper alimentary tract, larynx and skin in showing no inverse relationship to ascent in the social scale (Steven son. 1 f*--:>). Owing to the mixing action of the wind* there is let? difference in the outdoor air breathed by diffeirnt classes than in other social conditions such as food and cleanliness. {b) The higher incidence in towns (Stocks, 1930). Table XXV shows that " there at every age a steep downward gradient of rates from London thruugli * ` **r,itr i.f tl. :.:i\L;- :.f ..Ir-i. tin* jiurtkles vr*\? incite Ht l-civ-Mcr. The i`CT.,ri of ^-1... jt'o* 'U k-.- U,t <0 . '-nj' : r. O O-N -- ^ r?1- n; i- in.i to Cjri.uli:::, < ns n ieilip.-n:. " Xo iN.ict dviiiiit inti of ttn i.-it1..-i*_o- l:.;s \it 1.f-cii utau'e. l'"i !.... I" cm u-vd, m tie; }-\ r\ n:id f hetvi.er*. to i!"MTtl.e tlu- rciiir.vriil< v.!;:th ' nit irUli itM.lf. Del iitu the lntt t:.:.,*- ninr.tlis <.f the l-.eieii.tpr iMtrveV, sj.iwinl fittpiiiinn to tiip tui-n-nt, ::>.-nt nl vnrin 1'!..^ ''luititni i'Jt t urlil.lt nee. l.ir;mP of the iinj'i.riii'n-p of tisr.ntlt tfc-ill l^;rioj.ii" tl.o eetieen'tv.f.jri cf mled pollution, It v.-i,; t tn.it one of \ - liips ini"t>t j.'.jvp "vtilnl.lc for 7iti.ro j.*..|ieral tirp in ei>ni.e. ' ion with in.M-urefi'ent ^ of ott:io<pt:criL* pollution i]>- I14(, Appiir.-'nlv turiiului'.u uirlii.l.-. nil funi.s of di.t .irbhn.c due to in.ei;u.jl 1-a.i1 Jie-ntuy. 1 t*xi.. f CG 5261 ^ i as 0001212 \rr ^Ji^'-'.-.'.".?i..\; iyCx^i .*.: .`jliorf' .. 'V. I* * A,;. >. -* . .-n .-. - f 1 TA ` -*a"r4 --1-M ' ,i * r^-'^v S>* , -. - *.o ,* *4 . *.fc*.- ^ ..* de "n-^*wvj , -r4b*fr>1 - ,, -.,'. i--j ;, - '. ,\er:s^S*'.'rt*.u*ai _ -- - ' '- x* f. 11';. .*.-, _ < "_Vi.- *j/- 'TV^1 -* . *4* **. -. >',^_v-,'.<* v. v..*.i^ -iV ` - \ v ^ x*,*T**-*'*r*j V c.'-fri .. -.' '*'. 'r.'l&j: ,- .,,.. . ,'' -*'4*\-***" ?*y'.>.!*<>>*! . . '., :.v. p.vlJ ' ' . `X A'AeAi * ^ :>* .*1 - !.c^- ' ' ;:, yy:-4::i i; I*:, . ;.::rjr4 ? fej.: " '! .V5,*c-r':--sS<t ;:-&>n-\i :.`y..*-- ','s-**Tx'^ r/?2w * ' ? ';--/..'::-.;r.*:-4 : t- _|; >~ -: =;'rn ; r;- ` }~7.Z2zrz& t-/ ' -a2- :*;; . *92 E. L- AX'D X. M. KEXX.WVAY large anti Ainull towns to rural di.-tric-hs." There uro, however, exceptional lir. towns with a low rate (e.g. JJristol). Empirically, smoke concentration in u tow i.s in proportion to the square root of the population (Leicester. ' Atmo?pher; Pollution,' l!)+u. p. t+). (c) The low ineiilence in agricnltnral workers (Kennaway ami Ken:mwa\ ls*36). There is an equally low incidence in coal miners. (6) and (c) might he explained by the better conditions for diagnosis in uvba: areas. Coal smoke does not account well for an ircr-jaac in cancer of the lung dtiritn a period when, as one would think, atmospheric pollution has not inf'rev-*'d owLiu to greater use of gas and electricity. The domestic fire -ts- the chief source o. soot in the atmosphere,* and it is in the domestic field that the substitution o; gas and electricity for coal has been most general. One must, however, note that ten years ago trhue anmutuhoorriicties on atm.oosspphneric pollution were not unanimous on. athjej ^^uist^n, ^ybether fthert 'hUcl- 5eo?l lahy measurable diminution.f H . ; ,.:r,, .40. Table XXV.--Cancer of 'Eibty.~J stales. Emjland and C' i JV,!~\J Wales. 1021-1030. [Stocks.) r Hates per million at a^e* shown. London . . County Boroughs Other Urban Distri Bural Districts . . 25- 35- 45- ' * 15 . 55 . 121 , 7 . 35 .. 