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FILE NAME: Neighborhood Exposures (NE) DATE: 1965 DOC#: NE019 DOCUMENT DESCRIPTION: Medical Journal Article - Mesothelioma of Pleura and Peritoneum Following Exposure to Asbestos in the London Area gv5!1 *" ! , `i .. i*-.-. -v>*< I&virbely, /. L. fcl *od MlicheU, Toluene, fefoiKeniraiioa. StocfaMu/ jfc * 'i r 'i , .?' *7rorth, *. Brit. J. industr. M ed., 1965, 22, 26L MESOTHELIOMA OF PLEURA AND PERITONEUM FOLLOWING EXPOSURE TO ASBESTOS IN THE . LONDON AREA . i BY '` -. i M URIEL L. NEWHOUSE and HILDA THOMPSON From the Department o f Occupational Health and Applied Physiology, London School o f Hygiene and Tropical Medicine * (RECEIVED FOR PUBLICATION FEBRUARY I I , 1965) `V i -ij'. A series of 83 patients from the London Hospital with a diagnosis of mesothelioma confirmed by necropsy or biopsy has been studied for possible exposure to asbestos. The series consisted of 41 men and 42 women; 27 of the patients had peritoneal and 56 pleural tumours. The earliest death recorded was in 1917, but only 10 of the series died before 1950 and 40 (48%) between 1960 and 1964. In 76 of the series full occupational and residential histories were obtained. Forty (52 6%) gave a history of occupational or domestic (living !n the same house as an asbestos worker) exposure to asbestos compared with nine (11'8 %) out of 76 patients from the same hospital suffering from other diseases (p < 0-001). None of the 17 suspected cases of mesothelioma, rejected on pathological grounds, was found to have had any exposure to asbestos. There was also evidence that neighbour hood 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 half a mile of an asbestos factory (p < 0-01). Out of the 31 patients with occupational exposures only 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 series, lung tissue or sputum was available for examination. In 30 (62-5 %), either asbestosis or asbestos bodies were present. f'ir r. > ;7 , y !- V < -'- In recent years, the association between exposure among the women, 25 had pleural and 17 peritoneal lo asbestos dust and cancer of the lung and other tumours. malignant neoplasms has been the subject of much The aim of this study has been to establish the research (leading article, 1964). Wagner, Slcggs, and occupational histories of these patients and to trace Marchand (1960) described the occurrence of meso any other possible exposure to asbestos. There were thelioma of the pleura ir. those exposed to crocidolite tour surviving patients at the outset of the investiga asbestos in the mining districts of South Africa, and tion, but these have subsequently died. The earliest this has stimulated further studies of the occupa date of death in the series was 1917; 10 died.before tional histories of patients suffering from this tumour 1950, 33 between 1950 and 1959, and the remaining (Owen, 1964; Fowler, Slopcr, and Warner, 1964)/ 40 in the past four and a half years. The youngest The present investigation concerns patients in patient died at the age of 33, anil nearly half were whom mesothelioma had been diagnosed 'at,'the dead before the age of 55 (Table 1). London Hospital during the past 50 years. After examining the necropsy and biopsy specimens held Clinical Features in the pathology department, Hourihanc (1964) con firmed a diagnosis of mesothelioma in 83 patients, The ward notes of 65 of the patients were available of whom 41 were men and 42 women. Thirty-one of and give a picture of a disease with a consistent the men had pleural tumours and 10 peritoneal; symptomatology. Among those with pleural 261 /!' W .--is M t 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE T aiul I AGE AT DEATH O 83 CATIEN TS W l r i l MESOrtlFU AL 1 UMOUHS Age (yr.) <34 35455565 - Mule No. / T 4 > 7 17 i 15 36 6 10 24 4 7 17 1 Female No. ,, 1 24 6 14 3 9 21 4 18 42 9 8 IO 0 tumours, the commonest presenting symptom was the rapid onset of extreme shortness of breath due to the formation of a massive pleural etfusion. Pain was a prominent feature, 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, occutring either in previous operation scars or by direct invasion of the chest wall. The symptomatology of the peritoneal tumours was more varied. In some patients the pre senting symptom was pain on dcfaecation 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 ol the lung, deep v-ray therapy, instillation of radio active gold, and cytotoxic drugs. They were used alone or in combination but had little cffcct'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 third within two years, and only one patient survived for more than three years. The course of those with peritoneal tumours appeared to be equally rapid. Eight of the patients died within six months of the onset of symptoms. Sources of Information on Occupation and Residence _ In addition lo/thc ward notes, some of which gave good occupational histories, there were three other sources of information: the patient's general practi tioner; the records of an asbestos factory in the area; and personal: interviews with patients or their surviving relatives. As a 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 exposute to asbestos was revealed; in others the name and address of a surv iving 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 local executive council of the National Health Service, where they were destroyed within a period of three years. 