Document 82Z1ZG1MLJrZ7Bj1QOn4RDZGa

Jitsir. Mai., 1965, 22, 26!. c oOO^ps V \ Nc0;^gF MESOTHELIOMA OF PLEURA AND PERITONEUM FOLLOWING EXPOSURE TO ASBESTOS IN THE ; LONDON AREA BY MURIEL L. NEWWOUSE and HILDA THOMPSON Front the Deportment of Occupational Health and Applied Physiology, London School of Hygiene and Tropical Medicine (reci.ived for publication flhkuarv 11, 1965) , series of S3 patients from the London I lospital with a diagnosis of mesothelioma confirmed by '>psy or biopsy has been studied for possible exposure to asbestos. The series consisted of 41 and 42 women; 27 of the patients had peritoneal and 56 pleural tumours. Tire earliest death -ded was in 1917, but only 10 of the series died before 1950 and 40 (48%) between 1960 and a 76 of the series full occupational and residential histories were obtained. Forty (52-6%) gave itory of occupational or domestic (living in the same house as an asbestos worker) exposure to cFos compared with nine (11-8%) out of 76 patients from the same hospital suffering from other ,dses (p < 0 001). None of the 17 suspected cases of mesothelioma, rejected on pathological - ..'.els, was found to have had any exposure to asbestos. There was also evidence that neighbour 'd exposures may be important. Among those with no evidence of occupational or domestic 'Mires, 30-6% of the mesothelioma patients and 7-6% of the in-patients with other diseases d within half a mile of an asbestos factory (r < 0-01). Out of the 31 patients with occupational osnres only 10 were in jobs scheduled under the Asbestos Regulations of 1931. The interval ecu first exposure and the development of the terminal illness of mesothelioma ranged between d.nd 55 years. [ 47 patients in the mesothelioma scries, Jung tissue or sputum was available for examination. 39 (62-5%), cither asbestosis or asbestos bodies were present. ent years, the association between exposure ms dust and cancer of the lung and other it neoplasms has been the subject of much i Heading article, 1964). Wagner, Sleggs, and td (J9G0; described the occurrence of meso; of the pleuta in those exposed to crocklolite in the miiiing districts of South Africa, and stimulated further studies of the occupaiories (if patients suffering from this tumour 1964; Fowler, Slopcr, and Warner, 1964). i-restnt investigation concerns patients in mesothelioma had been diagnosed at the Hospital during the past 50 years. After >g the necropsy and biopsy specimens held .-ihology department, Hourihane (1964) coni diagnosis of mesothelioma in 83 patients, i 41 were men and 42 women. Thirty-one of ' had pleural tumours and 10 peritoneal; among the women. 25 had pleural and 17 peritoneal tumours. The aim of this study has been to establish the occupational histories of these patients and to trace any other possible exposure to asbestos. There were four surviving patients at the outset of the investiga tion, but these ha\e subsequently died. The earliest date of death in the series was 1917; 10 died before 1950, 33 between 1950 and 1959, and the remaining 40 in the past four and a half years. The youngest patient died at the age of 33, and ncaily half were dead before the age of 55 (Table 1). Clinical Features Tire ward rotes of 65 of the patients were available and give a picture of a disease with a consistent symptomatology. Among those with pleural ----mTETTmSDQCHVEm OllT 262 BRITISH JOURNAL *OI ,,JR&gMSfRM PPG FILES MI Tamu. 1 Alii AT DL-vTH OF FT FaTIL'NTS WITH MF.SOTHtl.IAL TUMOURS 34 35 -- 451565 - No. 2 .7 '15 10 7 Mile 51 4*9 17 1 ,V.*6 24-4 171 Female No. i x 1 I 2*4 6 143 9 1 Il-A 18 42 V * 19 0 tumours, the commonest presenting symptom was the rapid onset of extreme shortness of breath due to the formation of a massive pieural effusion. Pain was a prominent featuie, cither described as a dull ache, sometimes due to invasion of the ribs or vertebrae, or sometimes sharp and radiating, sug gesting nerve involvement. Tumours in the chest wall were not uncommon, occurring cither in previous operation scars or by direct invasion of the chest wall, 'J'he symptomatology of the peritoneal tumours was more vatied. In some patients the pre senting symptom was pain on defalcation or micturition. Diffuse upper abdominal pain was very common, and swelling of the abdomen due to ascites was always present terminally. The methods of treatment included pneumonectomy, decortication of the lung, deep .v-ray therapy, instillation of radio active gold, and cytotoxic drugs. They were used alone or in combination but had little effect on the course of the disease. Half of the patients suffering from pleural mesothelioma died within one year of the onset of symptoms, a further tliiid within two years, and only one patient survived for more than three