73 13 . 5 . -->>. . 45 , 7 . IS . 30 __ 50- r 35- CO- .193 . 253 . 203 . . 103* . 135 . 1HS . . 4 1 . 90 % 12S . <*>t-Tl * 03 . 73 - 236 . 14S . 1 of , ST , 4 * *"" T 199 . 215 144-. !.*3 11" . c;i 92 . 71 (2) One must look, therefore, for some other factor to explain the increase, if there is a real increase, in cancer of the lung in recent years. Many such factors have been suggested, e.g, influenza, tobacco, popular drugs, tarred roads, exhaust gases and other ermnmtions, including lead ethyl, from motor vehicles driven hv petrol or Diesel engines. Xo attempt is made here to discuss all these possible factors. * " . . . the pfirentiiiB of t*r in domestic smoke is very hieh. ri'm-hinst .'(<1-411 ner vent, while in indtwtrm! smoke from boiler fumnor* mul si`h rh**r is prnrricully no tnr " i' Piiilution,* Ii'th Report, p. Mi). " A hiah deposit of tnr can only"be due to pollution frr.tr. ilotuestiir chimneys or very inef"H i.ient ind'um-sttrriiaal ftumislniinmirrs. simin.-v imn u properly cioonn^stnlnuK.tttc-d1 matvl work--I furnace a liifrh tempemturo is imiiu1t..n11ien.nu l1 It.i.ir^ u.. M..iltitl,ic.!ie...u. st ,tKl-A.tantte_ II'V.,,w.._-_.i *thL e m_ ain plvaee ,,t , r.tn1hu.ti. on for nil eornhitstihU vapours to to* fully liitmed hfurc the fiim.v-c j-n-scs l.vtve the ekitruirv " j' Atno* pherie Pollution.' Report, p, !). Siwa from the c;voiey of a dwrllm* house jaw.- com.titi 40 per cent of tar (C'oheu unit iiu.-ton. I'.'Jet. are I the .Itt-t. i;i;v.iulnl iti til- mrof a ron -- .\tiiu,.ph-r:v I'olhitiou,' 1114.1) tiny roncaiu i4 p*r rnit oft.ir. , f In thp * iJttil Report on the rtivestie.it i .n of At'n'-pii-ric I'olluti-m ` < lt:iA_1 -q .; ,, Choirruuti sums up some rather ei|i|ivo.'Hl -viil-ni'e thus : " . . . on 111- whole tlier- 11ns h--u a deHtnte rwluction in the extent of pollution of thu atnu-rhere in llrit-.n durini* tii- n.-* to-.-nrv jvur, ' On p. If of the mine re|>ort. |r>'.r-x-er, tin1 coo.-. ..i.-ti i. ilnnvn t'u.t' no e-ri-rt tt-iit-n't can lie deru-.sl frotr the i!vr> a-s u:ul in .itn. .--.ihms ihirui- !''.V,-lu:;.',. f; . ,[ study of atinospheiio pollution in l-iue-'t-r C hen-^ter, Atioosjiheriv l'l.llntion.' Jpl.ii sh e.te., , difTervr.ee hettveen the two periods I'.lJi and 1 -i'.i:;'.) in the em.uiii of ;,ir in i;-ji.lr-.( matter; the r-port ;nukes the sn^eestum that a disTea^e m r,r no'^iit h- iiu.,srl by an itirrcts- ,,, Itiatenal from motor cars. Hut the ineofu lnsive nature of the tlata shows that ther*1 Ii.l. heen ,,o inerea-e m atmospheric |mllntion in any May pr.ijhiitn.ii ii '<> tit- if.-rvas- in c.ineer of tit- Tin-. GG 15282. \ BB 00^^23_i I\'< I.'-: (. Or * v; > NX > I. (; ,, r*..-. *. !: . ,ih in tlx* * t* Iiv^r pap* r (Kcnnav. ,.y Kt M:.. . l'.OU'.l. Im 'y!, t'-e iitciili :iif of ..iti-i r <m (lit-# occupations where then* i* it toad dust (>ce above. Table VJ) i rather above the general level, it- very t|ijesliojt:: 1 li* whether the reeeiit increase of this (license among the general population ean he attribute*! to the tarring of roads. For scores of \ vat> before this imic-.M- began coal tar was being discharged into tlie atmosphere in iIre form <*r soot by the domestic lire in quantities vastly greater than any that could now he derived from roads. Tarring of the ronds has undoubtedly increased the amount of dost derived from tar in the air, hut this increase appears negligible in compari'On with the amount of soot present already. One sees clouds of smoke, drifting over any large town, hut one does not see any similar clouds of tar-laden vapour arising continually from tuned roads. Tbe annual consumption of coal for all purposes in Great- Britain in 1030-1D3S was almut 1SS million tons, of which 40 to 45 million tons-was burned by domestic users, who are by far the greatest- producers of smoke and soot.