1 In one of the asbestos factories a file was kept with detailed records of all employees since it started in 1.913. The names of all patients were checked with these files. Nine men and nine married women (after their maiden.names had been ascertained from rela tives) were identified without difficulty. The exact dates of employment of these 18 patients and the jobs they had done were obtained from the records of the factory. The four patients alive at the beginning of the investigation were interviewed personally. A few relatives were contacted by post, but the relatives of 68 patients were interviewed by one of us (H.T.) at their homes situated mostly in the East End of London. Not only was an occupational history of the patient, the spouse, sons and daughters, and father taken, but past addresses were also recorded. The interviews lasted for at least an hour. To recall events of 30 or 40 years ago it was often necessary to explore the residential and occupational histories of all members of the family. Exposure to Asbestos in Three Groups of Patients Suffering from Other Diseases For comparison with the mesothelioma patients, three further-groups of patients suffering from other diseases were investigated. The first group was selected from the patients in the medical and surgical wards of the hospital during the early summer of 1964 (`in-patient' scries). Each patient in the mesothelioma scries who had been traced was matched with an in-patient of the same sex bom in th same five-year period. As there was a dearth of male patients over 75 years of age in the hospital, a sample of six patients of this age and older was taken from a neighbouring geriatric hospital. The second group were those who had originally been filed in the pathology department of the hospital as cases of mesothelioma but in whom the diagnosis was subsequently rejected on pathological grounds by Hourihanc (1964) (`rejected series'). As it had proved extremely difficult to locate the rela tives of those who died before 1950, attempts were made only to trace the three survivors in this group and the 14 who died after 1950.' The in-patient series, already described, were all admitted to hospital in 1964. The patients with mesothelioma were admitted to fhc same hospi.al over a period of 47 ycats during which there mirht have been a substantial change both in the rcsiden'ial ' M EserrtfL -- l '* r areas and sohiat da: i London Hospital.- T ' was taken from; the j .late of admission as p i with tlie patients is t places of residence a for comparison with l u *- f- Details of. the 3 jeries arc given inUl ,about past domestic available for seven p 76,40 (52-6%) gave a ; compared with only series (Table 2).j Jhe V, ' t i *56 .* V TYPES OF EXPOSURE WITH MESOTHELIOMA \ ` Type of Exposure - _________ ___ vEmployed at one factory ' Delivered goods to factory * Employed at other asbesto \ "T,, factor.i.es--. insulators and taggers ' Relative-worked wtthasbest R J'ppckers handling asbestc cargo No- history of work o i_* domestic exposure t H\ asbestos > ,' ....... -- -- -- . . . . . . -- Positive exposures to positive histories ui m-pati ` Seven cases of mesothei from this table. * *' I ' statistically highly 0 001). 'This result is by the two groups o . 'year of admission 1 significant difference or in the occupation and those admitted paring the confirmi mesothelioma grou; of the confirmed ar gave a history of t This difference is (X5 = U '83; p < C t e Vi' > s a K ;m MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS l `oftthree , 1' kept with Staged in 4tcd with' &ea (after {corn rela c exact jfjnd the., e. records f1T '1 ~ , a i ibe. few datives of ' iH .T .)at t(End o f/ | t ifyofth,, i d<father '& i cd. The V : iU-events ^ ) f tp < I J areas and social classes of patients attending the London Hospital. Thus, a third group of patients was taken from the hospital records matched by date of admission as well as date of birth and sex with the patients in the mesothelioma scries. Their places of residence and occupations were extracted for comparison with