Document wrjYRpLDvBB6eoXXpQD9O7qg4

!\ . ' \ LONDON AREA lY MURIEL L. NEWHOUSE and HILDA THOMPSON From the D>,tori,iu.nl of Oecnpaiionat Iftahh am! Applied FhfxMotf, Lomioo School of Hygiene umi Tropical Medicine UICUVIO OH PUIIUCATION FCIMUAKV II, 1965) A scn> .'i >3 patient* from the London Hospital with a diagnosis of mesothelioma confirmed by I r.c.vopxy or biopsy has been studied for possible exposure to asbestos. The scries consisted of 41 .r.en a no o; women; 27 of the patients had peritoneal and 5$ pleural tumours. The earliest death recorded . m 1917, but only 10 of the series died before 1950 and 40 (48%) between 1960 and 19>`*-. p 76 o:' the series full occupational and residential histories were obtained. Forty (52 6%) gate a .-..story of occupational or domestic (living in the same house as an asbestos worker) exposure to .abestos compared with nine (11-S %) out of 76 patients from the same hospital suITering from other c.scascs (r < C 0OI). None of the 17 suspected eases of mesothelioma, rejected on pathological grounds, was found to have had any exposure to asbestos. There was also evidence that neighbour* nood exposures may be important. Among those with no evidence of occupational or domestic exposures. 30 6% of the mesothelioma patients and 7-6% of the in-patients with other diseases lived within lulf a mile of an asbestos factory (p < 0-01). Out of the 31 patients with occupational exposures onj^ 10 were in jobs scheduled under the Asbestos Regulations of 1931. The interval between first exposure and the development of the terminal illness of mesothelioma ranged between 16 and 55 years. ^ In 47 patients in the mesothelioma scries, lung tissue or sputum was available for examination. I In 30 (62-5%), either asbestosis or asbestos bodies were present. In recent years. the association between exposure among the women, 25 had pleural and 17 peritoneal j asbestos dust and cancer of the lung and other tumoun. nalignant neoplasms has been the subject of much The aim of this study has been to establish the aearen (leading article. 1964). Wagner, Slcggs, and occupational histories of these patients and to trace ".archar.d (i960) described the occurrence of meso- any other possible exposure to asbestos. There were O -;!.o.r.a of t *.e pleura in those exposed to crocidolite four surviving patients at the outset of the investiga j.-,- .ox ir. mining districts of South Africa, and tion, but these have subsequently died. The earliest -x .-.as ed further studies of the occupa- date of death in the series was 1917; 10 died before hixx.-.ex of patients suffering from this tumour 1950, 33 between 1950 and 1959, and the remaining u.ve.n. .v3-; rowier. Sloper, and Warner, 1964). 40 in the past four and a half years. The youngest 7.-.c present investigation concerns patients in patient died at the age of 33', and nearly half were aom mexot.ieiioma had been diagnosed at the dead before the age of 55 (Table 1). landon Hospital during the paat SO yean. After camming the necropsy and biopsy specimens held "'Clinical Features a the pathology department, Hounhane (1964) con* amed a diagnosis of mesothelioma in 13 patients, The ward tiotes of 65 of the patients were available jf whom 41 were men end 42 women. Thiny-one of and give a picyire of a disease, with a consistent 7M-JDcn had pleural turnouts and 10 peritoneal; symptomatology. Among those with pleural 201 s I ! li t .i 5i i V I; ;..fIi i; i.iI ..*i! IS T O O I I 80S \ DOW 06018 7 S T 0 0 I1807 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Tuul ACC AT OCATH OP *) PATtr.WTS WITH MttOTHKUAb TUSIOUXS Am tf.i <>4 5!" *5 * Malt Na. W T IS ,, It 4-f it-i : in rtmtlt Na. * 1 34 a 14) 21 4 II 43* 1 14-0 patient, the notes had been returned to the executive council pf the National Health Scrx*-' where they were destroyed within a period of Uu years. In one of the asbestos factories a fife was *(|, detailed records of all employees since it Marivj 1913, The names of all patients were checked uni these files. Nine men and nine married womou,.,,,, * their maiden names had