* It is difficult to believe that tarred roads made any important addition to this total. , ... One must, however, bear in mind that the t-otal amount of soot- per unit volume of air may not be the only important factor. The size and physical state of tar particles derived from the domestic fire, and from a tarred road, are- no doubt different, and this difference may determine the amount- of penetration into the deeper air passages (see, for instance, Bovland. Gaddum and MacDonald, 194*7 ; Owens, J<>23). (h) Tcbiirro.--A possible connection between tobacco, and especially cigarettes, and cancer of the lung, has been suggested many times, perhaps most- recently in the ease of Turkey (Lancet. 194C. i, p. 435). Peacock (] 943) has pointed out- that cancer of the stomach is far more common lit mariT than. $o far as we know, in any other species, and has suggested that this is due to his use of heated foods. A similar argument might be applied in the case of cancer of the -lung, which is not known to be prevalent in any of tJie lower animals. The adenoma of the lung of*4hc mouse, and certain affec- tm-ns of the hmg of sheep in South Africa and Iceland, are neoplasms of which the exact nature- is uncertain. Vfe know one instance at any rate of the .susceptibility of tjie lung of an animal to a carcinogenic agent, namely the lung of the cat in relation to 2-acctylamihofluorene given by the mouth (Harding, 1946) : hence there- is no reason to think that animals are immune to any such agents. Unc obvious factor, possibly carcinogenic, to which the lung of man alone is exposed is tobacco smoke. During the pic-cnl century very considerable changes have taken place in this country in the social distribution of the various methods of smoking. There were, of course, exceptions to any ruie, hut roughly one might say that in the c-arkt: par* vf this period mcr, of the richer classes smoked pipes, cigarettes and cigars, and men of the l.ooicr classes smoked pipes ; cigarette smoking was iucrc;:-::'.:: among tbe rh hoi .'.omen, while women of the poorer classes did not amonc. On* never saw a v.cunnn scrubbing her front door-step, c*r hanging out the wr.'h:nr. with a cigan-ttv in her mouth. The great change which has taken A. i'.tiUvz. fi.uJuitk l.^-tin.'. M.iri-ii I.V, 1`Nf., + i.* J.mil We],--. i.-iorur c-f tlj -it>rei!i *# r.^<ieiir<l jm jle,*c.*u#e of 7ei* out of - i*i`.-.Ol:s froM s:irtnnr.-.',;i of ;i!i silv? ;:i antics p Hcjriswnr.fJciicr.irR Slnli-ticiii Itovii-w / 1 i, <ri A 'A-J - . 1 O 0J s--- I*"-- oo 32 22 i GG 15213 * At" *''* `* " * \* ` - r^ v*-* 1vl*vt-*r***r~?' -'**"** 4 >*-*--W)^ - ****-! ' :*** :**.'>**rt ti.V.T -7* * *r v ^ d' --*- ---- --^ ' | 0B f0tf0tA07TT2T/4Ii t| w. 'y i . # a*' - * - --- *.. ** . * w*. v ^ ^ : *-v ** % . *.***. *ta--w -*-v + *. 1*71 **'m ` t *' Lm \ '4 " , --. - . ., * u-i*1 .