ye i. The course of those with peritoneal tumours appeared to be equally rapid. Light of the patients died within six months of the onset of symptoms. Sources of Information on Occupation and Residence In addition to the ward notes, some of which gave good occupational histories, there were three other sources of information: the patient's genera! practi tioner; the records of an asbestos factory in the area; and personal interviews with patients or their surviving relatives. Asa first step, general practitioners were circulated with an explanatory letter asking them to complete a form giving details of the occupations of patients and their immediate relatives. Within two months 65% of the doctors had replied. In two cases a hitherto unknown exposure to asbestos was revealed; in others the name and address of a surviving relative were given, but in the majority the doctor was unable to give information because, on the death of the patient, the notes had been returned to the executive council of the National Health where they were destroyed within a period of years. In one of the asbestos factories a file was kept *.<. detailed records of all employees since it started 1913. The names of all patients were checked w these files. Nine men and nine married women la,their maiden names had been ascertained from w tives) were identified without difficulty. The t,*-. dates of employment of these 18 patients and t., jobs they had done were obtained from the rec? of the factory. The four patients alive at the beginning of t investigation were interviewed personally. _A h relatives were contacted by post, but the relative*.. 68 patterns were interviewed by one of us (H. 1,; their homes situated mostly in the East Lnj e London. Not only was an occupational history of; \ patient, the spouse, sons and daughters, and f.i 'v taken, but past addresses were also recorded. II.interviews lasted for at least an hour. To recall cvav of 30 or 40 years ago it was often necessary explore the residential and occupational bistort.-. all members of the family. Exposure to Asbestos in Three Groups of Fata.-.. Suffering from Other Diseases For comparison with the mesothelioma patten' -. three further gr tps of patients suffering from *.ddiseases were digated. The first guv.was selected from the patient,. the medical and surgical wards of the hospital duiir the early summer of 1964 (`in-patient' series). I:.'..! patient in the mesothelioma scries who had fie-v traced was matched with an in-patient of the sat. sex born in the same five-year period. As there w a dearth of male patients over 75 years of age in hospital, a sample of six patients of this age mm older was taken from a neighbouring gerini..' hospital. The second group were those who had origin::' been filed in the pathology department of t. hospital as cases of mesothelioma but in whom n diagnosis was subsequently rejected on pathologic, grounds by Hourihanc (1964) (`rejected series'). > it had proved extreme!} difficult to locate the. i.'. tives of those who died before 1950, attempts wr made only to trace the three survivors in this gm. and tire 14 who died after 1950. The in-patient scries, already described, were " admitted to hospital in 1964. The patients w:. mesothelioma were admitted to the same ho-jv over a period of 47 years dining which there mgr'' have been a substantial change both in the resident" . a, and so .-.don Ihwr taken fn of admi -:u lire path. - ,rs of re-,:, : eoinpari- ' f retails of t e.*es are give ,iN>ul past do: .writable for,X 10 (52`6<',,i .--.ipared wit! .. s vs (Table r mis or i \v ,'111 Ml SO I Hi t>is i I'.'^vrcd giN*. , ' Ji <- * t<f IC* 1 t-i f *Jn> K. jnc worS-c V 1 htvor> ' -nrCM*/ A'K'vbrt . .ii\c Kis-u- C.IS- ICflr ^xiiistica "001). 7 h> tiro tw 'ear of ; sig.nifiea: m the tn:d iho Ptuing 1 "KsOlhe >: the < Stave 3 I his < r NOTE:THIS DOCUMENT DID GG NOT COME l'H0?v] ?H3 HLES -"--goossoj" MESOTHELIOMA OF PLEURA FOLLOWlSG EXPOSURE TO ASBESTOS 263 .! sueiut clashes of patients attendini* the ^ Mospitnl. Thus, a third group of patients .Aen from the hospital records matched by i, : admission as well as date of birth and sex patients in tire mesothelioma series. Their .