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Brit. J. industr. Med., 1965, 22, 261. MESOTHELIOMA OF PLEURA AND PERITONEUM FOLLOWING EXPOSURE TO ASBESTOS IN THE - LONDON AREA BY MURIEL L. NEWHOUSE and HILDA THOMPSON From the Department of Occupational Health and Applied Physiology, London School of Hygiene and Tropical Medicine (RECEIVED FOft PUBLICATION FSBKUAftV II, !9`J) A senes of 85 patients from the London Hospital with a diagnosis of mesothelioma confirmed by necropsy or biopsy has been studied for possible exposure to asbestos. The senes consisted of 41 men and 42 women; 27 of the patients had pentonaTah? 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 TjjLof the series full occupational and residential histories were obtained. Forty (S2-6aA) gave- a history of occupational oTdomSlBrt^^ house as an asbestos worker) exposure to' asbestos compared with nine (11'8/0 out of 76 patients from the same hospital suffering from other diseases (p < 0-001). None of the 17 suspected cam of mesothelioma, rejected on pathological grounds, was found to have had any exposure to ilfetos. There was also evidence that neighbour' hootTcxposures may be imporiint. AmSnjTKoie with no evidence of occupational or domestic exposures, 30-6% of the mesothelioma patients and 7-6% of the in-patients with other A\**v*. livwFwithin 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. In recent years, the association between exposure to asbestos dust and cancer of the lung and other malignant neoplasms has been the subject of much research (leading article, 1964). Wagner, Slegp, and Marchand (1960) described the occurrence of tneto* tbelhxna of the pleura in those exposed to croddolite astenas in the mining districts of South Africa, and this has stimulated further studies of the occupa tional histories of patients suffering from this tumour (Owen, 1964; Fowler, Slopes, and Warner, 1964). The-ptaent investigation concerns patients in whom mesothehoma had been diagnosed at the London Hospital during the past 50 yean. After examining the necropsy and biopsy specimens held in the pathology department, Hourihane (19641 con. firmed a dlaynotis..of mesothelioma in 83 patients, of whom 41 were men and 42 women. Thirty-one of the men 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 anSTo trie anTogjgpogiiMc^taMuialoMBBIBgrTBgawe four surviving patients at the outset of the investiga tion, but thee have 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 put four and a half years. The youngest patient died at the age of 33, and nearly half were dead before the-age of 55 (Table 1). Qfefesl Fentons The ward notes of 65 of the patients were available and give a picture of a disease with a consistent symptomatology. Among those with pleural )NEUM * THE ia confirmed by consisted of 41 earliest death tween 1960 and 'y (52-6%) gave >er) exposure to ring from other on pathoiogicai that neighbourlal or domestic t other diseases th occupational I. The interval between 0 hination. al and 17 peritoneal een to establish the ?atients and to trace sbestos. There were set of the investiga- died. The earliest >17; 10 died before and the remaining ars. The youngest d nearly half were ). tients were available e with a consistent hose with pleural 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Tabu I 4GE AT DEA4H OF S) FATIENTS WITH MESOTHELIAL ._ TUMOURS 1 Mil* Femut as* i- No. + *; 1 No, ' e - * J4 ?5- _ 455$--65 - 2 : *4 7 1 17 1 15 [ 366 ( 10 24-4 i ? 1 17-1 1 , 24 6 i 14-3 9 ' 214 IS > 42* 9 : t90 tumours, the commonest presenting symptom was the rapid onset of extreme shortness of breath due was a^grominent-feature, either described as a dulf 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 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 defaecation or micturition. Diffuse upper abdominal pain was very common, and swelling of the abdomen due to ascites was always present tenhihalfy. The methods of treatment Included pneumonectomy, decortication oi the lung, deep x-ray therapy, instillation of radio active gold, and cytotoxic drugs. They were used alone orjn combination, but had iittie.effect, onItheedurse of the disease. Half of the patients suffering the onset of symptoms, a further third within two years, and only one patient survived for more than three yean. The course of those with peritoneal tumoun appeared to be equally rapid. Eight of the patients died within six months of the onset of symptoms. Somes of lafarautioa m 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 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 woe circulated with an explanatory tetter 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 local executive council of the National Health Service, where they were destroyed within a period of three years. In one of the asbestos factories a file was kept with detailed records of all employees since it started in 1913. 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 histones 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' senes). Each patient in the mesothelioma series who had been traced was matched with an in-patient of the same sex bom in the 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 pounds by Hourihane (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 the same hospital over a period of 47 yean during which there might have been a substantial change both in the residential mesothelioma of pleura following exposure to asbestos 263 _area* and social classes of patients attending the London Hospital. Thus, a third group of patient* as taken from the hospital records * date of admission as well as date of 1th the patients in the mesothelioma **"".!