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ut- ,. Difl'usc Mesotbelioma of the Pleura and Asbestos P. C. ELM.ES, M.D., M.Lc.J'.; W. T. E. McCAUGHEY,t t,LD.; 0. L WADE, M.D., l'.LC.P.
Brit. -' J., lie, I, ,._,,,
Diffine maothelioma of the pleura ii an UllalllllDClll nunour
whial, after prolaag,cd CODUV\Tny, .bu now becotne cmenlly
acx,:pted u ID mti:y (CMnpbcll, l9J0: Godwin 19S7 i
Mceaughe\, 1"1: WagJier, Munday, and Harin&wo, 1962).
E ~ ha ftCClllly been acam,ulotin& that inhdatioa of
asbestoa may be ID imponam factor in lb&: actiolocY of thia
tumour, and croups of casa IISSClciated with aposure toubcstm
NYC ba:a rcpomd from South Africa (Wqn,:r, Slcas, and
~ 1960}, Gcnzwly (Konig, 1960). lb&: Unitld
Kinadom (McCauihey, Wade, and Elmca, 1'62; HOllribanc, 1964 ; 0 - . 1964), and the United Sialft (Sditoff, Churs, and Hammond. 1964}. Crocidolitc, the blue aabc:mJa mined ia
'South Africa, appcan ID bqmtic:ularly caacioocauc ID dua
mpcct (Wasner 11 .i.. 1960). Tbcle ia .i.o cvidmcz that
aimilar nimoun arisiq in the peritOCll:IIID an: aha !dated to
ubestOI ai,csure {Kcal, 1960; Eaticklllp and Smuher, 1964;
a.. Houribane, 1964). la I prfflOUI ffport (Md:auchcr ff 1962) - dcscribcd lbc findinc of umtoe bodies in the IUDP of 12 out of lS
paricnta wbo bad died of ditlmc: pleural ,-x.hdiom in
Bdfast. Details of lb&: wort.ma: life ~ nilablc for only uiDc
of thcle patients, bm in four of them there wa dear history of apoaure to abcstos. This paper_ dncriba. ~ funt.:r
~ ~ l)q,onn,..c ti Th,npcadca IDd l'llaa ::\':;:;
Ill lklin1.
U----, t o . r - el l'ualau, die Q,ooa'
U.i-tkJ
fl Wal&.
iowatiptiam cnxd - in Bdlat: (1) I study of the indusmal 00Cl.lp,llioa of 42 Plicntl witb IDCMlClw:liom of die pleura and of 42 canaol paumta without meso<hclioma ;
(2) an iaftstiptio11 of lb&: prn1ena: of am1111 bodies m me
hmp ot paricnta ,ri1h and wilhout aaothclJoma ot lb&: pk:ma
or carcmoma of the lune: and (J) an in-tipu,:xa ol tb:
rdtion bcnn:al the ~ of utaio. bodies ia lb&: lunp Ill dcada IDd I history of aplllllff: ID aabcscol.
I. latwtrial O 1
P111in,t1 "1itll Maot/MlitwM of tlw P l ~
binoricl wen: obtiDcd from lhc pticnta rbcmadtQ or, ii. tb:
~ u bad died, &- friend& nd neigbbour&. IDdudiac
dloac prmously rq,on,cd. 4S cues ol me.othclioma ol tbt
pleura bad been ~ ill Bdfut by lhc time um INdy comrcc,ed. Only 42 wae included in tbc nl~ia becaulC ma: o( tbc any peticnu had died IDOl'C thm IS ,an prmoudy
nd DO dcuill - nilablc.
Control PGlialt1.--0ccupoonal historis -
obuiDed
fram macclxd CIDlltda ldccted fram tbc secords of tbc
dcpanmcat of Plholon- If ~ of aaochdioma ol 1hc
pleun io lhc proposina had been made by biopsy die pcimi
coauol - adcctcd u chit patient of tbc um: IClt and ~ l ,mt ol qi: whale-. ,ppcarcd cbcll 111 cb: , _ oC tb:
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,J,}_.., _.ary 1965
Mcsothclioma of Pleura-Elmes et al.
351
(ITOpO' linu in the N bioply report book N in which a daily ri:ioord
of rq,oru on biopsy apccuncm ia kept. If diaposis of _ .