-! . of residence and occupations were extracted \ uparison with those of the in-patient series. ! Results i miK of the S3, patients in the mesothelioma arc given in the Appendix. No information past domestic and occupational histories was jir '-'.Me for seven patients. Among the remaining 7t'. - 1 (52-6%) gave a history of exposure to asbestos 'tired with only nine (118%) of the `in-patient' (Table 2). The difference in this proportion is Tap.lt 2 OF EXPOSURE TO ASBESTOS OF 76* PATIENTS MESOTHELIOMA AND 76 IN-PATIENTS WITH OTHER DISEASES J \yc of Cspo.sur? . vj at one asbestos V .J fo fttciery ?J jt other asbestos and ; worked iM'Jt 3Sbvst(s 's handling asbestos 'iofy of ork of expcurc io !h* Mc/ol) clir.ma S? iuA No. % 25 0 < 5*3 8 105 9 UE 0-- 36 47 4 4in-paiicnt* Series No. % 1 13 I 1-3 4 5-3 V 1-3 1 2-6 67 SS-2 expoitrf to rsbvMOs in me*orhe)<oma scric* ver&ui h:\<orje> in in-patient series: x* ^ 27-11, r < 0 001 "`eft C4*ci of .n.ciothclinms could not be traced and are entitled tU<> table. sticalh highly significant (y* == 27-11; p < ' d ) This result is unlikely to be unduly influenced . '-he tv.o groups or patients not being matched for of admission to hospital, since there was no - .Team difference either in the areas of residence ' v . the occupations of the patients admitted in 1964 - - ii-.ose admitted between 1917 and 1964. Comt nt-;. the confirmed and rejected patients in the -jtliehoma group wjio died after 1950, 36 (50%) 1; th; confirmed and none of the 17 rejected eases c- .. a history of exposure to asbestos (Table 3). 1 difference is statistically highly significant 11 S3; p < 0 001). Tahi f. 3 exposure to Asaasios of confirmed and rijfctfd Cases or MESOTHELIOMA SURVIVING AFTER JANUARY 1*150 Exposure to A'ibcitoi Exposure positive No work or domestic contact found Untried DiacnosU of Mesothelioma Confirmed Rejected 3b 0 35 16 1 x* r- II 3. r < 0 001 Mesothelioma Series Occupniionaf Exposures.--There arc details avail able for the 18 mesothelioma patients who had worked at one asbestos factory which used croctdolite asbestos with small amounts of chrysotile and first introduced amosilc in 1926. Eleven started work before 1933 (the year when the asbestos regula tions controlling the manufacture of asbestos goods and tiie protection of asbestos workers became effective), and seven started work between the beginning of 1933 and the end of 1942, The occupa tions of these w orkers and the type of asbestos they used are shown in Table 4. AH of the 17 for whom details were available had used crocidolite asbestos. Five of the occupations listed are not, scheduled as Taiile 4 JOBS OF 17* PATIENTS WITH MESOTHELIOMA EMPLOYED AT ONE ASBESTOS FACTORY Statutory Obligation* Subject to rtgubiiont Nut subject to regulation* Job Male Spuming Carding Clothing and v.eav,i>p DixilHc-rxtittt and open ins 0 1 1 2 Filter making for A.K.P. masks Manufacturing ofprefunr.cd pipe insula* item Manufacturing of brake lining* Rubber compounding General labourer 2 1 0 t FriruU. Material 4 Crocidolite 1 Crocidolite Grncidotite, 0 chrysolite, omosiic Crocidolite, I chrysolite, arnosiie 0 Crocidolite Crocidolite P Crocidolite Crocidolite, t chrysolite Crocidolite, 0 chrysolite, amosilc Crnp!'>>rr.fiM history not available for one lemalc patient. t s, rtrp rsrtt1--- l^BB JL ^'NOIEJHIS^oeyMEWW-'- - ' NOT COME FROM PPf) FILES BRITISH JOURNAL OF INDUSTRIAL MEDICINE MbSOI requiring medical supervision under the Asbestos Itezulcdions (1931). four patients .were working at other factories nuking all types bf asbestos goods. One liad been employed in a wagon works sawing asbestos sheets lor partitions. Except for one, a woman employed in insulating ciectfodes with crocidolite, the types of asb-: -tos used in these other factories arc not known. The eight heating engineers and luggers 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 sterilizing 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 F.vnarm'i.--The group of nine, seven women and two men, whose relatives worked with asrr-tos, are of particular interest. The most usual history was that of the wife who washed Iter husbtm.d's dungarees or work clothes. In one instance a rJi'.i .e said that the husband, a docker, came home *v.' ite w ith asbestos every evening for three or four years ar.d his wife brushed him down. The two men in this group, when boys of 8 or 9 years old, had sisters v ho were working at an asbestos factory. One of These girls worked as a spinner from 1925 to 1936. In 1--if- she died of asbestosis. The press report of :he rquest states: `She used to return home from wcr'-. with dust on her clothes'. Her brother had apparently no other exposure to asbestos; he started wori-t 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 1956 of a plcuial mesothelioma. I::-patient Series Occupation'll and Domestic Lxposuics.-- Tv.o of series had \ orked in asbestos factories and four httl l-ecn employed as bggers. The husband of ar.t-trer wai employed at an asbestos factory for trr^r years, and two dockers in this group gave hi'-ories of handling asbestos caigoes from lime to i:t; throughout their working life. The diagnoses of these patients have been grouped into seven categories (Table 5). The patients with a py.h: .e histoiy of exposure arc scattered throughout the various diagnostic groups, and there is no indica tion That exposure to asbestos could be related to rhe disease which had caused their admission. .Neighbourhood Exposures of Mesothelioma and Jn-p-.uwnt berns.