those of the in-patient scries. Results Details of the 83 patients in the mesothelioma series are given in -the Appendix. No information about past domestic and occupational histories was available for seven patients. Among the remaining 76,40 (52 6 /',,) gave a history of exposure to asbestos compared with only nine (118% ) of the `in-patient' series (Table 2). The difference in this proportion is Table 2 TVPES OF EXPOSURE TO ASBESTOS OF 76* PAT1FNTS WITH MESOTHELIOMA AND 7ft IN-l'ATIENTS WITH OTHER DISEASES Type o f Exposure Mcxoth clioma Scr ics `In-patient' Senes No. V. No. t /m *`V * ^Patients,'1':/ 5: " t - r r i v `vV-` ft . I ' .mticnts, .. S Emothers 4 flluents in.,'3 til during 1 ' Each ., ^ had been' `i jhe same ijierc was y Fmployed si one asbestos lactory Delivered goods to factory ' *} 250 1 1 3 Employed at other asbestos factonc 4 5-3 1 i 3 Insulators and taggers 8 10-5 4 5 3 Retetiv'e worked with asbestos 9 1(3 l 1-3 Dockers handling asbestos cargo * 0 -- 2 26 No history of work or domestic exposure to asbestos 36- 47 4 67 88 2 Positive exposures to asbestos in mcsolheliomfl senes versus Pt'sitive histories in in-patient series: i ,,,,\ e in the; X* - 27 11, r < OOOt ige and' "Seven cases of mesothelioma could not be traced and are omitted rom this table. ;eriatri<S'.' originally \ d if" o f "the .yhom the >; $ thological f ti'). As the rcU*^.,., f ripts were , j h,*i?s gi roup*'>r !, | 1 j.were alt > t eats 'with'?/'; hospital. ,W`might v?., v cside--nit!ialy .h a statistically highly significant (x* = 2711; p < 9-001). 'This result is unlikely to be unduly influenced by the two groups of patients not being matched for year o f admission to hospital, since there was no significant difference either in ihc areas of residence or in the occupations of the patients admitted in 1964 and those admitted between tQ17 and 1964. Com paring the confirmed and rejected patients in the mesothelioma group who died after 1950, 36 (50%) of the confirmed and none of the 17 rejected cases gave a history of exposure to asbestos (Table 3). This difference is statistically highly significant ( * * 11-83; j- < 0:001). T able 3 EXPOSURE TO ASUESTOS OF COM IRMEB AND REJECTED CASES OF MESOTHELIOMA SURVIVING AFTER JANUARY 1950 Exposure to Asbesto Exposure positive Diagnosis of Mesothelioma Confirmed 36 RciccicJ 0 No work or domestic contact round 35 16 .Untraced ' 1 X` - II 83, r < 0 001 Mesothelioma Scries Occupational Exposures.--There arc details avail able for the 18 mesothelioma patients who had worked at one asbestos factory which used crocidolite asbestos with small amounts of chrysotile and first introduced amosite in 1926. Eleven started work before 1933 (the 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 1933 and the end of 1942. The occuoations of these workers and the type of asbestos they used are shown in Table 4. All of the 17 for whom details were available had used crocidolite asbestos. Five of the occupations listed are not scheduled as T vble a JOBS OF 17* PATIENTS WITH MCSOTHE! IOVIA EMPLOI ED AT ONE ASBESTOS FACTORY Statutory Obligations Subject to regulations Not subject to regulations ! Job ! Male - Spinning 0 Carding 1 . Clothing and weaving 1 i Disintegrating , and opening ! Filler making ' 1 fur A.R.P j i masks i ! Manulacturmg j 'I preformed 1 pipe insula- j ! turn 11 1 Mamii icttifiig \ of brake i lutings 1 Rubber v.nmI v'uunUing O J General i labourer i 1 i ! Female 1 Ma:eiial 4 ' Crocidolite i t Crocidolitt 1 Crocidolite. 0 chrysoi .e. i amosiie Croodoluc. 1 i cnr.wiMiie, amosite 1 1 i 0 l Crocidolite 1 ! . 1Crncuioiite a j CrcKulobte CrKi%l'lite. ! Lhr>sotile j Croeniobie, 0 chrysolite. , imovac :- 264 BRITISH JOURNAL OF INDUSTRIAL MEDICINE requiring mpdical supervision under the Asbestos Regulations (1931). Four patients were working at other factories making ail 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 crocidolite, the types of asbestos used in these other factories arc not known. The eight heating engineers and laggers 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 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 8 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 she.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 1956 of a pleural mesothelioma. In-patient Series Occupational anil 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 from time to time throughout their working life. The diagnoses of these patients have been grouped into seven categories (Table 5). The patients with a positive history of exposure arc 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 Mesothelioma and In-patient Series.