* ; i^#-. , * , P.' ~ *./ t- ' i-''** H *. ** *\ 1 | . *. -4 1 - h. ^ . ** 'A -. . * % ' ' -m ' <* * V ' **-*' ^............. A ' ' ' s' \ . * . ' ` *,*,,-* , * \ - w'- -"* 4 *> *- ^ -- m +. \ * 1. * I v ** *' ` * * , * . * ,1 * * *, S * -- m *r **'-<u* ' 1 4 ; '' - *' " *#''' ''b* -* - ^ ", . " ^ * \ ' - t * . '.7-` ' 'f N' * * y;--** rr V **, - * A*4-- ,, Kk*ti*u*iX. it ^>- * *>*'< .. ^ !% # .4. > ' V^ **** - > ***> -` -, . .V* % * ';t , *; *- `* T f f- ^ ^ ^ , 1 , , y} ;"*' ,,,,'','*`f.`V;r i.t?-,-: '*** ,- " V . *-' v-/*' " , >$* *. - ^ * & 204 P. L. ASD.X. 31. KE^SWWAY pluce in the later years is the general increase of cigarette smoking.* and adoption by women of classes which formerly did not smoke at all. Men k'?C > I GG I*i oLU'i -TV I BB 0007275 1 ! * v it:;:--!; !. ; ` u. j.. : niall'T. !'itW'.iriiJitni. {>.* i1 > )i.'.-.it'v *-|*.-v-cf-jiois, w!:n i ! `ifmlii*;i pipe at im-.ltix: -inukr vigreuI'-'whiii r vork. Cnuirvttc i- arc <nul tu ir.iude infill,- do smokers of jiip.-s. but it is very difihadt 1i> re! any conclusive evidence upon this matter. which might lie inijiorrant-. There is sonu* .American lit'rntv i s-. which has summarized [Brit. nml. J.\ i. !'4) upon the arsenic cetiient of tobacco and tobacco smoko. The occurrence of cancer of the lunr in makers of arsenical sheep-dip (p. 28/>) indicates the pof-ible importance of t his factor. Seme writers have contended that smoking cannot be associated with cancer of the iunjr. l*ecau?e this form of cancer has increased more among men, while the use of tobacco Inis increased moic among women. Hut the sexual distribu tion of cancer involves unknown factors (Table XVII), and does not provide a : (<--C!.tk** : ' O :J4 \^x ') \ c-] y soturc basis for an argument of this kind. Of course no claim is made he:-e that the simultaneous increases in the consumption of tobacco, and in cancer of the lung, proves any etiological connection between the two. Other '' changes which have "taken place in the same period, which no one proposes to associate with cancel- of the lung, e.g. the increase in the issue of wireless licences, show a very similar curve, and such correlations are'a common subject for statistical witticisms. Tlius wirc-le-; licences have increased at a rate (about 10-fuld in ilio Iasi 2u years) similar to that shown by deatlis from cancer of the lung, or from coronary disease (Fig. The annual consumption of tobacco in the United Kingdom has increased from 12* million pounds in IH24 to 3-3r million pounds in 104G, and the percentage of'these an emits moked in the form of cigaiettes has risen from 5G in 1024. to mer mi in l(Fig. 10 and 11). Thus the consumption of cigarettes shows a consider;:Me increase, both absolute and relative. * t\V h: iniJi-htf-H tu Mr. J. R. tVil!-.-. M.C.. of tin- Roarii of Trade for thess Tho jiropor- tioii of ti-unt;e< t t'4nl twtuici-c, i ciis'inii'iti-,.-. is nvoiUbir duly i:i ;:h>w ye-urs for which u Census of ]`ixi'iii'-`.iosi :.r- i.>~oa. The jnrmhly is*-t of tobn-i-f- r-a inly ),y irianufarunvrs for ltnsue s-urn-uumi ior. in tl.o Vniotl KinyUom of Gri-ai Jiruuin und Xorihifrn lrt-lmid arc given in the Mai.ihly *Jijt *f of Xlo.Xi*.<*.. GG 15255 fTTTiC";s-jy^-un-y.- i'- ' ' . *. ** - * *- i i i" rn " i".* , t * . J ' ^ V *. */ .---*' ` -V ' . *!_-- ' . f, -* * -.r j ` V :-t <".s M-*-**,i ' > * , ` *' w rprr | BB ? ' ' . 7* 0007276 1 ' *4 ** : v *" .7* * \ .** +' L i :V* .* r, "* * 'I't ' *-`V *: .* l.-' ` **-, U - * * * > i 41*'. * *11 i** 1 *r ' >. * - _ # ` '* I - ' . 