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FILE NAME: General Dynamics (GED) DATE: 1964 Apr DOC#: GED011 DOCUMENT DESCRIPTION: Journal Article "ZZr***?. iJL&?* EXHIB Jo 22 JHG LITIGATION JWt \|ii! |Jii4 Asbestos Exposure and Neoplasia Ir v in g ] . Si'FtAtiff, M D , J tin d i C hnrp. M D , a n d F. C u yta r H a m m o n d , D S r. \ r , r \o r h Building trades insulation workers have datively light, intermittent. ex|iosiire to asbestos. Of 632 insulation workers, who entered the trade before 1943 anil wen* truerd through 1962, furls-fix* died of cancer of the lung or pleura, whereas only fi.fi such deaths were expected. Three of the pleural tumors were mesothelioma.-: (here was also one peritoneal mesothelio ma. Four mesotheliomas in a total of 253 deaths is on exceedingly high incidence for iii'h a rare tumor. In addition, an unex pectedly large number of men died of can cer of the stomach, colon, or rectum 120 compared with 9.4 expected r. Other can cer* were not increased: 2ft.5 were expected. 21 occurred. Twelve men died of u-lie-tosis. ALTHOUGH PULMONARY CARCINOMA hud / \ b e r n observed in the earliest studies nf ashestosis, association between the two conditions was first suggested by Lynch and Smith in 1935.1 Ad ditional reports of such association followed. Per haps the most striking data was presented in the annual report of the Chief Inspector ol Factories of Great Britain for 1955 * Every death with as* liestosis in the files of the Factory Department, from tiie first recognition of ushestosis as a disease entity, was studied. Altogether 3fi5 such deaths were recorded (1924-1955). Sixty-five or 17.811 were found to be accompanied by cancer of the lung or pleura. D o ll/ after reviewing the problem and add ing data of his own, concluded that lung cancer was a specific industrial hazard o f heavily exposed asbestos workers. Nevertheless, some investigators have held that, while these observations might be suggestive, they did not establish an increased incidence of carci noma of the lung in pulmonary asbestosis, and further, that the association was unproved. The factor of selection was considered a poten tial weakness in evaluating reports of autopsy series. It was noted that complicated and unusual cases would be more likely to come to autopsy, thus raising the apparent frequency of associated lung neoplasms/ Further, it was argued that au topsy statistics, which dealt with particular groups of those who died, do not reflect total populations of asbestos workers/ Additional reservations were based on the frequent absence of data regarding F n a tha Divitioo of Thoracic Pirac. Dvpartmrnt o< MatiiclM, w d tfa* Department of Pathology, Mount Sinai Huapiul. Read M u re joint meeting o t the eectmm on radiology end dur.iue of the obt and the American College nf Chert PbvHdini al the 112th Annual Meeting of the American Medical AuoeiMioa, Allenhe City. N). June IT, 19M. exposure, .smoking habits, and permi.d histon o' the size of scries, and on inudcijii'.'*' hir.tolt'giia1 verification in some cases. Within the hist few years u number ol .uklitiouJ problems comiecieil with ashc-lo- twp.Kiiu- luv. appeared, making clarification ami ri*>olutiun of the foregoing statistical uncertainty a matler of cm> siderahlt* cimcern. First, there has b een cte.-.i !-. increased use of the various types of a.-hc-m five-fold increase in world utilization of tin's group of minerals, from `5<K>.<KK> tons to 2 T |(Wlill1tons per year in the last 30 years), as well as greatly n creased number and variety of industrial applii.iticins of asbestos (mer 3.