been ascertained ,,i lives) were identified without difficulty. n- I* /* r dates of employment of these IS patients and i,^ tumours, the commonest presenting symptom was jobs they had done were obtained from the reenr.:. the raritJ onset of extreme shortness of breath due of the factory. to the formation of a massive pleural effusion. Pain The four patients alive at the beginning of the was a prominent feature, either described as a dull investigation were interviewed personally. A few ache, sometimes due to invasion of the ribs or relatives were contacted by post, but the reunites of vertebrae, or sometimes sharp and radiating, sug- 68 patients were interviewed by one of us (ll.T.i ai jesting nerve involvement. Tumours in the chest their homes situated mostly in the E* llnd <4 wall were not uncommon, occurring either in - London. Not only was an occupational history of u< previous operation scars or by direct invasion of the patient, the spouse, sons and daughters, and feilicr chest wall. The symptomatology of the peritoneal taken, but past addresses were also recorded. Tu- tumours was more varied. In some patients the pre interviews lasted for at least an hour. To recall events senting symptom was pain on dcfnccation or of 30 or 40 years ago it was often recojry i,, micturition. Oiffuse upper abdominal pain was very explore the residential and occupational histwe of common, and swelling of the abdomen due to ascites ' all members of the family. was always present terminally. The methods of trratment included pneumonectomy, decortication ol the lung, deep .r-ray therapy, instillation of radio active gold, and cytotoxic drugs. They were used Exposure to Asbestos In Three Croups >m' 1\i.-his Suffering from Other Diseases V V v alone or in combination but had little effect on the For eomparison with the mcsotheliotu i'.hkmu. course of the discxsc. Half of the patients suffering three further groups of patients suifennj from oilier from pleural mesothelioma died within one year of . diseases were investigated. the onset of symptoms, a further third within-two. The first group was selected from the patients in years, and only one patient survived for more than the medical and surgical wards of the liaPhal during three years. The course of those with peritoneal the early summer of 196* On-paticnt' wries).- Each tumours appeared to be equally rapid. Eight of the patient in the mesothelioma series w)t> had been patients died within six months of the onset of traced was matched with an in-patient of the same symptoms. sex bom in the same five-year period, as there was a.dearth of male patients over 75 yean jfage in ihe Sources of Information on Occupation nnd Residence hospital, a sample of six patients of diis age and In addition to the ward notes, some of which gave good occupntional histories, there were three other sources of information: the patient's general practi older was taken from a neighbouring geriatric hospital. The second group were thoc who hid originally been filed in the pathology derartnent of tlw ii.*. J. f tioner: the records of an asbestos factory in thgarea: hospital as eases of mesothelioma but -n whom the and personal interviews with patients their diagnosis was subsequently rejected on pathological surviving relatives. n. \ grounds by Hourihane (I9fid) ('rejectee series'). As As a first step, general practitioners were circulate^ it had proved extremely difficult to loratc the rela with an esplanatory letter asking them to complete tives of those who died before 1950. attempts were a form giving details of the occupations of pulients made only to trace the three survivors in this group and their immediate relatives. Within two months and the 14 who died after 1950. 65% of the doctors had replied. In two cases a The in-patient scries, already dc'criocd, were ali hitherto unknown exposure to asbestos was revealed: admitted to hospital in 14b;'-. Tlw salients with in others the name and address of a surviving relative mesothelioma werg admitted to tlw *ame hotp-al win itafli hut in IN majority ihi doeier wii unibta ovr 1 nrM of 47 yftn tlu*in| hhn thin mL*M to give information because, on (he death of the have been a substantial change both in he residential DOU 06019 1 \ll..