--The 36 patients with meso- T able 5 DISEASE GROUPS OF PATIENTS IN THE' IN-PATIENT SERIES Disease Group Cardiovascular Metabolic 1 Reticuloendothelial (including anaemias) Gastrointestinal (excluding cancers) Respiratory (excluding cancers) All neoplasms Other Total No, of Patients No. with Exposure to Asbestos . 21 . 3 9 * ' 0 8 .. 6 ' 3 18 " 2 ;' . 2 l *.y o . i ; i 76 thelioma and the 67 patients in the `in-patient' series, who had neither an occupational exposure nor a relative living in the home working with asbestos, might have been exposed to asbestos dust because they lived in the immediate vicinity of an asbestos factory. One factory, where more than one-fifth of the mesothelioma patients were employed, opened in 1913, having been situated nearer the centre of London for the previous seven years. There were three affected female patients living within half a mile of the factory during the time it was in produc tion at its first site. When it opened they were children between 5 and 7 years old. At the present site, there were eight patients living within a half- mile radius of the factory. One man was born within a quarter of a mile o f the factory and remained at the same address for 16 years. The other seven were women, and all except one were children when the factory opened. The seventh was 23 years of age and remained in the same house until she died 48 years later. She is the only patient who had neither occupational nor household exposure but in whom asbestos bodies were found in the lungs at necropsy. Among the `in-patient' scries, one patient lived near the factory at its previous site and four others lived near its present site. One patient was 22 years old when she moved into the neighbourhood in 1915. She disliked it and, when interviewed, complained impartially about the dust from the asbestos factory and the rats in the house. / T able 6 RESIDENCE OF PATIENTS WITH NO OCCUPATIONAL OR DOMESTIC EXPOSURE TO ASBESTOS Senes Mesothelioma Impatient Lived Within \ mile of Asbestos Factory No. / 11 30-6 5 7 5 Lived More Than ,lr mile from Asbestos Factory No. 25 69 4 62 92 5 Total 36 6? 7 SJ, r < 0 01 - >,, .. `V_*Kf iT- ` ' , ' M ESO TJf. ,`i :f-e ` Thus, among thi domestic exposures t . patients in the mesa ' 'in the `in-patient' sei ,, ' of an asbestos facte p . difference a the pri jeries who lived in tf %- had no other expo. K' > significant (x 1 " ,7-f K ''*** ***?'1u*f Date of First Exp in Mesothelioma Ser [ had. been exposed, ?! lived near the.main , of exposure varied w " to. over 50 years. exposure and diath , (mean 37-5 ycqrs). workers, where expc . interval was shorto group living in tho factories, where, ex .. lowest. Table 7 she , gt first exposure and death in each group. M - .ft 1v RELATION BETWEEN n OF INTERVAL BEFOS V.I- ' MESO Factory work /, Domestic | i -r L a se rs and insulators 4living in neighbour- ^hood of factory varied between 29-4 death showed less v group of factory w - years in the other g Asbestos Bodies thelioma Series.--C ' thelioma series, h examination in fort all certified as suffer tissue available, ex; revealed the presen Both asbestos bod; asbestosis were four and laggers. A furl! asbestos bodies o r ; MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS IN-PATIENT J L _______________; I No. with r* Exposure to i? Asbestos' 5 3.- 1 0 t 2 /* 2 a r ;, 1 9 3f ' r -*- tine `in-patient' ' a ^ional exposure fg working withi. i TO asbestos dust i ^yjcinity of an be-fifth of the opened in il f the centre of There were if within half a i^was in produo$ped they were;. .A t the present ' i&'within a halfjuasbom within and remained at ' (her seven were iildren when the years of age and he died 48 years /ho had neither' trt but in whom mgs at necropsy, me patient lived 'fnd four others (fit was 22 years ourhood in 1915. ifid , complained phsbestos factory i Thus, among those with no occupational or domestic exposures to asbestos, there arc 11 (306%) patients in the mesothelioma series and five (7 6%) in the `in-patient' series who lived within half a mile of an asbestos factory in the area (Table 6). The difference in the proportion of patients in the two series who lived in the vicinity of the factory and had had no other exposure to asbestos is statistically significant ( x 2 = 7-85; p < OOl). Date of First Exposure and Interval Before Death in Mesothelioma Series.