(MX) such uses now re corded). .Second, suspicion has been growing that malignancy associated with asbestos exposure t\ include neoplasms other than carcinoma "f (hi lling. Thus, a significant relationship has been claimed between dilfu.se mesothelioma of the plem.i and peritoneum and asbestos exposure. This communication is concerned with imesti gations undertaken to study the loilowiog factors: (1) the incidence of deaths due to puhimnuiy car cinoma among a group of worker- exposed in abcslos under United States industrial condition in the past several decades. (2- whether or not such individuals would also lie found to luue an increased risk of other neoplasms, and (3 / w!i (her such risks would lie present in an industry other than the asbestos-producing or asbestos-products industries, with which most reports in the past have been concerned but which would not nec essarily represent the most important areas of as bestos exposure at this time. Further, it was hoped that study pf an industry with ashestos exposure of limited extent and intensity would throw some light on the potential problems associated with minimal exposure to asbestos. Materials and Methods Our investigations have been concerned with 1,522 members of the Asbestos Workers Union in the New York metropolitan area, memliers of New York Local 12 and Newark, NJ, Local 32 of the International Association of Heat and Frost Insu lators and Asbestos Workers. As the full title im plies, these men are insulation workers. Although the union is considered one of the building-trades unions, its members do insulation work in a va riety of industries, including shipbuilding. Called "taggers'* in Great Britain, they are often desig nated "pipe eoverers," "insulators," or "asbestos workers'* in this country. The union is one of the oldest in the country. 1 J* V,l 188, No 1 ASBESTOS EXPOSURE-SEUKOFF ET AL 23 The New York local, as the "Salamander Associa tion of Roller and Pipe Felters," was the first union of insulation workers in the United States, it amal- imated w ith other locals as the current Asbestos .v'nrkers Union in 1912. The stability of this union has been reflected in tlie stability o f its member ship rolls. "Once a pipecoverer. always a pipecov- erer" has been of epidemiological importance to ns and has made this group of men particularly suit able for tlie study of long-term'effects of asbes tos inhalation. Unlike unskilled workers exposed to asbestos inhalation in poorly paid industries, there is little labor turnover among insulation workers. Accurate employment records are main tained by the union, which has also been con cerned with health problems in the industry. The trade was badly hit during the depression: some men had to drop out and very few were added during the 1930's. By the end of 1942 the union rolls consisted mainly of men with consid erable experience, plus a few who joined in 1940. 1941. and 1942. Between 1946 and 1962 union meinlKTship increased substantially. Sinin e of Data.--From union records, a list was prepared of ever)' individual who was a member of either of tlie metropolitan locals on D ec 31. lvj-12. or wlm joined between that date and D ec 31. 1962. No one was omitted, whatever his snhse- |iM-nt work history. The 1912 list included 612 men. S!M) men joined after 1942. ^ . Personal data were obtained from union records, d tlie work history of each man was detailed, including withdrawal from employment (war ser vice, other employment, retirement, illness). These data gave the baseline for calculation of the onset .inti duration of exposure. For members xvho hud died, records of tlie Health and Welfare Fund pro- wiled date and plaee of death. Copies of death certiiicutes were obtained on all but one of them. \utopsy protocols, histological specimens, and hos pital records were ohtained and reviewed in those deaths, approximately one half, in which the ter minal illness had occurred in a hospital. Shiiixtnvl Analysis.