4 * ** t , * *\/ * j tf * * V i ***'' * * ^ yv"* '* -*`V {*-'**? '* - "d. v * .1 * * *v* **<* To summarize the evidence brought together in this section on the inciden of cancer of the lung: the higher mortality in towns, the low mortality in atg. cultural occupations, and the aI wetice of social gradient, are compatible with * factor in the air, such us coal sun ike. In any such comparison of urban ar rural areas, the (|uestion of facilities for diagnosis must he considered. Ji coal smoke,-which is probably a decreasing contaminant of the air, does tv account well for the iwovy/s*' of cancer of t tie lung. Among various nos sib factocs is tobacco smoke ; the consumption of tobacco has risen, and so has tl percentage of it smoked in the form of cigarettes, of which the smoke is oftt inhaled. An effect of tobacco would accord well with the absence of snei gradient. SOUL.VRW ' ------- (1) The death certificates for cancer of the lung and of the larynx in malt from England and Wales for the years l!>-2l-:5s inclusive, numbering 3S.+ 1: . have been investigated and the periods 1021-32 and H133-3S are compare: The 03 occupations examined employ about 3b per cent of the male populatio aged 20 and upwards. (2) Sources of error in statistical work on death certificates arc discussed. (3) The increase in the recorded cases of lung cancer cannot be attributed t any increase of data obtained by autopsy. (4) The agricultural and coal-mining industries show a low incidence c cancer of the lung and of the larynx. (5) A group of open-air occupations, where there is exposure to the dust c roads, has ratios above 100 for cancer of the lung and of the larynx, with th exception that motor drivers have a normal liability to cancer of the laryn> But the comparative incidence of cancer of the lung is not increasing distinct! in any ,of these locoupations, arid in the paviours. street masons, coia-retors an. asphalters there has been a distinct fall in the ratio. (6) The occupations in which there is a liability to silicosis do not- show high incidence of cancer of the lung, but there arc in the literature some studie of small numbers of cases in which the two conditions were associated. (") Cases of cancer of the lung have occurred in some occupations involvin', exposure to asbestos. ... (S) In the death certificates examined, and in the Reports of- the C'lrie Inspector of Factories, no occupations involving exposure to any kind of dust except those concerned with asbestos, arsenic and nickel, which emplov rer small numbers, have been found in which there might be an increased incidence of cancer of the lung. '- " (0) Workers exposed to coal-gas and tar tend to show an increased prevalence of cancer of the lung, but in the later periucl studied the incidence does not excce( two-aud-a-half times that on the general population. (]<>) (A-ciipations concerned with the supply of alcohol have a high incidence of cancer of the larynx. (11) The later period studied shows a considerable decrease in the occurrcnct of canr-cr of the lung in those engaged in the preparation and sale of tobacco. (12) The very moderate ratio ilJ.'o Ibr cancer of the Inn:; in medical men i- impertant in regard to the view that the recent rapid increase in recorded d.-arli- from cancer of the lung is due io the detection of more cases by improved diair l BB 0007277 1______ . \il\ ' A no;;- J*,r thi.- is an ii* where "in ii\ail:dii;`.