, a n < - the dunciaa of CXlJOAif'C varied from 3 to '6
3.S.S
IS.3 years). The intenal ber.ftm fint aposure aod die
1hehoma of lh' plcun in the prop.,s11m bad been made nccropsy lhe paired control patient was IClccted from me N necropsy re-port book" in the aame way. The OCX'Upalioaal hiatoricl of the paired coauvl paucnts On"C obcaincd in the ume way u for the pabeni:s with mesodlCIJoma of the pleura
anJ for 41 of the control patients. lnfonmti.xi could - be
diagnosis of fflCIOthclioma flricd fnxn 22 to 73 ycan (mean
43.4 IJ y,eanl. ElghtC'CD of tlr apo,cd caxa ~ niD
workinR when ~ became disablaf by their moothclioav.. ID the remainder the ian:rvl bctw.:m the Lut known apasure and th: diagnosis of tbr: dilcalc varied from 2 10 49 ,an (mca
23.1 1.U ,an).
obtained for one of the a>DUVI patients initially ..clccicd, a .be
had liwd in an area of mmsive ahan dearanoe IDd DO Rlatifta
or oeighboun a,uld be tncxd. The next nemat milllblc patient in the m:onl book wu cbosco in his plaa:.
z. Prnalaace o( AahatOI Bodia la .....
Tli, Tuin, of Hutorv1.-0ccupatioml hiatoriel wa-c
obtained by one: of- from a few of I.be patimu with - thelioma and from a few of the caattol patimu in bolpital.
Othcrwilc the iodusaial his1oriea wm: obtained by one of nro
~ worbn wilh a apc,cial bawlcdae al the industrial
proccsata in whic:h ubcUoa may be buud. Their inquiries
( - greatly helped by the stability and aacill cohaioa of me popula1ioo of Belfast. E- whm death had CICl:mftd many ymn qo dote Rlatiffl wae ofim ,till lirinJ: at the aunc
addnsa, ar neis:hboun ltncw bow they misl:t be found, or
rancmbcrcd the patient wd1 mouah to sift ICXlle lllformatiaa
about bia ocaipation. AlthouRh the knowlcdre that infonunta
IIYC of the type of wart undc:nakm by pallClltl WU oftal
limited, thit dcfcet applied equally to patlcna who bid died
u,o,..-, al IIICSllChelioma and to conlnll patients.
Ali,1111'1fflt of
to Albntoi.-The llbeltOI 1111d ill
the insulating and buildia& iodllSttJ ia Belfast baa ftricd ia
ciomp01irion and contained eroc:idolitc u wd1 u c:lvyloruc and
amo&itt ; bccaU9C of this DO attanpt wu made 10 idc:lltify I.be
matffial to which each iodindual was ~ l!zposure wu
UICSICd from I.be wdua:rial history and padcd ubitnrily
follows: HIGT7Y np,nw,: A ddinin: history of workios wi1h ubrst0& full-time for at 1cut one ymr. u,1i1 apo,w,: A
history of wonting with ubcstoa full-time for ba 1bUI ymr or of working cm:r a period of many ,an at a jgb IIUCh
C u hnil~ airrr, lumm, or 6ner in the i
lntC'mmttnl cxrosw,: to
o a,oun: No bistCll'J' cl
eipo,ure tu 116dtm.
luuJu.-The occupetional hiltory, a n d . . - . of CJl1)0aW'C to ubc:atOI of die 42 patir:nta with ISIOChcliom cl the pleura a.ad l)f die matchad ODDttola an: fllfflll1lrUl:d ill Table I. At the time cl diqnaaia the DDOChdimm patir:nta
M,tliod.,,-A R8tdi for ubcstm bodies bu bem made by bistolop::1 CDIDination of all nilablc acctialll (mully
bcnrcat two and ais) of l11111 tissul: from cacb patient INdicd. Tb: ft!SWI of die ecarcb WU called p,sitm if llbeitOI bodic were identified. To be identified asbcst111 bodies bad 10 br cl clamcI fann--tha1 ia, yellowish brown or aoldm ydlaw iD colour, cJoapted, and usually ICIDlalted. Shapes mnapaadias to thole illustnial in Figura I, 9, 10, 11, 21, 24, 25, 27, J:Z. JJ, and 40 in the paper by Gloync (1932) were 1n01C o11m - . -
l'tllinit1 aril,._, Morlulio- of tli, Pin, or C r ~ of tli, Brcm&liur.-To dctenniDc die frequency with wbicb asbeatOI fibres aNld be identified ill die IWIII of -1c patiam d)'ina in Belfast - whom necropsy was performed. 1ana acr:tiona wen: CDmincd from 100 JMlicnh aa,cd .SO- ' md from
100 pa1icn11 ac,:d 60-69 yan. The patients were cbom nndomly from the N necropay record booka" occpt that tbaae
with mcaothclioma of the plcun ar cn:inoma ol tbc broDdnll
were adudcd. Albcatoa bodica ~ found in 14 o( t.be 100
patima am .S0-59 rmn and in 27 of the 100 patimb aaaS
60-69 :,.:an {Table 11). Tbc ~ bawcm dac c puupa ia i&ni6cwar
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ltO 100
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Ill II
to
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II
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a a
fc0-001).