--Previous studies have sug- gestod that neoplasia associated with asbestosis sel dom occurs until 20 years after first exposure to as- h. stos dust. Therefore, w e decided to limit the I.resent analysis to men with such an exposure history. Our complete records cover all mendicrs ui the union iincluding active and retired mem bers. both dear! and alive) during the 20-year period from Jan l. 1943, through Doc 31, 1962. However, wi'li few exceptions, tlie only men with a history of 20 years or longer since first exposure to asbestos were the 632 men on the union rolls as ui Jan 1, 1943. (The exceptions were a few men who joined the union after Jun 1, 1943, but who !"d been employed previously os asbestos workers r where.) .1,1963. Of these 632 men, 255 died before* Jan Table 1.--Man-Years of Experience of 632 Asbestos Workers Exposed to Asbestos Dust 20 Years or Longer Vun 3539 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 84 85 h <1* .................... ........... ;...... ....... ..................... ................... . ............. ....... ...... ...... . , ___ .......... .............. 19431947 35.0 230.5 339 5 391.5 382.0 221.0 139.0 83.0 31.5 5.5 3.5 19481952 185.0 486.5 324.0 364.0 390.0 341.5 181.0 115.5 70.0 18.5 2.0 19531957 70 291.5 530.0 308.0 316 0 344.0 286.0 1370 70.5 38.5 80 19581962 110 70.0 3145 502.5 268.5 255 0 280.0 197 5 75 0 23.5 13.5 T o u t* ............... 1,912.0 2.479.0 2.336.5 2.011.0 Of these 632 men, 339 had been exposed to as bestos dust prior to 1924. In other words, as of Jan 1. 1943. 20 years or longer hail elapsed since these 339 men were first exposed. The remaining 293 men reached the 20-years-since-first-exposure point at some time after Jan 1, 1943, and before the end of 1962. The 339 men who were first exposed prior to 1924 were counted in each of the 20 years (or up to the time of death of those who died). The 293 who were first exposed in 1924 or later were counted only after they reached the 20-years-sincefirst-exposure point (those w*ho died being dropped at the time of death). When the statistics were completed, w e found that we had records covering a total of 8,737.5 man-years of experience of men with a history of 20 years or longer .since first exposure to asbestos dust. Of the 8,737.5 man-years. 1912.0 were in the fiveyear period 1943-1947; 2,478.0 were in the period 1948-1952; 2.336.5 were in tlie period 1953-1957; and 2.011.0 were in the period 1958*1962. Table 1 shows the age distribution of the man-years in each of those five-year periods. Table 2 shows (1) the average age-specific death rates of all US white males during each of these periods, ami (2) the average age-specific death rates from cancer of the lung, pleura, mediastinum, and trachea among US white males during each period, as reported by the US National Office of Vital Statistics. The man-vears were then multiplied by the cor responding reported US death rates to ascertain the expected number of deaths under the null hypothesis that tlie death rates of asbestos workers do not differ from death rates of all US white males (both age and date being taken into consid eration). The results arc summarized in Table 3. Results Total Deaths --During the first fhV years (19431947) only 28 deaths occurred among the asbestos workers, whereas 39.7 deaths would have occurred had their age-specific death rates been the same as for all US white males during those years (Ta ble 3). In other words, at the start of the study, tlie asbestos workers hud below average death rates. This is by no means surprising. Indeed, such t-ta 24 ASBESTfW EXrOSl'IUv-SELIKOFF ET AT, /A S IA , April ft, m u Tabt 2.--Tout Deaths and Deaths From Cancer of the Long, Bronchus, Pleura. Mediastinum, and Trachea per 10,000 White Males per Year'1 ... ....A*.......... 35-39 .......... 404* ........ . 45-49 .......... 50-54 .... S5-S9 .......... 6064 ......... 65-69 ........... 20-74 75-79 -------80-84 .......... 8$4* 1943-1347 To*! Lung C*ne#ff ~ 36 55 1 85 2 133' ' % 196 S * 295 7 435 7 ' 634 6 977 6 1,453 S 2,422 3 9481952 To!*! * 30 48 78 J24 189 231 417 605 915 T.353 2.162 Lung C*RC*n " i 3 1 a 10 n ll 0 8 7 1963-1957 .T. et.