\*>nn:UOMA OF PLEURA FOLLOWING EXPOSURE TO ASIlFSTOS 263 41U mVu! el.i'WN of ;'.iuetm attending the . ,t, ito't'-iah Tlm.v a tlirU group of patients ..-om the i;."piul records matched by I a,:mi"i'n a' well as date of birth and sex ^Ittht jvtticiiis m tlw mesothelioma series. Their >" iv'idotee and occupations were extracted ^ ss iill those of the in-patient scries. Kt-vults i Oct*-' '* ^ pt.e:.i\ in tlie nteviiliehtiii.a *1.0 are gi'cn in the Appendix. No information paj; ,,omc>nc a.iu occupational histories was jj.ijt'lc for sesen patients. Antoni; the remaining ! ^edt52 f>* J ga'c a history of exposure to asbestos omsared unh only nine 11 I S '/.) of the `in-patient* ; (Table 2). The dtiTesenee in this proportion is t AULf , 7i; or IM'OSUHR TO AMU STOS OK V* J*ATJI:NTS ;* mcSOTHlliOma AMI :* in*PaTICNTS with OTHCA 014LA4L* *---- - --------- - 7>m f C*powu McwtKti#no Sana `lAsfdmt' Utm l0p4)*J $t l' MMthn . >I*,f.*'< Jl g*0-i l4 ItO*'/ \*4+rf4 -.... W(iM41 >* , V. I No. I % * 7J 1 1 ) .kik*A *<*4 lug*ck i J |0) 4 3) ;,^|>hS.d..thaM^l.l^t 9 > IH 1 l-l htsiory oi v.r Af . 'wsiw' exposure i<* j ..NrMin 1 --\ ; 34 j 47-4 2 47 2* 112 t' mis< ktpmurn w* kxhoM** in khmiMIi^N ur rtry iNtiti pum*#*! n mafSiiscni *cr. i* n n. f < oooi Srit cases of mcaehl*oma cost>4 *ot 4* tn<4 and art muioft k-a ifco iaM. I utijiicaily highly significant (\l -- 2711; r < J01). Tins result is unlikely to be unduly influenced \ kj ihe tsso gioups of patients not being matched for < y:ar of ^omission to hospital, since there was no '.,'.ihei;-.i o.ffcrcnce either in the areas of residence | nn me occupations of the patients admitted in 1964 I ..id those admitted between 1917 and 1964. Com- ;-:mg t.ie confirmeo and rejected patients in the | rcsoihchoma group who died after 1930, 36 (30%) . jf .he confirmed and none of the 17 rejected cases ' ^\c a history of exposure to asbestos (Table 3). d^Tais dhTcrcnce is statistically highly significant ' n*'- U *3; KO-OOl). Tabu 3 i.xrOMtiu. to vMii.xTosnr crtst iKMi-n mi kiji.cti r> CAM.V 01- MLMIIIII.UOMA MIHVIVING At- TLX MNLAKY IVS# UapnMr% Nn nf dnwrdO (MIMl fMMlA Oicmn>s of MuAimidMu CAnCirmo* j l(Ck04 .1 1 M1 0 14 11 I1 II IS. < SCSI Mcsotltcliuma hicrics Occupational F^poutrrs.--There are details avail able for the It mesothelioma patients who had worked at one asbestos factory which used crocidolitc asbenos with small amounts of chrysolite and first introduced amosiic in 1926. Eleven started work before 1933 (live year when the asbestos regula tions controlling the manufacture of asbestos goods and the protection of asbestos workers became effective), and seven started work between the beginning of 1931 and the end of 1942. The occupa tions of these workers and the type of asbestos they used are shown in Table 4. All of the 17 for whom details were avail.:1'.# had used ct.vido'..;c a*'ne'.ov Five of the occupations listed arc not scheduled as Tabu 4 JOOS OK |7- KATII NTS WITH XtC-SOTIinunMA EMPLOY CO at onc asbestos FaCTOHY Suidigry J4 Mato PlAWk Material SdllKI It nttlMoti OtllkAC g*4 Oinfii(|riiM| mi 0P4IMO4 Not Mtim i# rtfoUuoM Fititf ostktoji for A.A.F. iMtki MtAwfoctoriAi p<fH tntoU* ItOA Mififgcitri| of . knki isitsnp Rvhto' coot# POMl4t4lf 1 I l 2 1 4 Oocnioiita i Crociaolao C/octtfohia. 0 C4r)oikl0. mosaic Ooc*4oii. 1 cKrywml^ IIMWU Cratittlif CfTCiBBllU 0 CrociUolna Croci4oli. dtfnotk UOoortr 1 0 cvrtoiii*. oioaiit `iBplipwii kui) mt xT.il.su far tm fault p.iw. t l I I! 1i oo o o CD O CD 'I ,I I ! ! 4! . 1 I t I M !! J i I 06020 264 BRITISH JOURNAL OF INDUSTRIAL MEDICINE requiring medical supervision under the Asbestos Regulations (1911). Four patients were working at other factories making all types of asbestos goods. One had been employed in a wagon works sawing asbestos sheets for partitions. Except for one, a woman employed in insulating electrodes with crocidoliie, the types of asbestos used in these oilier factories arc not known. The eight healing engineers and taggers were all men. Three had been employed in dockyards on ship repairs, two in various types of lagging, one in a power station, one installing hospital sterilising equipment, and one installing central heating. All were consistently employed on this type of work for more than 20 years, but, in some, exposure to asbestos was intermittent. Domestic Exposures.