flried In aee from JI to II ,en (nan '9 10.9 ,an ,tuldrd
dC'\uitK'D). Thcff wae onlv two wuma1. In J2 al the 42
patients wi1h mnolrl- ti-. - a history of Cll('Olure to aat,ou-. In ai;hl the aposure v.-u a..~ u hravy ,ad In
24 l11thl. In IM 42 p,iffJ contn,I r,atirr111 there ,o-u a
hitotnrT of CXJl(llure Ill nine, and in onlv two of chclc ,.... it clAl.:d as hcJi,-v. TI111 d11irffN.-C .ia hchf, ait:n&ficnt
(dd!C'm'lcu arc rn:vded a11:111hcan1 whm P<.U.U.S), M<>St ol
' the md1nduala v.11h hca,-v Clll""'llff had Wlvbd lar acvne ,an
aa r,i~-c:ovn-cn ur had ,.t1.-n bttn cx11<.....S uhotm dun in
c11nh11cJ 1lat'n hen ..-r,amn11 ~il~n and 11t11m l'l'et. M,-.t t1f th<- ela111IM'J under lu.:ht ftflOlollft' hlJ wt>rlr.nl in the
ah1ryarJ1 a, C'~r.:i.ns. rlumlc-n, nr ~"""" hein1 lftlffm111m1h CJlf""Cd tn ut,e,.1< du.r whMI ,....,r,.UIJI cl.:IIC to 1'11"'-
cn=n an C\ll1f.ncd 1r,a,"t'S. Shir,-.rJ ,,..,rt,.c-n ~ fl<'I
d.-1,n,"' da,.,11-J u n"""'1 ta L,hn,t,n uni,-. a
"""'"'un- wa,
w d,:K,-11-c-J. In th, CStlt"I - ~ rK!'<"U:T to '1ft!UI
wnuttcd
c . n - htir,,t1 witll
of ,,., Bro11Cllaa-5ectioaa ol luaa
riaue from 100 men who died with cn:imm of the brot1chul
wa-r cumincd and ubcato6 bodia - idcnt.ificd ID ectiar
from 20 of lhcm. l'or th: ,o paticma who bad died -
-11, palffll control parimu without carcilloml ol the hma
n... - chuecn.
c:antrola we-c men ol the aune qi: ..._
namn wn\ doam to cht>le of the propoai1i in the _ , , . ,
,o ra:,ord 1..on1t.." Amun,r thcwe parrnts w11h carcinoma of the
t-nwkhus tl-ooff _,., niM in whooe Junes a.beat.. bodies -
iden11hrJ ; 1n the 50 matched controla wre wm: 1J in whcff
Jun,p aabntOI budica wa'C idmt~. The dllfama: la DOI
aianllii:ant (Tahk 11).
l'Ollffltl ,. M11a11N1;- of ,,., pt,,..._-Nropay
ma1er11.I wu a,-.i1a1,1, In>m only 24 of the ra11cn1, who olird
w11h mnu1hri,u,ma of the pinna. The tuna twuc nl .DYtdltd
control pe11m11 was .1.., cumincd. The lw11.1 or ~I c,f thr i
pttmn ,. 11h -hrhutn <>I th, pleura ._untau,rJ Lhclu-a
buJ1:a. In 111111 ga,n tl>r K\"lt\1no ahln,~ nurr"'""'" tn.1,... 111
the res anh lfflall numl~n wen- l,.111nd. A,l.-:,.t"" bnJ,.., -
i<Sm1,htd in luna an1ns from anh 6 <>I ur 24 1na1d-.:d
cunnul i,aun,ra wh<, ,lul nnt t.~ ll'IM<llhrhoma ol thc l"kura.