\ ol the existing tncthuas for ctiuii of cancer is preMnnubri* at a maximum. it:'.) Xo special occupation* h..ve been found, among the H3 examined, to the H!'iv:i.'C in the of of cancer of the Jung can be attributed. Tlii' incroA-e is now* so g:eat that tie.' incidence upon any such occupations would haw to be very Jug:, indeed. (14) Xo evidence has been fuuml that tarring of roads lias affected the inci dence of canter of the lung. Such data as are available suggest that coal-tar O CO O in the atmosphere, whether derived from roads, domestic chimneys or any other source, does not, cause an exceptionally Inch incidence of cancer of the lung. Cotton mule spinners show an especially small liability to cancer of the lung, Uj although they inhale air sprayed with an oil which produces cancer of the skin. Much further work is required on the factors which regulate the penetration of particles and droplets of various shapes and siz.es into the air passages. (15) The higher mortality from cancer of the lung in towns (Stocks), the low C^/ mortality in agricultural occupations, and the absence of social gradient (Steven- L; son) are compatible with an etiological factor in trie air such as coal smoke. - But in any comparison of urban and rural areas, the question of facilities for"^ diagnosis must lie considered. I*-4TM . . ^ (Hi) Soot is probably a decreasing contaminant of the air owing to the sub- r^~' c j stitution of other sources of heat for the domestic fire, which is the chief.source of soot-com aining smoke. Hence coal smoke does not. account well for tLiiyfa*--' recent increase in cancer of the lung. ' Among various possible factors whichCp have been suggested to account for the increase is tobacco smoke; the conns^ sumption of tobacco lias risen, and so has the percentage of it smoked in the form of. cigarettes, of which' thfe smoke is often inhaled ; such an effect of tobacco would accord well with*trie absence of social -gradient. . ,,; - m\ We are indebted to the Registrar-General for the data considered in this paper, and also for kindly permitting u$ to'use some figures which have not yet been made public officially. We have received much assistance in the classifica tion of occupations, and on various other questions, from some members of the staff of the General Register Office, to whom we wish to express our gratitude. We wiMi to thank Dr. E. R. A. Merewether. Senior Medical Inspector of Factories, for information upon various matters, and esjiecially upon asbeslosis, and also Professor R. A. Willis for unpublished material. We are indebted to trie Anna Fuller Fund for secretarial assistance, to the Sir Halley Stewart Trust for a grant, and to Miss Blanche Goode, who has taken part in th? classification of death certificates. REFERENCES. Xot;;.--Xo attempt is made in this paper to review the statistical liter..: ore relating to cancer of the lung in ;hb or other count ti*'S. Andeuspn. C. S., and Duile. J, H.--,lt`3S) J. Oim'j.. 3S. Iso. ' Atinospln rie Pollution. The Inre-tii'.if ion of.7 Reports London: H.M. iftationery Office. HoYLtsn. E.. Gaddi'm. J. H.. and MacDonald. F.--{HOit.f. Hirj. C<nli.. 45. djiu. Cohen, .1. It . and ItfsToN. A. G.--(lUiloj ' Smoke. A. St inly nfTimit Air.' London. Diuli:. .1. H.--(l'.)34) ii, !*>2. j.i * i` o#4 '4 :v;xr * ,i; y*-' * --V .s:-i> : ? It v2 ii Tt- y ?. 1 rf, tL * * * ^ i .< ** 5-. J- ir % -V - ' h/ * ?'* \ GG I525f , m .