--Fifty-one men and women had been exposed to asbestos, including those who lived near the main asbestos factory. The duration of exposure varied widely, ranging from two months to over 50 years. The interval between the first exposure and death varied between 16 and 55 years (mean 37-5 years). Among the group of factory workers, where exposure was probably heaviest, the interval was shortest. It was longest among the group living in the neighbourhood of the asbestos factories, where exposure to dust was probably lowest. Table 7 shows the mean age of each group at first exposure and the mean of the interval before death in each group. Although the length of interval T able 7 RELATION BETWrHN TYPE OF EXPOSURE AND LENGTH OF INTERVAL BEFORE DEATH IN 51 PATIENTS INMESOTHELIOMA SERIES Lung tissue was available in only four patients exposed either through relatives or by living in the neighbourhood of asbestos factories. In two, asbestos bodies were present in lung tissue hut there was no evidence of asbestosis. T able 8 EVIDENCE OF ASBESTOS BODIES OR ASnESTOSIS IN 47 CASES OF MESOTHELIOMA WITH LUNG TISSUE OR SPUTUM AVAILABLE FOR EXAMINATION History of Contact with Asbestos Positive Negative Untraccd Total* Asbestosis or Asbestos Bodies Present Absent 22 6 4 4 3 .10 Lung Tissue not Available 23 n 0 36 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 botli 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 traced, three had asbestos bodies and histological evidence of asbestosis and one had asbestosis alone. Type o f Exposure No. Factory work 23 Domestic 9 j^ss^rs and insulators 8 uving in neighbour- hood o f factory u Mean Age at First Exposure (years) 22-5 17 9 15 6 85 Mean Interval between First Exposure and Death (years) 294 37-9 38-4 48 6 Discussion In the mesothelioma series there are 25 patients in whom no evidence of any exposure to asbestos could be found. A chief source of information was a history taken from a surviving relative. A surprising amount ofinformation was obtained, but in some of those interviewed the memory may have been defec tive or they may not have known of short periods of varied between 29-4 and 48-6 years, the mean age at exposure during the youth of the deceased. For death showed less variation; it was 50'6 years in the example, one of the patients was eventually identified group of factory workers and between 55 and 57 as having worked at a large asbestos factory for two years in the other groups. months in 1941. This was before he married, and his widow did not know of this episode. It is of Asbestos Bodies and Asbestosis in the Meso interest that asbestos bodies in the lungs were found thelioma Series.--Of the 83 patients in the meso in only four of this group, and it seems probable that thelioma series, lung tissue was available for . among the remainder there were those who had had examination in forty-three. In four other patients, no exposure to asbestos. all certified as suffering from asbestosis, with no lung In the mesothelioma series of patients, both in tissue available, examination of sputum during life dustrial and non-industrial exposures were recog revealed the presence of asbestos bodies (Table 8). nized. Among the men the exposure was pre Both asbestos bodies and histological evidence of dominantly industrial; 22 wbrkcd in asbestos asbestosis were found in 15 of the 24 factory workers factories or as laggcis, two were exposed at home, and laggers. A further five showed evidence of either and one lived near the asbestos factory. Among the asbestos bodies or asbestosis. women only 10 worked in asbestos factories, and a 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE further 17 had non-industrial exposures, seven in the home 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 uglier 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 mesothclial 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 1952 (Lcatliart, 1964) and its uses arc more widely diversified in industry. The increasing pioportion of the popula tion exposed to asbestos during the past 30 years may be expected to give rise to an increasing occurrence of mesothclial tumours. The choice of groups for comparison with the mesothelioma series of patients was not ideal. Tile number of patients it was possible to trace in the 'rejected' scries proved to be very small. The `in patient' scries, although matched for date of birth 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 series.' How ever, in the 'in-patient' scries 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 mesothclial tumours. There was no evidence that, because of their more recent admission to hospital, the in-patient series was less likely than the mesothelioma series to work in con tact with asbestos or to live in closer proximity to asbestos factories. There seems little doubt that the risk of mesothclioma may arise from both occupational and domestic exposures to asbestos. Wagner and others (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 the pleura has been found in the population living near an anthophylllte mine in Finland (Kiviluoto, 1960). More evidence is required of an increased risk to the population living in the neighbourhood of asbestos factories or other areas, such