--The group of nine, seven women and two men, whose relatives worked with asbestos, are of particular interest. The most usual history was that of the wife who washed her hus band's dungarees or work clothes. In one instance a relative said that the husband, a docker, came home 'white with asbestos' every evening for three or four years and his wife brushed him down. The two men in this group, when boys of S or 9 years old, had sisters who were working at an asbestos factory. One of these girls worked as a spinner from 1925 to 1936. In 1946 site died of asbestosis. The press report of the inquest states: 'She used to return home from work with dust on her clothes'. Her brother had apparently no other exposure to asbestos; he started work as a shop assistant, then became a sawyer of iron girders until 1948 when he worked as a loader of groceries in the docks for five years (but never on dusty cargoes) and then returned to sawing iron girders. He died in 1936 of a pleural mesothelioma. In-patient Scries Occupational and Domestic Exposures.--Two of this scries had worked in asbestos factories and four had been employed as laggers. The husband of another was employed at an asbestos factory for three years, and two dockers in this group gave histories of handling asbestos cargoes front time to lime throughout their working life. The diagnoses of these patients have been grouped' into seven categories (Table 3). The patients with a positive history of exposure are scattered throughout the various diagnostic groups, and there is no indica tion that exposure to asbestos could be related to the disease which had caused their admission. Neighbourhood Exposures of MesoihHioana end Io-patlent Scries.--The 36 patients meso- Tasix 3 oiscass caours or rvrteNTs in thi in.htmt OtMAM CfM# McitM* IMIfMIl) C*taf408yu1 RnpifiMO' AU OUur Tool uan) tMKan) N. ( 21 9 9 3 II II 7* Ct9tW| ) X l 1 1 9 thelioma and the 67 patients in the 'in-patient' series, who had neither an occupational exposure nor a relative living in the home working *r.h asbestos, might have been exposed to asbestos Svu, because they lived in the immediate vicinity of sa asbestos factory. ,, One factory, where more than one-fif'Ji of thr mesothelioma patients were employed, opened ss 1913, having been situated nearer the centre cf London for the previous seven years. There see three alTected female patients living within half s mile of the factory during the time it was in prod* tion at its first site. When it opened they sere children between 3 and 7 years old. At the prncai site, there were eight patients living within a half- mile radius of the factory. One man was born 4lv* a quarter of a mile of the factory and remained <: live same address for 16 years. The oilier seven c women, and all except one were children when thr factory opened. The seventh wu *23 years of aarW remained in the same house until she died as yean later. She is the only patient who nad neither occupational nor household exposure but >n ho asbestos bodies were found in the lungs at nctrorv Among the 'in-patient' senes, one patient i`d near the factory at its previous sue and four others lived near iu present site. One patient was 22 yean old when she moved into the neighbourhood m I?1-*- She disliked it and, when interviewed, compiamrd impartially about the dust from the asbestos factor and the rats in the house. TamlI6 xestocNca or rATtcwrs with no occur*t,o*i. o* DOMESTIC tX.OSUKC TO AMlL.roi Series U-M'Um U>M WukiA | -U.M AjMiim rkir y. II su Nm. :s : l0tm *. __ _ ' :> - s-as, t * mi 6 0 8 1 I0 0 1 S DOW 06.021 // v<//;/ / //mm nr riJ.Uftf^&iLOWlNC, hxtosuri: to asm.stos 2f5 dime \<iil no <cc>i{v*tkwr?Vw^- t.nng livvne wax available in only four patients *" 10 .isIvm.