Th11 dllkfUK'r l11chl1 a111T1it.._,.,1t ,Tal-ic II)
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352 6 February 1965
Mcsochclioma of Plcura-EJJJCU et al.
\
i. Aal,ccoa Bodies ud I.Dcluaial Hlllory
abcslm To d&n>w light both on the meaning of the pracocc of bodlC'S an lun11 t'~,ucs and on the accurGCY of ind~nal biuoncs taltcn her death from rdative5, fncnda, or nc1gbboun, 20 paumu wm: chosen who had died in recent )Cfl, wbo bad not had either carcinoma of the lung or mcsothcl ioma of the pleun but in whoi,c lu."lg tissues at necropsy ubcwll boch::s !-.ad been idcnntic:d. Ma1chc:d 0011uol pauc:uts who had nenhcr caranoma no: mcaothclioma and in who,e lwig ti111ucs no ubestoo hodies bad been found were also aclected, the con!J'Ol, being eclcacd u that patient ot the uc,c age and aa wb.lsc
D&IIIC - neuat to that of the proposinD in the .. necropsy recnrd book." 1lie adection ol the 40 patima - done by the parhologisr (\V. T. E. Mc:C.).
"Ibc occupational hmorJ of each ol dae 40 patients was
abcained by one of the IOCia1 woctas who isill:d and questioned rdatiYa 1111d friends. Tbe ap0IUl'C to ubcatOI WU aa:ucd from the indllltrial history u hcaY)', light, or none by the other two auchon (P. C. E. and O. L \V.) bdorc the pathologin l'C'YC8lcd which were the pa1icnt1 la whom utacoa
m. /\ bodies had been identified and which were the coulJ'Ola. &,Mlcr.-Thc rau1.. ._ 1Ul'llffl8rizal la Table histury of hcny or light aposurc: to asbclto& wu elicited for 14 of the 20 patiena whole lunp contained ubcstOI bodn,
with mcaothelimm of the pleura were found whcrca lftYioudy
DCYCI' more thAD fin patJCDC. had been disco,m:d in ~
:,car.
1lie invetiptioa bu shown tbrt history or c:q,osuR to ubcstoe during worlting life was fOUDd in about tluu-,quancn
\ of palicnta in wham a firm diagn.3Sis of mesothcliama of the \rlcura wt11 made compared with such a hiscory in oa1y one-
lliuamr of tholC without mootb:liama.
IA 1cudy of the occupational histories suaesta that tbe intaval bctwccn fint cxp05Ul'C tO ubcsu,s and the dilaoftrr o/ the tumour ii often Iona and IDIT acm1 40 ~ and the
cxr,osun: may be light and in 101DC imW10C1 CrY tnmicm..
A similar obscrntioa wu made by \t'agncr a. (1960).
nae lone latmt period meam Iha die prc,mt iDcidmae ol thia diocuc mar have been dffl:rmincd by industrial pncDcC
,o U to YQn ago j ii also mcam that pm,a!DllC mcuura
Iundat.um now will not alla:t the ~ for 11Wl1 :,an. It ii intaariu& that about QUUta' ol mm drinc rca:ndr(, bcnPftll 60 and 69 :,mn old in Bclfut lhould ha..c ubca1D1 ..I , bod.a in their hmgs. Tbcae older mm ltUtCd their workina ;
~ I o1,o life bctwccn 190S aad 19U. But aabcltOI bodlca - fouod ' 0111, in 14% of the younaa men (dyi&.1 bawr:cn we aaa and '9 -,ean) who bad 1tartcd work between 191S and 192S. 1lie ahipbwldan& iadusa, in Bclfat wu puticu1arly actiw bctwccn 1906 mi 1923 and Dftr 1,000 tom C'l boiler imulatiaa composition (ooocainina ubr:1101) wu UICd ,car campand with ~ mon: usual kvd of 600 tom year. Br the lime ahip-
TMNo. H-, I...._ .... I ,....
bur oaly two of tbele paciena bad bad hmvy apoaurc to abesto., A history of ai-urc to a1bcsto1 was obtained from fm: of the 20 matched mntrol paucnu in wholC lunp no abesto1 bodies ftre 11Ca1: anly one o( \lac bad W bcavy CXJ'Ol\11~. The dilfel'fflCft in hiatory of expoaurc to asbestos br1wclrn the two aroup, an: wr.rufic:ant. 1n abo-Jt thud of
the p&limll who ha\'\: had l\llbcicnt CIIQllle to ubcstol to haw: ashrstoa bodies 1dc1mfied in their lun,:s it hu not bcm
possible to oh&aUl histOI') of CllJ'l'IW'C from rcla:iffl, fncndo,
m or iiciahboun. In a -re.'! for atx.101 bodica in tuna ti..uc,
mnfuJCd to the aamination of two IO m:t10111, asbnll'II
bodies may nol be found although the pancni ba been cxpaicd
to abcato1 durma hil worlr.ins life..