--The 36 patients with meso- Tabee 5 1 hus, among DISEASE GROUPS OF PATIENTS IN THE lN-rATlE.NT SERIES domestic exposure p:u rents in the me Dt.csc Group Cardiovascular Metabolic RetfcuL>fi<!0thf&.i w:WudmB ana?rr.i;ts) (ctciudir.s cancer*) Respiratory cancers) AH neoplasms Othtr Total No, of Patients 21 9 * ft 3 ts Jl 76 No. bxposurc to Asbcsu.v 3 0 2 2 0 1 1 9 ir. die `in-patieiu': d :m asbestos far dmercnce in the. p wiies who lived in Ltd no other exp M "'!ficant (y-2 y Dale of First Ex in Mesothelioma S km! been exposed thclioma and the 67 patients in the `in-patient' i lived near the mai series, who had neither an occupational exposure / o: exposure varied nor a i dative living in the home working with \ lo over 50 years, asbestos, might have been exposed to asbestos dust j exposure and dent because they lived in the immediate vicinity of an im.-an 37-5 years) asbestos factory. j wcil.ers, where e\| One factory, where more than one-fifth of ;h: : :i i val was shoe mesothelioma patients were employed, opened in I'ltijp Jiving in ih 19)3, having been situated nearer the centre of la.'iorics, where t London for the previous seven years. There war: lo. e;l. Table 7 s! three affected female patients living within half a . il l ist exposure zr mile of the factory during the time it was in prochte- 1 v!e uli in each giou. tion at its first site. When it opened they were < children between 5 and 7 years old. At the presci.t l. site, there were eight patients living within a halfi ; mile i adius of the factory. One man was born within ` Ml ' M ION BETV.T'FX I'l INTERVAL BLlt a quarter of a mile of the factory' sod remained :> ! Mrs the same address for 16 years. The other seven vmv women, and all except one were children when the | factory opened. The seventh was 23 y ears of age and 1 >ic of Hxjovdre ] remained in the same house until she died 4S years 1 laier. She is the only patient who had neither l ( occupational nor household exposure but in whom l , j cr% sitid msu'aUus asbestos bodies were found in the lungs at neciopsy. I j 1 r .,! of factory j! Among the `in-patient* scries, one patient lived near the factory at its previous site and four other- lived near its present site. One patient was 22 year. old when she moved into the neighbourhood in 1915 She disliked it and, when interviewed, complained impartially about the dust from the asbestos faciory and the rats in the house. Table 6 RESIDENCE OF PAT I ENTS WITH NO OCCl'PATIOSAI domestic exposure to asbestos Scrivk l.iwd Within t mite of Asbestos factory Lived Morel bait miti: from AsbtfMov 1 actor> lot.*: 'n ed between 29 showed less ' rti',p of factory \ J '1`1 > in tlie otb.er j f xsbestos lluJici I In euma Series.--( ; d'-Mma series. ninniion in for `-H -ertificd as sufiVi :i"i<e available, cx Me.votheh'srv.a In-patient No. | "1 *I */. 30-6 7$ ei No. j 23 / 6(>4 92-5 v"- .-aled the preset asbestos bod :''vxtosis were fou !m! luggers. A r X` .. 7 is, < 0 01 !'!,-'4os bodie or i_fL005505 J >I ( . . J`* I 1 S ,'3'lent' rcwure whh dux'. C'f 211 : r the r.J ir. ::e of . were within :.r,ed at -n were .jn (he age and -i years neither whom .;rop~.y. .-it lived - other.' I'"' vear.' . in 1915. ..plained factory jNAl O '- Tc't.il 3s a MESOTHELIOMA OF I'LL1'I'1 f` A.OWING EXPOSURE TO ASBESTOS 265 iInHnV'st>,t among those with <nox- o..e.ic--u,; ,.t t* 0` ^ i,/ mastic exposures to asbestos, there are 11 1' ' n-.-nts in the mesothelioma series and hr* ^ ~ ' * fie 'in-patient' seric* who lived within ImII an asbestos factory in the area (Tab)' M / !I n-t Terence in the proportion of patients in >' f 4 ies who li\ ed! in the vicinity of the faclot y <n r .! r.o other exposure to asbestos is '.full''1' J` 1 mificant (*4 - 7 85; p < 0 01). hung tissue was available in only four patients exposed cither through relatives or by living in the neighbourhood of asbestos factories. In two, asbestos bodies were present in lung tissue but there was no evidence of asbestosis. FV1I3FNCE OF ASBESTOS BODIES OR ASULSTOSIS IN 47 Cases of mesothelioma with lung tissue ok sputum available fok examination < lllr i Date of First Exposure and Interval Bcf"**1 U- * ' ( in Mesothelioma Series.--Fifty-one men iM"t v''!in>'j '/i ' had been exposed to asbestos, including It i:\ed near the main asbestos factory. 