as dockyards, where asbestos is used in quantity. We should like to thank Dr. D. O'B. Hourihane for his co-operation and for making the results of his investigations available to us. Our thanks are also due to Professor C. Wilson, Professor V. W. Dix, Dr. N. L. Rusby, and Mr. G. Flavcll, F.R.C.S., of the London Hospital and Dr. C. P Silver of St. Matthew's Hospital for permission to inter view their patients; to the general practitioners who col laborated in this enquiry; to the managements of the asbestos factories for arranging access to their records, to Miss Joan Walford for statistical assistance, and to Dr. J. C. Gilson, Professor R. S. F. Schilling, and Dr. W. Smither for their advice and help. The contents of this paper were communicated to the Conference on the Biological Effects of Asbestos, arranged by the New York Academy of Sciences in October 1964, and will be published in a shorter form in the proceedings of that conference. R eferences Fowler, P. D. S., Sloper, J. C., and Warner, E. C. (1964). Brit, med. J.. 2. 211. I cadmg article (1964). Ihitl., 2. 202. Hourihane. D. O'B. (1964). Thorax, 19. 268. KiviluolO. R. (1960). Acta radial (Stnckh.), Suppl. 194. Lcalhact. G. L. (1964). Occup. H lth,(Lond), 16, 119. Owen, W. Glyn (1964). Brit. med. J., 2. 214. Wagner, J. C.t Slpggi, C. A., and Marchand, P. (1960). Brit. J. ndustr. Med., 17, 260. ., i * MESQjm : i.s vi .$ . y-'. Caw No. Site of > Primary ' Tumour ' J f ' (.Sffllon A: Factory`work*rt ':? A M? I fit Pleura : ` M Peritoneum Peritoneum 1f '*: S'. M.y pi^ur* ' ; Peritoneum* i f V* .u Peritoneum \ .1 Peritoneum F Peritoneum . V1.1.1J . *Irj 9 7 . it V; J /.-1 7 Peritoneum Peritoneum, F Pleur Peritoneum Peritoneum" XI Peritoneum - M< ,4 2 Pleura M H 20 Peritoneum F' > . . . 17 Pleura F- Pleura M ,!6 ; 10 Peritoneum F `H i 'fu* 1 Pleura M f - 23 Pleura aM y 3 Peritoneum 4 Peritoneum M Appendix opposite i Section B: Loggers and In. 25 I Pleura M ' 28 1 Pleura M 22 I Pleura M . i 30 ! Pteura M 27 | Peritoneum M ;-2 6 Peritoneum Xi `31 Pleura M '29 Pleura M nuVT *-'**v JM * S t a ' v. p.- . *6 work in conjapproximity to MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS .267 APPENDIX EIGHTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS Jfrisk of mesoWipational and 4sS*er and others >, Xposure other (Of the asbestos tlaques of the bn living near fciluoto, 1960). "risk to the bd of asbestos jleyards, where B.Hourihane for , "jjresalts. of hi. ? Case Site of No. Prtmary Tumour Dura Year tion Year of of Year Sea of First Expo of Birth Expo sure Death sure (years) How Diag nosed Section A: Factory workers 3 Pleura M 1901 1921 17 1938 Necropsy 19 Peritoneum M 1895 1919 22 1941 Necropsy 18 Peritoneum F 1908 1925 5 1947 Biopsy 24 Pleura M 1880 1929 12 1950 Necropsy 14 Peritoneum F 1893 1917 *7 1951 Necropsy 16 Peritoneum F 1906 1922 7 1931 Biopsy , C. Wilsonbyan d Mr. Q`.r\ IS Peritoneum F 11 Peritoneum F 1894 1913 1893 1917 3 1933 Necropsy l 1953 Biopsy 1and Dr, C. P. . tiision to inter* i fitioner* who col-' nents of the z "to' their recorda; .j- distance, and to X 13 Peritoneum F 1901 1918 II 1955 Biopsy 9 Peritoneum F 1897 1919 1 1956 Necropsy 21 Pleura M 1893 1928 1 1957 Biopsy 12 Peritoneum F 1918 1937 * 2 1958 Biopsy Uihg, and Dr. W. 2 P "'I founicated to the *. tIIS1 o f Asbestos, S tjy. of Sciences in In a ihortcr form fi'-. *s . . 3 Peritoneum M 1908 1927 30 1958 Necropsy 7 Peritoneum M 1925 1940 4 1958 Biopsy 2 Pleura M 1923 1941 1/6 1959 Biopsy 20 Peritoneum F 1907 1921 10 1959 Necropsy v k k ' v 11 f vi > : ippl- M..V ; 17 Pleura 6 Pleura F 1908 1924 1 1962 Biopsy M 1907 1942 10 1962 Necropsy 10 Peritoneum F 1899 1923 H 1963 Biopsy 1 Pleura M 1899 1936 26 1963 Necropsy 23 Pleura M 1908 1925 X 1963 Necropsy 3 Peritoneum M 1911 1930 2 1963 Necropsy N ~-: W f.iH - J ' 4 Peritoneum M 1917 1937 27 1964 Necropsy p P P V * is : I ; . r v .Mi.'. ? Seei/o 23 23 30 3| S: Logger* and Insulatorx Pleura ' . i M 1874 Pleura ; M 1893 Pleura M 1921 Pleura M 1908 Peritoneum M 1908 Peritoneum M 1911 Pleura M 1897 Pleura M 1912 * 1888 53 1910 22 1937 22 1922 39 1922 36 1927 34 1916 41 1927 34 1935 Necropsy 1955 Biopsy 1959 Necropsy 1961 Biopsy 1961 Necropsy 1961 Necropsy 1962 Biopsy 1962 Biopsy Asbestos Bodies in Lung Tissue Positive Positive Positive Positive Negative Positive Positive Positive (sputum) Positive (sputum) Positive N/A N/A Positive N/A Negative Negative Positive Positive Positive Positive Positive Positive Positive Negative N/A Positive N/A Push ivc Posiiive n /a N/A Patho logical Evidence of Asbcstosis in Lung Tissue Survival from Initial Symptoms (momhs) Relevant History Positive Positive N/A Negative Negative N/A Positive N/A N/A Negative N/A N/A Positive N/A Negative Negative Negative Positive Negative