*J6t *"*Luxn-wg. >* 43 1 72 3 US 178 10 276 l* 416 17 586 16 878 14. 1.346 lz 2,017 9 u<Su-196? to!*! $ m lib 7 178 ! 272 17 *(4 21 i0` 2! 1/ " ' t.:s3 if 2.* " OeRlh faits* a* repotted annually by (ft* US Nation*! OWie* (Si Vital Statistics A live-year venge m atvttt hete for :t:ls pet>i,ti A n - > for 13584962 i* proittition of 1958-1966, inc* 1961-1962 ratas are not yet avallabl, fOeath rate* m elufl* near e l M u lung, bronch*- pfu/a. madiastinMttt, ami iraehei. assigned to mtamattonat list to' No. 47- * t, to 19*9 and to No. 160-164 Mtareaftar. is almost always found in the first tew years of a prospective epidemiological study of this tyjje, The explanation is almost certainly as follows: The 632 men in this analysis were actively employed as as bestos workers in 1942. Since disability from illness or other causes precludes employment in a trade of this type, these men were presumably well (or at least not disabled) at the start of the study pe riod, Almost any group so selected as to exclude the ill and disabled has a lower death rate during the ensuing tew years than does the general popu lation, since ill and disabled persons have extreme ly high death rates. A selective effect of this type gradually wears off with time and largely disap pears within five to ten years from the time of in itial selection. During the second five-year period (SM84952) the death rate of the adn-stos workers was slight ly higher than the death rate of all US white males, ie, 54 observed deaths compared with 50.S ex pected deaths. In later periods, the death rate of the asbestos workers was proportionately higher. For the period 19534957, there were 85 observed deaths compared with 56.6 expected deatlis, and for the period 1958-1962, there were 88 observed deaths compared with only 54.4 expected deatlis. Table 3.--Observed and Expected Number of Deaths Among 632 Asbestos Workers Exposed to Asbestos Oust 20 Years or Longer / IM3> 194. tie- --ne--w.,Tm*tsl-, Cu** 44 0th 1*47 1952 1957 | M2 1962 TOI*!, (1 *M*4N ....... Ob*rvo (**bita* work*) 28 54 8S a 255 ttpmtto (US wfcrt* .... 39.7 50.6 56.6 54.4 203.3 Tall c*ncr. *14 it*.... ObMUrad (ttmto* work*} 13 17 26 39 95 ExiMtctad(USwna# m*!*t).... S.7 8.1 13.0 5.7 36.5 C*nc*r ot lung *nd <tf*ur# ........ 6 Ob*4M-vd Usimto* work** 13 18 45 EnooctoO(USwhit* mat*) .... 0.0 1.4 2.0 2.4 .* Cncr*rdotifmtloflia.c.l.t.,..c..o.lo. n, and, * 4 7 14 29 ts**rv*d (Motto work) *o#ct*d (USwftrt*irait).... 2,0 2.5 2.8 2,3 9.4 Cnc*r of *11 oh*r tit* ont- Obbtlwn*vod..(..i.b..o..t.i.o.*....w..o,,rk) 3 8 8 ' 7 21 E*Betd (USwhit*!**}.... 2.9 4,2 8.4 5.0 20.5 A*b**tol* _____ ___ 0 1 4 7 12 OOttrvad (tbocto* work) Cancer of (he L m g . Pleura, ami Tun-hat - i each of the four five-year jhw kK. f.u more ifeytlw Irian cancer of the lung and pleura - hi-i <1 among the asbestos workers than uouUI h.n * (.sirred hud their death rates hum these d e .*,..< been the same us for ail US white m u h iTable 3Altogether 45 of the 612 ushesles vsurkers died nl i-jiMT of these sites, whereas uith fi.ti sut-h ilt-aihwould he expected from gcner.d VS esperiem. Of these 45 deaths. 42 were retw ded as due tu bronchogenic carcinoma and 3 to neoplasms ot the pleura. The pleural neoplasms were all recorded as mesotheliomas. Thus- it was found that the death rate Iron cun t er of the bronchus and pleura was 6.8 times as high among these asbestos workers as in the g* eral US white male population (both age and dale being taken into consideration). It may he asked whether tin* high rat- of hmg cancer among these asbestos workers could pm sibly be attributed to an unusually lame proportion of cigarette smokers among them. We cannot an swer this question directly, since we have not yet been able to ascertain the smoking habits of the men who died. However, the following pieces of evidence indicate that unusual smoking habits can not account for the high death rate from