7he dm < ^ of exposure varied widely, ranging from I w" l"M,' J ' to over 50 years. The interval between lb'` ''it exposure and deatli varied between 16 and ' ' ' crean 37 5 years). Among the group of , x rkers, where exposure was probably Iwinb ", interval was shortest. It vans longest .unf"tl ; creep living in the neighbourhood or lh<* i"1'' fa. lories, where exposure to dust was l"'*'' i '-..si. Table 7 shows the mean age of m* *' a: first expo sum and the mean of the ini' ' (| ; death in each group. Although the length ul h'1,1 Table 7 .nos hLTwcrN tvph of bxrosuiU'. anm ! * ! INTERNAL BtrORU DEATH IN 51 PATHA'1 ' MHSOTKF.UOMA. SEKJf.S 1>,>C of Evfiusurc rv^'Mnn Ate ut M. It. i>" l..t > \. No. T irit UipOMifo * V 0rs) i r>. , ;r< iid * j in rci;hb*>ur* - vl of fjfi^ry 2i 9 8 n 21*5 17-9 15-6 s*s I V" w t x j~:cvl between 29-4 and 48-6 years, the ns-'1* ^ c.v-h showed less variation; it svas 50 (> x, yrocp of factory workers and between v' " v-' r. in the other groups. . V- \x 'V \mjcMus Bodies and Asbestosis m ih.iiera-.i Scries.--Of the S3 patient' in '' ^ <'Jlmne sciies, lung tissue was a\" " v' ^ ev..ivnation in forty-three. In foui otli- v . { ' c.Ttif.ed as suffering from asbestosis, V * ^ available, examination of sputum ''' ^ ii ft..tiled the presence of asbestos bod;*' \ b . ' asbestos bodies and histological 'A vV ^ N'tosis were found in 15 of the 21 In* vXi 'i..1 luggers. A further five showed e\ ide-s'. '' i t'1'. sto; bodies or asbestosis. Iliilory of Conf*tt viih Asbestos live lintr^ctd Tool or Asbestos Uodic* Fmont Abient 22 Ag 43 30 17 Lun^ 1 . rot Available 23 0 3G Among the 12 patients in whom no definite contact with asbestos could be established, there was one, a merchant seaman from South Africa, whose lungs showed botii asbestos bodies and asbestosis; he may have had contact either in South Africa or at sea, but his early history could not be established. There were three others in this group who had asbestos bodies in lung tissue without evidence of asbestosis. Of the seven patients whose histories could not be paced, tliree had asbestos bodies and histological evidence of asbestosis and one had asbestosis alone. Discussion In the mesothelioma scries there are 25 patients in w horn no evidence or any exposure to asbestos could be found. A chief souice of information was a hiitory taker, from a surviving relative. A surprising smount of information was obtained, but in some of dvose interviewed the memory may have been defecu\e 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 identified as having wojked at a large asbestos factory for two .nonths in 1941. This was before he married, and 'U widow did not know of this episode. It is of merest that asbestos bodies in the lungs were found :> only four of this group, and it seems probable that imorig the remainder (here were those who had had >o exposure to asbestos. In the mesothelioma series of paticnls, both in dustrial and non-industrial exposures were recogliaed. Among the men the exposure was pieieeninantly industrial; 22 worked in asbestos actories or as loggers, two were exposed at home, md ore lived near the asbestos factory'- Among the -lomeu only 10 worked in asbestos factories, and a i ii i ii i BHWYTl lGitO*; o SXI o_ a_ \ mZD I o oCJ) ^ \ ;r*~r\. uuZC \ TL? UJ 1 o LU ^ o o*-- I-- mmmpt wh 1 1 ^ \ | BB 0005506 | 4 I ---S 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE MFSOTI further 17 had non-industrial exposures, seven in the here.* and 10 living near asbestos factories. There is no evidence that the patients with peritoneal tumours differed in their type of exposure from the patients with pleural tumours. The propor tion of positive 'findings of asbestos bodies or asbestosis was similar in both groups. A higher pro portion of women, particularly among the factory workers, was affected by peritoneal tumours, but the difference between the sexes was not statistically significant. The recent increase in the number of patients diagnosed at the hospital may be partly due to an increased interest in mcsothclia! tumours and partly to the long interval between first exposure and development of the tumour. Those exposed between 1915 and 1925 might be expected to die from about 1950 onwards. Asbestos imports to the United Kingdom have mounted steeply since 1932 (Lcathart, 1954) and its uses are more widely diversified in industry. The increasing proportion of the popula tion exposed to asbestos during the past 30 years r.r. be expected to give rise to an increasing occurrence of mcsothclial tumours. The choice or groups for comparison with the mesothelioma scries of patients was not ideal. The number of patients it was possible to trace in the 'rejected' scries proved to be very small. The `inpetient' series, although matched for dale of bhth and sex, differed from the mesothelioma series in that all were admitted to hospital during 1964. Neither of these groups could be interviewed without know ledge of the disease from which they were suffering. This could have