**., ilu-rc .me 11 OOjf^&Tcxpnvcd cither thrmiph rrlaiivex nr hy living m tlx 1* liu li.M,!,) v, ,., s ,,i,,i five (7t4$0^vncirhl'n^iwl nf a-.Ik-.Iov fvinfies. In twn, ., . '..vi' n.t n:' 'vi :v\ wini locil ttnlun Ualf*WlSc asbcUox bmlicx were prevent in lung imuc but there ,.,t i.ntiMy m IV area (Table 0).;tjlVgL WIW evidence of avlKMrr.it. ..o'lt'C in tie s'ipporlion nf .. |.. i... -f iiir firtnry T*air. ,1 no olVr exp'vurc to ;tvl\-x|<vx it MatiiticnHy- ..muanl t \* 7 MS; P < 001). r.vtm Mt or Atnt trot annus o* amh trout in At CAMS Ot> Ml Vlllll IIOWA W|fM l.tffwi imuc srvruu avaiuwx ron ijcamiwatiom IVitr *C I irti Ctpntor* and Interval Ikfcrr Death j MrvnilirltiKna Seriev--l fty*one men anrl women : rvpnvtl to axhexfrn. including those who IlM.Wf mf C> .** Aw> ; the main athcMm factory. TIk duration- flWWVW * .. tvpoxure vaiicd widely, ranging irom two montltt a over JO yearv The interval helwxtn the first- l/amnC n.v*ure and death varied between 10 and S3 yean - Twal AAwwii m AiVnm amuv ^199 * ASwm - A St A a s t | as -ran 37-5 yrart). Among the group of factory*- 'fvcrv where etpoture wat prohaMy heaviett, the * ____ .... . ..." r erval wat Mvorteti. It was, longest among Hoy Among thCMe peiwwtn mnampa p.'vn ioing in the neighbourhood of the asbestos with asbestos could he established, there wasi ^taricv w Vrc exposure to dust waa probably-- merchant seaman from South Africa, _. Table 7 thews the mean age of eaeh group stowed both asbestos bodies and ashextoais: be meytf_ ti fju exposure and the nwan of the interval before have had contact cither in Sooth Africa or at sea,< ^jth in each group. Although the length of interval but hit early history could not be established. There " were three other* in this group who had asbestos-- bodies in lung tissue without evidence of exhestori*.-* Taw? 7 Of the seven patients whose histories could not be*, u*tion nr rw it si tvrr or r.xmtunr. and irmotm traced, threshed asbestos bodks and hfrtolacfcsl; 0 INURVAI. HIIORK OCATII IN VI FATICNT1 IN evidence of asbcstocie and one had asbeMoeis * McaoiiiiiUOMA scam Tirv At tlfK, M,m Am Al UMtnM*niiMrmtrol N*. Im r.fMM Sim(V1M"S m (VAAfU UA--rimswodtMuon Irv^ am mm^hrnmmf land if llr IVA II l-A S ft m-A 44 sued hetwem 29-4 and 41d years, the mean age at luth sitowed less variation; it was 30-6 years in Ihe group of factory worker* and between S3 and 57 jars in the other troupe. Adietiet flodlrt and Ashrttosh la the Morn arumui Strive--Of the <3 patients In the meso* dseimma write. lung tissue was available for rumination in fnrtyHhreti In four other patients^ iu uru/kit at wribrtog from asbestos!*, with no lung mvim available. etamirution of sputum during life mealed the presence of asbestos bodies (Table I). Setii svbcMos bodies and histological evidence of Moeviosis were found In 15 of the 24 factory workers ue iaggers, A further live showed evidence ofeither mburns bedim or asbmtosie. la the mcaothetfama series there ere 23 perkose whom no eridanco ofany ttpmure to axhaiwa wxddis.' he found. A'chief aowee of information'.wao:2L. hlstory taken from a survtvtng rttaiiva. AsurpchfogT amount of Information was obtained, but in some of- those interviewed the memory may have been defeo live or they may not have known of short periods of exposure during the youth of the deceased. For example, one of the patients was eventually Idemidrd as having worked at a large tabcatos (booty for twomonths In 1941. This wee before he married, andMr widow did not know of this episode. It is of interest that asbestos bodies in the iungs were found in dnhrfour ofthis group, and it teems probable that goiafmioentiKi l1la11m9 eTommisoirla^vl^r mil 9i sink^oMii wnv im nn iw rapture e iiNwfc- In the meaothdiome aeries of patients, both In* dustrial and nominduatrial axpotures were recop> niaed* Among (he men the exposure was pre dominantly Industrial: 22 worked in asbestos foetcries or u Iaggers, two were exposed at home, and one lived neer the asbestos factory. Among the women only Id worked in aabmtoa foctorim, and a ; O IU lu O IS DOUJ 0602? 