long can cer among these workers: We have interviewed 320 of the 377 surviving members of the 1942 group. TaWe 4 gives a sum mary of the smoking habits in this group compared with a sample of men drawn from the general population of 1,121 counties in 25 states.' The un ion sample is somewhat inadequate since it does not include the men who died and does not in clude all of the present Jiving members of the union. Nevertheless, It shows that a substantia! proportion of asbestos workers never smoked ciga rettes regnlarly. Certainly the 632 men in onr analy sis of death rates were not all heavy cigarette smokers. In the general male imputation, lung-cancer death rates are about ten times as high among cigarette smokers as among nonsmokers; and the Vol 188, No 1 ASBESTOS EXPOSURE--SELIKOFF ET AL as Table 4.--Smoking Habits of 320 Abestos Workers Exposed to Asbestos Oust 20 Years or Longer Compared With Sample of Men From the General Population*2 A* <049 50-59 60-69 70 - Nvm- SmokMt epilly AttMkllM W ork*, % 9.3 4.3 20 3 25.5 .......... Q M r*l P0(Kilion, % 18 8 9.9 23,6 " ' " 3?.i Smokwt 1 , Cigar, Nf Aft*l0* Work, % 4.6 1 M "" 10.2 ' 11.8 S*r*r*l PoouUlion. % 1.3 9.9 ' ....... " i 5 T " ...... ....... .. 23.9 ........ Samp) o f m m from general popufaiton as reported by Hammond and G a rh n M l* H.tior f o( C l**f imaking A*heo* W ork*, % 86,1 7 9 .6 ." 69.7 2.7 :: Gn*rtf Psputrlioo. 73,7 70.2 60.2 390 death rate from lung cancer increases greatly with lh<* amount of cigarette smoking,'1However, a large proportion of all nun in the United States have history of regular cigarette smoking, Front data jo a prospective sloth oil smoking." H may be esti mated that if all nicn smoked a pack or more of cigarettes it tlay (i<>, if all the nonsmokers, cigar smokers, pipe smokers, and light cigarette smok ers had. instead, been heavy eigarptte smokers) the lung-earner death rate would lx* approximately 11 times as high as it is at this time. From this * may conclude that even if a ll our da-slMs workers hud smoked a pack or mure ol rigurrUes a lay (and, indeed, from *mr sample we know ihev lid not), and if exposure to asbestos u*e oi no simiiiicante, then their lung cancer death rate would have been about 3.1 times as high as the rate in the general US male populao-n. Clearly, tin* smoking habits of the aslmstos kers cnmint account for tla* fact that their lung* earner death rale was fi.fi times as high as that of white males in the general population. V,asim intesihtaI f'oiri.--Rather to our surprise, the death rate from cancer of the stomach and the death rate from cancer of the colon and rectum were higher among the uslrestos workers than would- In* *vpect*d from the rates reported for the r,s white male population, calculated in the same w.tv as tor long cancer, Twelve deaths from gastric i.iiHV!' occurred among flic asbestos workers, as simparvd with only 1.3 expected. Seventeen deaths Irwin eancer of the eolon and rectum ocettrred among the ashestos workers, as compared with 5.2 oxju'i'ted, C tiH ffr af A ll O ther Sites.--The comhined death -ate trom cancer of all sites other than lung and pleura, and stomach, colon, and rectum was not im rvised. Twenty-one such deaths oceurm l among ,,shfstus workers, as compared with 20.5 expected. .Wirs/rMi*.--Of the 235 deaths. 12 were due to asln-stosis {pulmonary insufficiency, cor pulmo nale !, The lapsed time from first asbestos exposure to death from usbestosis averaged 45,3 years, with a range of 32 to 3ft years. Comment ( lOMiri of the L ung,-T he results with regard In en.cinoma of the lung are clear. Industrial ex posure to asbestos by insulation workers, as stud ied here, results in a marked increase tn the inci dence of cancer of the lung, approximately six to seven times the expected incidence, Altogether, 15 (17.67) of 253 men with more than 20 years elapsed since the onset of exposure died of cancer of the