** * *> *'* *' * J-fc r T' ' + ^ v*. '* /:;4iv' * * *** * "* " * ' - H .1 t*. i,.; \ ' ' #v, V ' -r 1----j- QQ07273 1 ; ,* ' .;* ** , i * * -* - f/;:* . >- * 1 *1 fc * ' ' r 7**" V *4 - ,, * * 4 A .. * * \ *4* v-fT--.* r "*' . J .tw. * * *' 44* (i i, ' j i.j**.. > u". **'**|*">h~i-4fc ,, 1 . i A ,. j . ,* .* t , *, - - .-*.*.,#* < '-j : . a* t \" y , I ^ ' *,'"y* * . -*'* / '>7"* 1 * i' '**' ' *** -l~'*' **'*^~-f*+- ;,*, '_ ; V'_v * . . . * - *-.'* ; - --' *- *.*"%**/*; **' '* v *. ^ ` k , * * ` rV * 4 v * v**- >**>**? * .- **>' .- +*sr'T* -,, - ' -. 1- ]_/'* , '-' T ff .V;.!j' .^rcr.'-' yq; z<i '-'A ? . > .:,--J It= .'4 'e.';:'L- y$ j s.; r 'f - ^ : it ' ' --I -r- *: "'U-f :: : . v- -H 20S C. C. SPICER Egbert, D. S., and Geiger, A. J.--flOSrt) Tuhtrc., 34, 143. `Factories, Annual Re^wrt of the Cliitf In.*i>tr<?tor of.' London : HAl. Statiun*rv Office. Fried, B. M., and Bccklxv, It. C.--(1030) Arch. Path., 9, 4S3. Cloyse. S. It.--(lnno) Tnh^rcfn, 17. 5. HardESC, H. E.--(li)4*>) 23rd Ann. Rrp. Brit. Emp. Cancer Camitiyn, p. 92. Henry, S. A.--(1949) * Cancer of the .Scrotum in Relation to Occupation.' Oxford Univ. Press. Idem, Kennaway, X. M.. and Kennawav. E. L.--(1931) ./. Ihfj. Camh., 31, 12.`>. Kennatyay, X. JI., and Kznnauay, E. L.--.1936) Ibid., 36, 236. Klgtz, If. 0.--(1939) Amer. J. Cancer, 35, 3s. . ` Leicester, Atmospheric Pollution in. A Scientific Survey.' Loudon : K.M. Sta tionery Office, 1943. Lynch, K. II., and Smith, W. A.--(1933) A,iter,./. Cancer, 24, 5G. * Miners' Phthisis Medical Bureau, Report of the. for the 3 years ended July 31, 19:;.>.' Pretoria : Union of South Africa Government Printer, 1036. Montgomery, H.--(1935) Arch. Derm. S>/ph.r 32. 21S. Idem, and Wais.man, M.<--(1941) J. Incest. Derm., 4, 363. Xecractr, 0.--(1947) Brit. J. Cancer, 1, 192. Owens, J. S.--(1923) Trans, med. Soc. Loud., 43. 79. Peacock, P. R.--(1943) Glasy. med. J., 139. 117. * Registrar-General's Statistical Review, of England, and Wales,' Tables. Text. London : HAL Stationery Office. Semon, H. C.--(1945) Proc. Bop. Soc. Altd.. 38, Section of Dermatology, p. 123. * Statistical Bulletin,' Metropolitan Life Insurance C'o., Xew York (1939), 20, 7. Stevenson, T,. H. G.--(1923)-Bi<wWri:, 15, 3.';2. . Stocks,.P.---(i936) 13`A .4ah. Rep. Bril. Bmp. Cancer Campaign, 23% Wrr.Tjs, R. A.--(1941) Med. J. Austral., Sept. 6. p, 25S. v ; >. .. . NOTE:THIS50^7."010 > NOT COM2. fHOwi ;i u fiLtS , * ,THE ESTDUTION OF TU?.IOUK SUSCEPTIBILITY i IX PURE LIXE3. / ! . c.C. SPICER, Prom the Imperial Cancer Research Fund, London, and the Department of Biometry, Vnir-rsity College, London. Received for publication August 29, 1947. It is the purpose of this paper to dUeu.-s the problem of assigning mea-un-s of cancer susceptibility to inbred strains of mice, selected for their proneuesi to mammary cancer. The question has been previously discussed bv Murmv .uni Hoffman (1941). and the related problem of the as-essment of potenev of carcino genic compounds by Irwin and Goodman (l9Mi). Twort and Twort (I9:;n. 1 ti:;::. Rr^an ami Shimkiu (1941) and Lea (19:-.*.). Jr is suggested that the p'oi.ieu, most clearly exam inert by using an actuarial function, the " force of mortalirv," on whose characteristics the mortality of a strain depends. This function, which is usually denoted by the svmbol measures the rate at which tin- members of a life table arc dying out. It can be calculated* for a single can,.-. GG 15268 I BB 0007279 |