led to bias with under-reporting of exposure to asbestos in the in-patient scries. How ever, in the `in-patient' series the actual patient was interviewed, and more detailed and reliable histories were obtained than was possible from the relatives of those who had died of mcsothclial tumours. There v.as no evidence that, because of their mote recent admission toJiospital, the in-patient series was less likely than the mesothelioma series to work in con tact will' asbestos or to live in closer proximity to asbestos factories. There seems little doubt that the risk of meso thelioma may arise from both occupational and domestic exposures to asbestos. Wagner and ol'i.re (1960) described patients with no exposure other than living as a child in the vicinity of the asbestos mines, A high incidence of asbestos plaques of th.; pleura has been found in the population living r.vac-. an anthophyliite mine in Finland (Kiviluoto, 196 .;. More ev idence is required of an increased risk to die population living in itis neighbourhood of asbestofactories or other areas, such as dockyards, where asbestos is used in quantity. We should like to thank Dr. D. O'B. Hourihaue fhis co-operation and for making the results of h > investigation; available to us. Our thcr.ks are also due to Professor C. Wih. Professor V. W. Dix, Dr. N. I.. Kusby, and Mr. 0Flnvell, F.R.C.S., of the London Hospital and Dr. C. 1\ Silver of Si. Matthew's Hospital for permission to inter view their patients; to the genera! practitioners who laborated in this enquiry; to the managements of asbestos factories Tor arranging access to their recoi l', to Miss Joan Wulfoid for statistical assistance, and Dr. J. C. Gilson, Professor R. S. F. Schilling, and Dr. V. Smilher for their advice and help. The contents of this paper were communicated to the Conference on the Biological Effects of Asbesto . arranged by the Ncsv York. Academy of Science- r; Ociohcr 1964. and will be published in a shorter forein the proceedings of that conference. REFERENCES Towlcr* P. bv K,. Mopcr, J. C,# and Warner, H- C. (1964), Erti, / .- Z, 2M- Leading artkl (IX>1). //>/</., 2, 202. Hoi.rihane. D. O'B. (19(4). Thorax, 19. 2<K. Kisiluoto, ft (19*0;. Ario ruiffoK (Snn`hh,)t Supjil. 194, UjlhdM, C. L.(hv), Qrmf*. 16, 119. 0*cn, W. C/>n (1904), Jirlt. tnrti. J., 2, 21-4. wj n 19Warner, J. C., S!cj^a, C. A,, and Marehand, P. (I960). iWmsrr. V .l, 17, 260. PN ' *, * f. %r NOT j > -^ 1.^ Appendix opposite ( itnc No. Site of Primary Ttunour S. < lion 4: Fucioty s Pleura 19 Perilonrum t S Peritoneum :4 Pleura tt Peritoneum Mi Peritoneum 13 rcrii<*ncum >1 Peritoneum 15 Peritoneum 9 Peritoneum :i Pleura i > Peritoneum 5 Peritoneum Peritoneum Pleura M Peritoneum 17 Pleura 0 Pleura 10 Peritoneum I Pleura ?i Pleura x Peritoneum | Peritoneum . linn II: ^ I Pleura un.i ' Pleura ] ! Pleura Pleura Peritoneum - ` Peritoneum 11 Pleura Pleura K 34 1 0005507*7 t MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 267 APPENDIX EIGHTY-THREC PATIENTS WITH NfESOTHELUL TUMOURS (. . s v.. ! ,* 1 - ' ; - Site of Primary 1 uniour Dura* Year ton Se-x Year of of Year or First Expo of Birth Expo sure Death sure (years) How Diag nosed Asbestos Bodies in Lung Tissue 4: Factory ^or-er; fleura I M 1901 1921 17 1936 Necropsy Positive Peritoneum m IS95 1919 22 1941 Necropsy Positive Peritoneum F Pleura Peritoneum peritoneum M F r Peritoneum Peritoneum y 1, Peritoneum Peritoneum Picwa M Pei jtoncum f Peritoneum ; M Peritoneum ! M 1906 1925 I860 1S93 1906 1976 1917 1922 1894 1915 1695 1917 190! 1S97 1693 1916 1908 1918 1919 1976 1937 1927 1915 1940 S 1947 Biopsy Poetise (sputum) 17 1930 Necropsy Positive * 1951 Necropsy Negative 7 1951 Biopsy Positive (sputum) 5 1955 Necropsy positive i I9JJ Biopsy Positive (sputum) u 1955 Biopsy Positive (sputum) 1 1936 Necropsy Positive 1 19S7 biopsy N/A 2 1958 Biopsy N/A 30 1958 Necropsy Positive 4 195S Biopsy N/A rk-ura M 1925 1941 1/6 1959 Biopsy Native Peritoneum \ Pleura ' Pleura i 1 iPeritoneum F F M F Pieum Pleura ;i : Periu-i.-.im m w M Pc-itoneum M 1907 1905 1907 1971 1924 1942 1699 1973 1S99 1936 1906 19|| 1917 1925 1930 1937 10 1959 Necropsy Negative 1 1962 Biopsy Positive 10 1962 Necroi>sy Positive 11 I9C3 Biopsy Poiitive 76 1963 Necropsy Positive f 1963 Necropsy Positive 7 1963 Necropsy Positive 77 1904 Necropsy Positive / Pleura t.t f I'tMifators M | 1574 Pivura M | 1893 Picur# Plvuru Peritoneum M , ,Ml M i ,9<>!i M i 1908 I criion^um Pieura P#ei;ra M ; 1911 M 1j 18..97 M J J9I7 1885 1910 1937 1972 1922 1927 1916 1927 53 ` 1935 ! 22 : 1955 ! 