..
Diieauloa
Exrosutt to high mnccntntiona of ubeatos dust hu ""111
bc,cn known to 01119C L'llacoaia Wllh lll>roln of Ille lun1 1nd
pltura. and then: is in thil c-nnd11111n an incff'ucd iDc'IJmQ- n(
oir,....,vn of the lun,i (Mcn:wctht-r, 1949; Dnll, 19H).
Ahhnuah wnrlt1111t a,nd111on1 ha,-c l'ceo imrro,~ and ti~
f'l'n'Sk-ncc nf a.,hestl,us uh ICW1'C lll>rn,u ol tile luna has heal
.,i,.,,,,,. rnh..-cJ, \l 111,am an:J llu,:h-J,mea (l',1()(11 lui~ .Ju,..n char
mam wnrt.rn m an
factur,, m..- lui,~ dnturl>nl lunit
fu,1.11,,n rwn th,mi:h no r,ulrnnnan 111m-.11 bu b,m dcu,.iai
buildang l"lltlWn'N from the slmnp and tticd to IDCICI the m:da
cl the 1939-45 war, the: ~ of handlinc ubr:atm wen:
bac,wn and pru:auuona were talri:n. 1lie ditfcrmce m
fRqucncy of findrnc abcatol fibra iD the luno of 111C11 in the
two all"-sroups pnsumablr rdlcm tbcae dwia,cs minduatria1
condici.>m.
.
l nae ahipyard& - situated in a circumlCnocd area on di: loudi ,adc. Tbc,n: ii oar anal1 factory in which alatoa ia 4 uacd in the DtiJJlc: of a comiMC( rcsiJcntial - . PloaJoa oa
a map the bonacs of paticoD with IDCIOthclioma ol the pleura . .
does not ahow any ,eoerai,II!ea! ouai,hQ! 101tiiiiic1t"contami-~. )
natiall of ft'lodcnual afta by alatos d,_. eimcr from tbc '
~ factory or from the ahii,)ar\11.
11
Unnl rca:ndy most asbcstoa UICd oua.idc the abipJuda -
\\
ill the form of conui;atcd n,c,fjni; Thia wu imported frrm
\,. '
Ellatand, and thi uSuiilly cut and handled in tb: open w1dct
Icond111ons of ~ ftllllbtinn. The ux of ul-atoa in manr induan,n,. and cs;'CCiallY ill tbc bualJma trade. Unaw incrcuinc (Tl Ti-,. 1964!, and th1111m:1 n,e to anaucty that tberl will be an .iDcreucd iacidma:: of mc1oth:hama ol the plan.
le ii oltcn dillruh to abcain dCUlls of paaf cmplc,yna;r from
\ il
a paucnc, and thia ii apcciallv dllfaculc af the infonnatioa IOU&hl
ooncuns work d.JDe ?0 or 40 "9n qo. M'0ffl rdatifta ot
DCll:hboun 11K'h Ulformation ii bound tu be lea IICX'URtC. and
th11 rn1v ecrouru for the 1hAma: of a hi.story ol aroaurc to
abtsn In aomc of the r:iticntl in whnoc IUIIRI ubac,111 bodicl
~ found, 11>J ~bly 11M, In oome of the: i,atamts with
r.r,.o1hel."IITII t1f the pleura. Thrl"C 11'1: .1,u u1:n.'9 ID wbid!
h!.-!i~.1'1'1:' mu r1:"'."...
bltSic, ,u:rg founJln r:~ lm~ll mg, "hn l!IJL
R
..., ......,, ~~,~ ""t 10 1:J.....:,... lth t h ? t ? ,
,,uLJ ttnJ hJ Ir ant ta U1\"nl1 :i'iiJ1il\, r.r-mt:rcr-
cs11111,111,n of 11,r rart Jll:lral br CX1"11urc to 111i>MtU1 111 the
acciolog ol mc-,.xhclioma ol th: pkun,
t,, ch,-..1 raJ1os:"'l'II\".