2uA URtTISII JOURNAL OF INDUSTRIAL MEDICINE further 17 had non-industrial exposures, seven in (he likely than the mesothelioma series to * home anti 10 l.tine near avbcvtus factories. tact with asliestos or to live in ooscr prn T!u.-rc is nu evidence tlul the patients with asbestos factories. peritoneal tumours Uulcrcd m their type of exposure There Kents little doubt tlul the m- from the patterns with pleural tumours. The propor- tlteiioma may arise frnm both occupati< non of poMtise funiuiRs of asbestos bodies or domestic exposures to asbestos. Warner ai usIvsIoms was similar in both groups. A higher pro (1960) described patterns with no expm*. portion of women, pmiiculat'y among site factory than living as a child ut the vicinity of the workers, was aifev-tert by peritoneal tumours, but the mines. A high incidence of asbestos ptaeu UiiVetcnee between site sexes was not statistically pleura b-t beat found in the population Us sifmiieant. an anthopbyilite mine in l-'udand (Kivtiuot. The reoent Increase in tlie number of patients More evidence is rctiuired of an increased rr diai'iiowd at the limpital nuy be partly due to an pops iation living in ilte neighbourhood oL UK-teased interest in mcxothclud tumours and partly ferneries or other areas, such as dockyard to t.ie long interval between lirst exposure and asbestos is used ia quantity. development of iIk* tumour. Those exposed between 1015 and to2S nut:i'a he capecied to die from about WT should Me to thr >h Or* bvtflk Uour. IWl onwards. Axhcdut imports to (lie United Jus (MfunMi and for maUxg the result Km.-Join Itaxc mounted steeply since 1932 (Leathart, iescxiigatmns avadaMe to us. and us uses are more widely diversified in Our thanks arc aHu due to Professor C. 0 industry. Tnc iiuTc:isirt: proportion of Use popula tion exposed to asbestos during tlsc past 3U years Professor V. W. IKx. a. N. L. Rushy, and Flawti, F.R.C3.. of tin London tlospoal and 1 Silver of St. Mauho** liospual for nuy he expected to give rise to an increasing view ibeir patienit; to tlw general practitionert occurrence of nwxathclial (unuuirs. luboratcd n this enuuuy; to the nuiueemeni- The titoicc of p.roups lor comparison with (lie avheslot factor-- for ut+n^na access to the* mesothelioma senes of patients was not ideal. Tiie to hint Joan Watfoid f<a \Wniul exusionce. tnimlvr of p.itK-nis it was possible to troec in tlic `i ejected* vrs proved to lie sery small. The `in patient* series, altluu<:li nutclied for date of birth rfi.d sex, diifered fiom Uk* mesothelioma senes in that ,.!i were admitted to luispital duuni* l'M4. Neitlief <i i.'icse rumps eouhl he inieiviewed without know ledge of tlie disease from winch they were suffering. Or. J. C. (idxnn. Prufrsv* H. S. F. S^hilJaig. aod' Smutier for their advict and help. The Cooimis of this paprr were cun----rnr. Cuafeicnce on tlw lUotoawal t lUcts of A MiMiinl by the New Vuk A.aurmy of Sea (Vf.iOrr 1*44, xnd will he puhUshrd ox a xhoru in the promcdinm of that confer--ee. *1 ins could have led to bus with under-reporting of exposure to asbestos m the in-pe.iM.-nt senes. I (ow RUIXtNCTl es cr, in the *in-patcm* series die actual patient wax interviewed, and more detailed and rciutMc histories were obtained Ilian was possible from tlie relative* of those who had died ofmesothclial tumours.'There was no evidence that, because of their more recent aomhaioo to hoxpital, the in-patient ser.v. was leu Fmmtu. f. U t. J UC.Mtvtnn.e.Cima t /.till, itwmo--Sm-M, aol.eiirlXx.M(iitniuu, n1.oMni., 1%, M KwiUUK I.|IStW 4tl IWO.I X-Op1 IXX. LinXki.U L.II-MC OnMMUUVKIlS ssu'rctts e-ett-iis-. - S T 0 0 I1811 a DOW 0f>023 sn:snnn:ua\u nr puiura roujow/NG r.xrnsunt: to Asanxros ur v ........ . Al'l'K-SniX. I II.III V. Ilia I rwinm with mi-whimai. tumounji n..u Vr .# ! , V# >9 Yu* . Wi H Atnl I m| I i|V I *r M tWMk' l ltM(< WM*4 t f A*tw*** | fc-f i I' ' ffuttl i | || iIM(i*Mli'fttf iI | hi |m| ! 4 * J !! ' 1 Timm i **** >!!> M1<I nw. ! 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