22 1959 3 1961 36 1961 1 34 : 1961 j41 1963 34 i 1962 Necropsy Biopsy Necropsy Biopsy Necropsy Necropsy Biopsy Biopsy Negative N/A Positive N/A Positive Positive N/A N/A Palhological Evide-rce of As* tvitosii in Lung Tis-ue Survival from Initial Symptoms (months) Relevant History Pniliie Positive N/A Negative Negative N'A Positive N/A N/A Negative N.'A N/A Positiv e N/A Negative Negates Negative Positive Negative Positive Negative Positive Posu*e 7 Brake liner, boiler covercr. uxbesto* factory; mainly croctdulitc 7 Disintegrator and other jobs. asbestos factory; amosite, crocidolitc, chryvmle e Sectional ripe maker, asbestos factory, certified axbeslotic; main ly crocidolite 9 Used asbestos boarding in railway carriage construction 7 Asbestos factory, job unknown * Opener and sectional pipe maker. asbestos factory, certified nsbe*totic; amositc, crocidolite, chiysotile 12 Spinner, asbestos factory, certified ftsbestotie; mainly ^rccidolito 3 Sectional pipe maker, asbestos factory', certified asbcstoik; mainly crocidolite 6 Spinner, n$htvlox factory, certified astx>toic; mainly crmJJohte 3 Disintegrator, aibcstox factory; amositu, crocidolt'.e, chrysolite i$ Asbestos mixer, north England asbestos factors 18 Carder, asbestos `factory; mainly crocidolite 18 Clothing and weaving, asbestos factory; nmosite, crocidolite, chrysotilc 3 I liter maker Tor A.R.P. masks. a&bestus factory'* mainly crocidohte ii Filter maker for A.R.P, masks, asbestos factory; mainly croci dolite 7 Electrode covcrcr; crocidolite Spinner, asbesu** factory; mainly crocidolite * Delivered chemicaN to asbestos factory; amo.ate, crocidolite, chrysotilc 5 Spinner, asbestos factory; mainly Crocidolite 7 Labourer, works and buildings. asbestos factory; amositc, croci dolite, chryxol.le 8 Worked tn yard of insulating contractors 6 Carder, asbestos factory; mainly crocululitc 24 Disintegrator ard other jobv. asbestos factory, amositc, croci dolite, chry.'Otik Negative N'A 1 1 Positive ! N/A ! pw,i`* ! P<hi'.*c [ N/A N/A ! i j 17 24 9 25 17 5 10 Worked in close proximity to boiler rcpairci in dockyards Boiler cleaner and stripper, dock yards Boiler covcrcr and tagger to various firms Erecting and hiring central heating Uoilcr covcrcr and pipe insulator, contracting fii m lagger and boiler covcrcr, various film* Intermittently boiler bigger, ship repair* Installation of ho-.pitnl sUTiluing equipment {r/wtinurd) t fi \ X i J | BB 000550!: 26S BRITISH JOURNAL OF INDUSTRIAL MEDICINE APPENDIX (.canting) EIC.HTV-1HREE PATIENTS WITH MESOTJIELJAL TUMOURS Case No. V Site of Primary Tumour 1 ! ! Sex * Year of Birth Dura-! Year lion 1 of ol 1 Year hirst I:\p0-1 cl Expo Sure ;Dcaih sure How Dias* nosed Section C: r.\;>oi:iff of relatives 40 Pleura M 1912 1925 It 1956 Biopsy 34 Pleura 3S Pleura F 1913 1919 2 1957 Biopsy I7 1395 1919 41 I960 Biopsy 37 Pleura F 1903 1925 14 1960 Biopsy 35 Peritoneum F im 1921 21 19'4> Necropsy 33 Pleur.! F 1916 1930 4 1961 Necropsy 39 Pleura M 1919 1923 2 1961 IliopiV 32 Pleura F 36 Peritoneum F 1900 1941 1KS9 1912 5 ,963 biops) l 13 1953 . Asbestos bodies in Lung Tissue N.'A N/A n;a N/A Positive Negative N.'A N/A n;a ' PaihoJoeical F.\/dccce t'f Asbestesis in Lung Tissue N/A N/A N/A N/A Negative Negative NA NA NA 1 Survts a! from lmtM Symptoms (months) Relevant History 27 Elder sister worked ai >pin:*:r -* asbestos factory ditd 19 certified j-vbtrtoiic 14 Elder sister employed 21 \pinnv-. looked after patient *i child IS For sever*! years husband workrf In ship's engine rocrw, ciose proximity tr* Jagging operation 3 Hushsnd worked as boiWr wvrr.-r. overaHv brought homeior -t-ashi.* 24 Husband foreman and evrcuiiv,; . asbestos factory * Husband a ^ docker; frcqifrn.;* htmJled 'white* asbestos 111 F-Mer s:,ter worked h* sr-jvier at asbestos factory nnd svPet* re-- nsbvMtfViJ* IS Dauphur workedinacbu>t'*$f`'Ct<'.'. for 5 years; patient `<*h:d :*-< overalls 15 Husband railway carria"; lined co uparttmus. with ^ sheeting; work clothes va^hn! home I i\ 1 sf I \ 13 l Section D: Scighbonrkood com 44 Pleura 4* Pleura 42 JTciirp 50 FlctiM 43 Pleura 47 Pleura 64 Pleats 71 Pleura 41 Pleura 45 Pleura 46 Pleura F 1905 1913 1 1959 Biopsy N.'A N.'A s Lived vhhin ? mile or fwrtt yi: of a^bevi*-** factory M J922 1922 16 I960 Biopsy N/A N/A 17 Uved within J mile of present .-it: of esb<N'.ON factorv F 1SS9 1913 43 19.41 Biopsy Positive Negative 15 Lived within 100 yard* of pr*-^*: file of .rO'Mius factory F 1903 190$ 6 1961 Biopsy N/A N/A u laved wiilim 1 mite of old sue y asbestos factory F 1905 1913 13 1961 Biops> n;a Nf A 4 Lived within 1 mile of p'e'eui v; ; of aslvcstov factory F 1917 1917 10 1961 Biopsy N/A NA F IS99 1907 6 1962 Biopsy Negative Negative 14 Lived wrl.in 200 yards of pnrv--. Isite of a'-hcslo* factory 5 Lived wuhm j mile of o!J *ic f' F J399 1907 C 1362 Biopsy N/A NA 12 asbestos factory Lived within * mite of old v '*' *4 i asbevto* factory F 1900 1913 32 1962 Biopsy N/A N/A 29 Lived within } mile of present Of asbestos factory f 1900 1913 7 19C2 Bio?s> N/A N/A 9 Lived vith'n $ mite of r?v^> w: of asbCvto* factory F 1907 1913 7 1962 Birp*y n;a N/A 7 Lived withm 1 mile of p.