The~ m~StlllllM ron!lrma lhal mrsoc'xti.wna of the ,,.,ma u an,,cher 1..,,a,J fur ,ti.,.e ear,,otJ to aobN1,:,e.
,s__,,.
'. :.. u5:h ~otnc-lh1P11 11 nrc tumour II has h:rn pna.,1Nc- to
, I a, lie':."' H r-,111 wrth nac,..,,1,c,~m of thr ;,~ura
l. .! 1rmc:J lwhhtrh .,,,. h, bln['I\' 'I' flt'\ r,:.. ,. 1he tr.air
r ,:-.!rn,":"' nVI\ well Y hu:hcr, bn.11u..c trc dmklll.l daut::fl'-'1 i
r "' ,r, ... Ji ar.1 \l'1th.._t1 t,hP v ,u n:,":'!""' 1hr u&Jtl"'tt"l!I r-: nt
., h- 11! ! f,, ... -' wn--n
~ ,ur -- ~ '"
a-:,. ~, 1 , ..- .... , .. ,:.,r...c-et:-,1 u1 ti . n1u.t1:1 n. I 1 r,.a ,..... ,~
A history uf occu,...u.-n.l nr,, ..ure 10 a-.hntr wa, ubtauttd
f'>'""""' tn 32 uut of 4_: r,a1w:-nn ""'h ~-t!'\du111~ nl the r-lc-ura m
llclfur. In ~ 1,-&1,linl at<tn,I
ul tl>c IUIIC ~ an'1
.-s hnhtrY o! Cl.i'-"u,c "' ohtLDl"'J U'\ unk a,u:.
A,!, .... ~t N,!,.,. W("tt f,uuJ ac "'"--Ti"."""' tn tJIC' h.1!';:1 of 14-
~ t1f mnt ,,,-...~ ~o ,.,, t-J ,tnn,: re::.rPI\' u( duic-atie, w:.c:r 1h1u
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196S
Mcsothelioma of Pleura-Elma d al.
353
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~ ol tbe bronchua ad DIOlbrliorN ol the pk,n. AabeslOI boda Wlft fowad ill die hmp al abour 20% of
paticou dJia& with c:ucinoma ol die Juac. TbcJ - fOWld
( in IDCft Ihm l0% of mm d)'ina ol aaothdioma ol the pleura.
A bislOr}" of u indllltrill occvpatio4 wida ClqlOIUl'C to Mbcsroe - obtaimd from ldatna, aci&hboun. frimda al
about duu-qiartaw of pa1icna ill wham Mbcs10I bodicl fOUDd in the lWIII at necropsy. Such a bi-,. - obcaiDed for onr:~ of JMUCDU in wbClm aabcaol bodice - DOC found in the 11111111 at necroplf.
~Jt i, caacludcd that there ia cridc:ncc tbar apamre IO ubclcos,nm lboulh ic may bate bcaa lnllSicDt 111d lllmlJ ~ previom, a.a imponant facuw ill the acriololy ol ~ . f tbe pk.n. Tb llOClduaioa r;;.,a c:auae for amicty bcca1llc the iDczalml commcrcill UIC al 81baJtw.
11adldcll adriae. We lff kidelicmd I anaia die Sll'WU1 Prtlr Puad admmina-ed t,y die FKU!tr of Mcdicloe of <ll-' Uanw-lity, !be Bnwll Empire <.aDr CA,nr,oicn, &be Nonbaa lnlad
Hoopitw Alllhority, the Ro,al Vicwia Hoapa1 Eud a.mt P-C.
aad die Madica1 it-rd, CouadL
We wiab ID thulk Mn. Y - Dudsec,a end Mn. Mariaa
C lz'-"- Stmroc,a who -,t,m 1111drfna)y witb patience Uld 1Kt to obcalD
acx:vpellatlal hittorin frun s-timtl tbdr rda1iwa.
michbaun. We are 1n1dul ID lbe nmnla offim-1 of lldtalt
ntcmaa boopiul1 f tlldr ~Ip In ecarctun, OUI old - aad IO aun,
mllNsu,t wt., Mft hdped .,,
patimta ta ... Te wi.111
10 thank Dr. Mana, of the Depa- of Sodal Ma1iciae. I
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