lung nr pleura. These data do not give the "incidence of cancer 4 the lung in asbestos,s." Tliey relate to the spe cific comlitinns of our investigation: to a group of men with only intermittent exposure to materials ' ntaining limited amounts (often 2% to 20'*) of asbestos Mitder working euiiditioos varying from u>ry <lust\', as to c.xtrueting Id insulation in closed carters, to those with little dust exposure, as 111 building construction in open air. Moreover, they relate to the relatively recent past, in a troth* with the shorter work week of the strong building trades unions, in an era when industry has been aware of potential asbestos hazard and the working popu lation has had some consciousness of potential risk associated xxith dust exposure. These data would not necessarily apply to asbestos exposure other industries, such as the factory production of asbestos products, the asbestos textile industry, etc. where conditions of employment might le Hite different. Our results do not contradict the even liiglmr incidence of lung eancer suggested in other studies they are merely a shade l*ss strik ing. Diffuse Pleural anti Peritoneal Multe>tnnq/~Mesothelioma,TMDetermining the incidence if dif fuse pleural mesothelioma is complicated by the insecurity if its liistological verification. While .some pathologists will so categorize a high propor tion of diffuse pleural tumors, in the experience of others it is a very rare tmn>r and may be mim icked by anaplastic peripheral carcinoma of the lung and diffuse fibrosarcoma of the pleura. It Is difficult to evaluate completely the published re ports of diffuse pleural mesothelioma in asbestosis in the absence of complete details of each case. To the present time, there has been no informa tion concerning the incidence of diffuse pleural mesothelioma in usbestosis, since the published cases are reported without reference to a total pop ulation in which they occur. Nevertheless, the 4> 26 ASBESTOS E X I'O M 'H t-s tU K O t'F I.T AL J .t.U .t. \ |l l i l li, I :ll>4 growing number of reports of nulivicUml ws stiggests that these tumors arc perhaps hecorumg relatively frequent complications of asbestos ex posure. Our ufjscrvatkms in ibis series are similarly sug gestive. In three of the 253 deaths among the men who had worked for 20 years or mure, the essun* ining pathologist tomulered the death due to dif fuse pleural mesothelioma, and in the two eases in which we have* been able to review the histological material, the lustnlngleat appearance was that of ten so categorized, and asbestos bodies wore pres ent, This incidence of more than 1*7 of deaths from pleural mesothelioma is strikingly high for a tumor whieh is generally considered to he extreinly rare, In one case in our series patbologieal ex amination suggested dilfo.se peritoneal mesotheli oma, This single experience is tew* fragmentary for evaluation, Castraintr\l mil Carcinoma.--Isolated installers of gastrointestinal carcinoma in the preset;* oi asbesiosis have hcen known, hut there Jiuve been no data to indicate that these were more than coinci dental findings. Among tin- asbestos workers studied Imre, cancer of the stomach, colon, and rectum was three times as frequent as e x p ee lu l T h ese data suggest that there may perhaps be an etiological relationship between industrial asbestos exposure anil carcinoma of the gastrointestinal tract. F.nditinnieiUal ,\sltcshix K.\'fto.xnrr.