-ewu:'. ;f of asb.>t< factory Sec 1tor, E: So hi nor \ of contort with tisbntrs 65 Pleura r 1900 6S Peritu-'i'-um F 1902 49 Pleura M W5 75 Pleura F 1899 /4 iVruunrum r 19(14 62 Pleura M 1899 1 1947 Necropsy N rgntive 7 Worked as nursemaid to r:anac*.' Jj 1954 Ncci'vpsj Negative Negative of gas wo*h* in La> lot-*-*, asbestos insulation ui.ed ;:i '-rut . J Short hirf-typiAt and he <>r*. i 1954 Biopsy N;A NA lived Lft-rJ area Baker's rouiuSnr.m, nnu?. ger.^ labourer, p ilik.an for 3o ^cirs a 1'*?5 Biopsy N/A N/A hast Cud of La.mdi'n Kluniiio^H v ork lcfore n: i'ri>irr, 1 j thvn h'-uscwife; lived Ahhc>. 1`ssax 1955 Necropsy Negative Negative 27 *)jilnrcsk nrnl housewife m F-'11 r.nd of l.imdon 1955 Necropsy Negative ri.iiiivc ?S Emplo>cd as lutcmim and rrc_vr:. Beckton gas work* 3f ><-- persUtent Uivch-uping 1'* side of chest fallowing cn*p> , 1925, acute chest infcct**n I4* -4i Subsecpicnt vltpracnpLs:/ N* deterlofa'cd from this date Ml I ('aw Site o' Pri.uar Tumou ol l'erito,`cv. ; Pleura ib Pleura Pleura fa. Pleura *7 Pcritoncu `J 1`lsur.i Pleura Plcum *"/ Pleuia 7.1 Pleura TO Pleura 72 Pcrittineiir <5 Pleura (41 Peril oneur (.7 Pleura <r. Pleura i*> Pwitoncmr .. ' 1 ( Plei..,. j 1 //rT A: L'ufrurr, 78 I Pleura j llvura <\ 1 Plcurj SO | Pleura V2 | HL*ura 77 \ Pvritonc *> Pleura ! j_ff__005509~} MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS n* * APl'HNDlX {coiiiinthd} EIGHTY-THREE PATIENTS WITH MESOTHELlAX TL'MOURS 269 j Dura. ! Year lion 1 S::e of Year of 1 of Year How V P.'rii^^v S-N of Kirjt Expo- of Piss- Tumour Birth Expo- sure Diath nosed sure (years) ! M 1013 1955 Biopsy V : **>rufa M 1S*H F 1916 195G Biopsy 1957 Biopsy M 1&91 a r 1393 1957 Biopsy 1958 Biopsy * hrjt3 J Rr=ra M 1379 M 1390 M 1904 M 1910 M 1911 1958 Biopsy 1959 Biopsy I960 Biopsy 1960 Necropsy 1960 Necropsy rKt'j `- 1-- I .. jfu PJrj'4 F !K*7 F l&Sft 1893 M 1838 M 1915 J-" IS97 At 1912 r 1901 M 1892 _ ' ' t nfr,H'e.f F 1391 ` -'X -J M 1860 f M JK77 1 M l*A*0 -*;a j j M J'* -`'rum j F 1893 1910 : ---- -- F ij 1K7 1 ! i 1 1! 1962 Necropsy 1962 Biopsy 1962 Biopsy 1962 Necropsy 1962 Necropsy J963 Biops> 1963 Biopsy 1964 Necropsy 1964 Necropsy 1917 Necropsy 1922 Necropsy 1925 Necropsy 1936 Netropy 1938 Necropsy 1945 Necropsy 1<M5 Necropsy Asbestos Bodies in Lun Tissue N/A N/A N/A N/A N/A N/A N/A N/A Negative Positive Negative KcW N/A Noeative Negative N/A N/A Negative Positive * Negative Negative Negative Positive Positive Positive Patho- i logical j Survival Ev idvnc? from of As* Initial beMosis Symptoms in Lung (nontliv) Tissue Relevant History N/A s Merchant sc&mati, c^jocs from S, Africa 1930*32, no definite evidence of contact with asbestos: subse quently employed on cross-channel boats N/A 12 Labourer and builder, finally cm- ployed in tunnelling; lived in East End of London N/A 19 Employed rerxviking old sacks in Bow, previous comeal of sucks not ascertained; lived East End of London N/A u Garage hand, chauffeur, mechanic; lived Wolverhampton and Epping N/A 6 Worked ns printing machinist before marriage, then as housewife until death; lived East l*ud of Jxmdon n;a 3 Siereoiypcr and primer; lived originally in Last Loudon, then moved to Ipswich N/A 12 Van boy, regular army, cutter and grinder; lived NC. 1 onJnn and D.icenlum N/A 1$ 1`rjv.jj lycr, cement worker, post man; lived East Hod of I-opdon, Ntgalive moved to Mninault. Essex in 1931 IS Filler and (timer; Jived principally in hast End of London Positive Coloured S. African merchant sea man, stoker at pta** factory; possible contact with asbestos in S. Africa or at son Negative 10 1-ived until marriage in Wales, then housekeeper in SAW Loudon Negative 30 Machinist of celluloid collars. housewife and canteen worker; 'lived Fast London N/A 10 Machinist m hosiery trade, Notting ham, housewife; moved to london J9no Negative 2 Labourer, merchant seaman. docker, carried eml / meat Negative 54 Apprentice printer, bjrrran cook. and butcher. 1 or 25 years before death lived East End of I .onion N/A 29 Dressmaker and hcm^wtfe: lived East End of London then Sorucryel N/A 24 Steel erector, army, steel erector. labourer and potter; lived East End of I ondon Negative 42 Lnjp)o>c1 as packer in pharma* ccutical firm for 12 >cars, then housewife until de*!b; Pved in Oagrnham Negative 24 Fisherman, fireman, d^-cker, I9IS 39 at Tilbury dock*, fireman and finally storekeeper; contact with asbedos not probable at Tilbury docks; lived Tilbury ***ea Positive Negative Neoalive Negative Positive Positive Positive Not traced Not traced Not traced Not traced Not traced Not traced Not traced *[ N/A tissue not available.