Positive Negative Positive Positive Negative N/A Positive N/A Posit|\ c Positive n /a N/A ? tos factory; mainly crocidoltte ? Disintegrator and other jobs. asbestos lactory; amosite. croci- 7 dolitc. chrysotilc Sectional pipe maker, asbestos ly crocidolite 9 Used 3sbcsios boarding in railway carriage construction 7 Asbestos factory, job unknown ? Opener and sectional pipe maker. asbestos factory, certified asbes- totic; amosite, crocidolite, chryso- hie 12 Spinner, asbestos factory, certified asbcstotic; mainly crocidolite 3 Sectional pipe maker, asbestos factory, certified asbestolic; mainly crocidolite 6 Spinner, asbestos factory, certified asbcsiolic; mainly crocidoiiie 3 Disintegrator, asbestos factory; amosite, crocidolite, chrysotilc 18 Asbestos mivcr, north England asbestos factory 18 Carder, asbestos factory; mainly crocidolite 18 Clothing and weaving, asbestos factory; amosite, crocidolite. chrysotilc 3 Filter maker for A.R.P, masks, asbestos factory; mainly croci- dnluc 11 Filler maker for A.R.P. masks, asbestos factory; mainly croci- , dotite F.leclrode coverer; crocidolite > Spmncr, asbestos factory; mainly 7 crocidolite Delivered chemicals to asbestos -, factory; amosite, crocidolite, chrysotilc 5 Spinner, asbestos factory; mainly crocidolite 7 Labourer, works and buildings. asbestos factory; amosite, croci- 8 dolite, chrysotilc Worked m yard of insulating contractors 6 Carder, asbestos factory; inainlv crocidolite 24 Disintegrator and other joos, asbestos factory; amosite. croci- doiite. chrysotilc -- ---------------------------- 12 Worked in close pro \ nity to boiler repairer m dockvuiJ-. 24 Boiler cleaner and stripper, dock- yards 9 Boiler coverer and Ingger to various firms 23 Erecting and fitting central healing 12 Under coverer and pipe insulator. rnntruciing firm 13 1agger ami boiler coverer, various firms Intermittent!) boiler lugger, ship ,0 repairs Installation of hospital sterilizing equipment Ico/in/iued) U * *.`a t*H 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE APPENDIX (ctmllnutd) E IO Iirr-fH R U E PATIENTS WITH MESOTHEUAL TUMOURS Case Site of . Tumour DuraYear (ion Year of of Year Sex ot First Expo- ot Birth Expo- sure Death suro (years) How Dmg> nosed Section C. Exposure o f relames 40 Pleura M 1912 1925 II 1956 Biopsy 34 Pleura 38 Pleura F 1913 1919 2 1957 Biopsy, F 1895 1919 41 1960 Biopsy 37 Pleura F 1905 1925 14 i960 Biopsy 35 Peritoneum F 1890 1921 21 I960 Necropsy 33 Pleura F 1916 1930 4 1961 Necropsy 39 Pleura M 1919 1928 2 1961 Biopsy 32 Pleura F 1900 194t 36 Peritoneum F 1889 1912 -- Section D: Neighbourhood casa 44 Pleura F 1905 1913 48 Pleura M 1922 1922 42 Pleura F 1889 1913 50 Pleura F 1903 1908 43 Pleura F 1903 1913 47 Pleura F 1917 1917 64 Pleura F 1899 1907 71 Pleura F 1899 1907 41 Pleura F 1900 1913 45 Pleura F 1900 1913 46 Pleura F 1907 1913 5 1963 Biopsy 18 1963 Biopsy . 7 1959 16 I960 48 1961 6 1961 13 1961 10 1961 6 1962 6 1962 32 1962 7 1962 7 1963 Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Biopsy Asbestos in Lung Tissue Pathological of As* bestoiis in Lung Tissue N/A n /a N/A N/A N/A N/A N/A Positive Negative' N/A N/A Negative Negative N/A N/A N/A N/A. N/A N/A N/A Positive N/A N/A N/A Negative N/A N/A N/A N/A N/A N/A Negative N/A N/A N/A Negative N/A N/A N/A N/A Survival Initial Symptoms (months) ,, Relevant History 27 Elder sister worked as spinner at asbestos factory, died 1945 certified asbestotic 14 Elder sister employed as spinner looked after patient as child 1 18 For several years husband worked iry ship's engino room, close proximity to lagging operations 3 Husband worked as boiler covertr- overalls brought home for washing 24 Husband foreman and executive at asbestos factory ? Husband a docker; frequently handled 'while' asbestos 18 Elder sister worked as* spinner at asbestos factory and suiters from asbestosis 18 Daughter worked in asbestos factory for 5 years; patient washed her overalls 15 Husband railway carriago builder lined compartments with asbestos sheeting; work clothes washed at home 8 Lived within j milo of preseat site of asbestos InUory 17 Lived within fc mile of present site of asbestos factory 15 Lived within 100 yards of present sue of asbestos factory 13 Lived within l mile of old site of asbestos factory 4 Lived within t mile of present site of asbestos factory 16 Lived within 200 yards of present site of asbestos factory 5 Lived within t mile of old site of asbestos tactory 12 Lived within mile of old site of asbestos factory 29 Lived within l mile of present site of asbestos factory 9 Lived within mile of present silo of asbestos factory 7 Lived within mile of present site of asbestos factory S '1 1 M ES. E ! * F'i r N ' " , . . x ,"`*1 1 ft' ' P " MP. l 'V . \ ,'Cuo S <; npx 2r 'xt*i\ 