--The recent demonstration, by South African" and British" in vestigators of pleural and peritoneal neoplasms among individuals who had vliuuec environmental exposure to aslx-stos many years before raises the very important question of possible widespread carcinogenic air pollution. The possibility of en vironmental exposure has long hcen known. Snort after the initial clarification of ashestosis as a clinic entity. Haddmv " demonstrated asbestos bodies in u man not employed in tbe indiistry but living next door lo un asbesto, hietnn, Tbfs fcmling ,> lat*r mirri ned in tbe findng of elinmic luivlimm ih - case ami mg lesdeiUs of a community u*ar a benili factory." \VIuit i\ new. liowevr. ,m appie datili of (he ixitenti.il evieni of th pi.shiem Thomson and ussiieiates " baie reporo-il th tir* quent findings of asbesto* Itociics in tla longs orba dxvellers. Arnung $.313 imiti tdual- \-r.tyed in ali area abmtt an asbevfos mine in Hitlu.d, K i'iluotrt11 fomiti 490 cases of pleural e.tlei,abeti of th type eburucteristfcttlly seen amowg asbesto, workers. without ubvttnis cause. In a cuntpnnihit area wflhnut any ashestov mine no tasta u rr fouitd. aimmg 7.101 persons v-niivd. Jt sltuuld be notetl timi tiiese nere imt prople nini uliveti in (he mine--none diti--bnt. ratber. vere bninefv hiMisewiu's, and otbers u b o bveil tu th generai location, fu irte nbject ho cauto to iitbtjnA polarizrtl-lght miuoscopy demnstr..fed asl-oso*. fibi'cs in tbe long. .Stiutfarly, th Jung of a voi giw big tteur th mine al.so siamoli thv [tnseiiei.- *t ashesfos, p.triieular eariety of emirnumental exposun irniy la* of eie ureater coileoni, Asbesto*, expo-tre in imitisi ry ili not be limititi to tbe pr!*td,u orafi ihat utili/** th materia!. Tbe (.itiug fiheis do ut respect job classi Reatiniis. Th*. Iur **.ampli*, insulation workers nixlonUtctlb sitare ti*- sposine uitli tbeir workinates io oflier li.nle* intimate eoutaet irli asbestos is pnssiblo l'or l'Ii-t trieians. plumlicrs. slieet-metal workers. strambi* lets. lahoivrs. eaipenlers. boiler ninki-rv and Iure nten: perliups cveti tlie superiising nrcliilccf sbouli! fe inelildeil. t 1. MHHli SI. New Vutk 1002*1 i |),. Selli.,.11 ). This ami)* wiis supportisi hy llw* Ilealtii lti*M*.ir. li Comiil ni tlii* t.'ity of Meli* Vurk. CiMiper.iting in this investigati!! Ileo* tbe cxcouiiw *fiicrs nt Mie Internatimi.! Associtlttoit et lleat miri Frasi lniul.itors nnd Asbestos Workers, VVastimcUMI. OC. .imi il* nflem and mombership of lite New York ami Xovark. NI. liM-nls of this Union. References 1. Lynch, K.M., and Smith. W.A.: Pulmonary Adiestosis: Carcinoma of Lum: in AslK'slieSilicosis, Amvr ] Cancer 24:56-64 (May) 1933. 2. Annual Report of Chief Inspector of Factories for Year 1955, London: Iter Majesty's Stationery Office, 10.46, cmnil 6, p 206. 3. Doll, R.; Mortality From Lime Cancer in Asbcstm Workers, Brit J hduetr Metl IShSl-Mfi, 1955. 4. Bohlip, H., and Jacob, Go None GesichLspunkte iiber den Ltmue.ikrehs der Asbcstnrbeitrr. Dcutsch Sicd Vvchr 81:231-2.13 (Feb 17) ISM. 5. Braun, D.C., and Tman. T.D.: Epidemiological Slinfy of Lunc Cancer in Asbestos Miners, M IA Arch Imlustr Health 17:634-653 (June) 1956. 6. Wagner, J.C.; Siege*. C.A.. .mil Marchand, IV: Ddlu.w Pleural Mesothelioma and AsIjcsIo* Exposure in North Western Cape Province, Brit J Induxtr Mrd 17:260-271, I960. 7. Hammond. E.C., and Carfinkel, La Smoking Habits of Men and Women, J Xat Carucr Imt 27:419-442 (Aug; 1961. 8. Hammond. K.C., and Horn, Da Smokim* mid Dealt R.ti*s: Report tot Forty-Four Months of Follow-up of 167. 7,S3 Men. I. Total Mortality; II. Death Hates by Untv . iAMA 168:1159-1172 (March 8), 1294-1: *M.<*h m um 9. MiCttuglwy. W.T.E.: Wade, O.L.. amt Wines. F.C.* Exposure to Asbestos Oust and Diffttse Pleoral M*vtli li.tnas, Brit Med l 2:1.19? (Nov 24) Ht6*2, 10. Ifaddmv, A.C., in Report of Annual Mix-ting of British Medical Association. Vianchester, 1929, Lami't 2:230-231 (Aug 3) 15)20. It. Chesner, C.: Chronic Ptilmnnary ( aaimloniatosis in Resiih'itts of Community Near IWryllium Plant: Three Autopsicd Cases, Ann Intern Med 32:102S-IU4K (tune) 1930. 12. Thomson, J.Ch: Kuschul., H.O.G.; and MacDonald, R.R.: Asbestos sis Mwdern Urban Hazard, .S Afr Med / 37:77-81 (Jan 19) 1963. 13, Kivihtoto, R,; Plctirai Caldfitatimi as RiM<iitueihuic Sign of Non-Occupaliotud Endemic Andinpflyllile-iUbevtosis, Aita Hadinl Suppi 194, pp 1-67, {960.