3lu of Prunary Tumour * } ,.f> Peritoneum 'O 1 > 11V`;^: 7U6 ' * 1 / ( Flurs , * a!. Plsur V 3Sl 1 66, I . /(. " - Pleura' ' T Plcurs *' ! I ' 32 Petit u m Pleura l *6J Pleura 1 51 Pleura * Pleurt : 1 \ 73 5 ; 70 Pleura Pleura I w - 'r a Peritoaeurz 1 55 y -'V60 Pleura Peritoneun 67 Pleura 1 55 Pleura 65 Pleura F 1900 68 Peritoneum F 1902 49 Pleura M 1893 75 Pleura F 1899 Peritoneum F 1904 62 Pleura M 1899 IVC 1947 Necropsy Positive Negali 1954 Necropsy Negative Negative 1954 Biopsy N/A ` N/A 1955 Biopsy n /a n /a 1955 Necropsy Negative fc 7173 1955 Necropsy Negative Negative Positive 1 :!a & , Peritoneun 7 Worked as nursemaid to manager of gas works in Last London; asbestos insulation used in works 5 Shonhand-typist and housewife; . . Pleura lived lllord area ? Baker's roundsman, army, general labourer, publican for 30 year* in Last End ot London ? Munitions work before marriage. then housewife; lived Waltham f Section F: Untract 27 Abbey, Essex Tailorcss and housewife in East 5 K- 78 Pleura End of London 28 Employed as luteman and greaser, Pleura Bcckton gas wonts 36 yean; 81 Pleura persistent discharging .anus R. side of chest following cinp>ema t 80 Pleura . 1925, acuta chest infection 1953, subsequent thoracopjasty l*ul 82 Pleurs deteriorated from this date Pcritoneuc 79 Pleura {continued) J rr\ . *- -* j ' i- 0" 1. 1 MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS APPENDIX (continued) EIGHTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS Case Site o f No. Primary Tumour J DuraYear non Year of of Year Sex of First Expo of BirLh Expo- sure Death (years) How Diag nosed Asbestos in Lung Tissue Palho logical of Asbestosis in Lung Tissue Survival Initial Symptoms (months) Relevant History 61 Peritoneum M 1913 64 Pleura 76 Pleura M 1904 F 1916 SI Pleura 66 Pleura M 1891 F 1898 7 Peritoneum M 1879 32 Pleura M 1890 63 Pleura M 1904 51 Pleura 59 Pleura M 1910 M 1911 51 Pleura TO Pleura F 1887 F 1883 TJ Peritoneum F 1398 55 Pleura ' M 1888 60 Peritoneum M 191S 67 Pleura Pleura F 1897 M 1912 69 Peritoneum F 1901 51 Pleura M 1392 ---- 1 1933 Biopsy N/A 1956 Biopsy N/A 1937 Biopsy N/A N/A 8 Merchant .seaman, cargoes from S Africa 1930-32, nodcfimtecvidcncc of contact with asbestos; suosc- quently employed on cross-channel boats N/A 12 Labourer and builder, finally em ployed in tunnelling: lived.in East F.nd of London N/A 19 Employed remaking old sacks in How. previous content of sacks not 1957 Biopsy N/A N/A 1958 Biopsy n /a N/A ascertained: lived Last End of London H Garage hand, chaulTcur. mechanic; lived Wolverhampton and Eppirg Worked as printing machinist before marriage, then as housewife 1958 Biopsy N/A N/A 1959 Biopsy N/A N/A I960 Biopsy N/A N/A until death; lived East End of London 3 Stcrcotyper and printer; lived originally m East London, lhcn moved to Ipswich 12 Van boy, regular army, cutter and grinder; lived N.E. London and Dagenham 18 Bricklayer, cement worker, post 1960 Necropsy Negative 1960 Necropsy Positive Negative Positive man; lived Last End of London, moved to Hainuult. Essex m 19U 18 Fitter and turner; lived principally > in East End of London Coloured S. African merchant sea- man. stoker at glass lactory; 1962 Necropsy Negative 1962 Biopsy Negative Negative Negative 1962 Biopsy N/A N/A possible contact with asbestos m S. Africa or at sea 10 Lived until marriage in Wales, then housekeeper in S.vv. London 30 Machinist of celluloid collars, housewife and canteen worker; lived East London 10 Machinist in hosiery trade, Notting- 1962 Nocropsy Negative 1962 Necropsy Negative Negative Negative 1963 Biopsy N/A N/A 1963 Biopsy N/A N/A 1964 Necropsy Negative Negative 1964 Necropsy Positive Negative ham. housewife; moved to London I9f0 2 Labourer, merchant seaman. docker, earned only meat 54 Apprentice printer, barman, cook. and butcher. For 25 years bciore death lived Last End of London 29 Dressmaker anti housewife: lived East End o f t ondon then Somerset 24 Steel erector, army, steel erector. labourer and porter; lived. Last End of London 42 Employed as packer in pharma ceutical firm for 12 years, then housewife until death; lived in Dagenham 24 Fisherman fireman, docker, 1915- 39 at Tilbury docks, fireman and finally storekeeper; contact aith asbestos not probable at Tilbury docks, lived Tilbury area i': tintraced cases n Pleure F 1899 1917 Necropsy ? Positive Not traced U Pleura M 1860 1922 Necropsy Negative Negative Not traced 1 . U Pleure M 1877 1925 Necropsy Negative Negative Not traced io Pleura M 1900 1936 Necropsy Negative Negative Not tr.iv.cd ti Plein a .M 1893 1938 Necropsy Positive Positive Not (raved n 1Peritoneum F 1910 79 ! 1 Pleure F 1878 1945 Necropsy Positive 1955 Necropsy Positive Positive Positive Not traccvl Not traced N/A tissue not available.