* piaco of residence and occupations were for comparison with those of the in-patient series. Results Derails of the 83 patients in the mesothelioma are Jrenin the* Appendix. No information about past domestic and occupational histories was Sble for seven patients. Among the remammg 7A 40(52-6 ) gave a history of exposure to asbestos compared with only nine (11-8%) of the `in-patient leriesl Table 2). The difference in this proportion is Table 2 TYps OF EXPOSURE TO ASBESTOS OF ? PATIENTS WITH MESOTHELIOMA AND T6 IN-PATIENTS WITH OTHER DISEASES Type of Exposure - Employed at one asbestos factory Delivered goods to factory Employed at other asbestos , factories insulators and taggers f Relative worked with asbestos > Dockers handling asbestos cargo j No history of work or i domestic exposure to j asbestos 1 Mesothelioma . Series No. 1$ I 2S0 I 4 33 1 & ' 10-3 j 9 ill 1 ` 0 il 36 | 7- | *In*patim' Series No. 1 * 1 ! ,3 1j 4| t ti 2i ,-3 S`3 1-3 2-4 67 1 31*2 Positive exposure! to ubt^m in mesothelioma scries versus positive histories in m-patient series i 27U.P < 0001 "Seven cases of meamhejiomt couid not be traced and are omitted from this table. statistically highly significant (x* = 27-11; p < 0-001). This result is unlikely to be unduly influenced by the two groups of patients not being matched for year of admission to hospital, since there was no significant difference either in the areas of residence, or in the occupations of the patients admitted in 1964 and those admitted between 1917 and 1964. Com paring the confirmed and resected patients in the mBothdioma group who died after 1930. 36 (50^) oTtne confirmed and none of the 17 rejecbDdfaia ipve*~tllefy ot exposure to~g5cs5M {t able ~3). TSh-iiflfatacc IS Statiaiiealiy fiigHly* significant (x4 - II 83; p < 0-001). ^ ~~ T*LE 3 /-riMflRMED AND REJECTEC li^W^^g^S^v.VINO AFTER JANUARi Exposure to Asbestos Exposure positive s work or domestic contact j found Untraced Confirmed 36 33 1 x* - II *3. p < 0 001 Reacted 0 16 1 Mesodwliotna Series Occupational Exposures.--There are details avail able for the 18 mesothelioma patients who had worked at one asbestos factory which used crocidoiite asbestos with small amounts of chrysotiie 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 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 available had used crocidolite asbestos. Five of the occupations listed are not scheduled as Table 4 JOBS OF IT* PATIENTS WITH MESOTHELIOMA EMPLOYED AT ONE ASBESTOS FACTORY Statutory ObH^tioas iob Mala 1 Famafa Malarial 1 Spinning 0 4 Croctdoiite Subnet to refutations Cardin* Clothmg and weaving Disintegrating and opemng ' , 2 ' CrocidoliM Croctdolice, 0 chrysolite* amosite Crocidohtc. ! ehryeottta, amoaae Filter making for A.R.P. masks 2 (3 Croodoluo Manufacture ofpreformed ptpetciM&a* turn t i Not aubieci to Manufacturing of txaJta list* I CroodeUes Croejd!*** 0 i chiymflo Gawaral^ Crocidotatt, l 0 chryseestea amoeose 'fimptoywiMg te-tawy Mi available foe one female pattern. BESTOS 263 '4ED AND REJECTED . AFTER JANUARY 1 lesotnetiofTu w Resecled 0 16 '* e are details avail- patients who had which used croci5 of chrysotiie and Eleven started he asbestos regula tor" asbestos goods workers became ork between the i 942. The occupa>e of asbestos they f the 17 for whom ocidolite asbestos. 1 not scheduled as EUOMA EMPLOYED ;tory # Materiel Cfocidolue Crocidolae Crocidolite, chrysottk, amosue Crocidolite. chrysoule, amosite Croctdoiite Crocidolite 0 Crocidolite Crocidolite, t chrysoule Crocidolite, 0 chrysotiie. amosite female paiiem. 264 BRITISH JOURNAL OF INDUSTRIAL MEDICINE requiring medical supervision under the Asbestos Regulations <1931). 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 crocidolite, the types of asbestos used in these other factories are 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 and Domestic Exposures.--Two of this series had worked in asbestos factories and four had been employed as taggers. 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 Tasle 5 DISEASE GROUPS OF PATIENTS IN THE IN-PATIENT SERIES Oiseaae Group CAnbovaacuUr Metabolic Reticulo-endotheiial (including anaemias) Gastrointestinal (excluding cancers) Respiratory (excluding cancers) All neoplasms Other Total No, of Patterns 21 9 8 6 3 18 I1 No With Exposure to Asbestos thelioma and the 67 patients in the 'm-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 yean 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 of the factory and remained at the same address for 16 yean. The other seven were women, and all except one were children when the factory opened. The seventh was 23 yean of age and remained in the same house until she died 48 yean 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' series, one patient lived near the factory at its previous site and four othen lived near its present site. One patient was 22 yean 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. Taile 6 RESIDENCE OF PATIENTS WITH NO OCCUPATIONAL OR DOMESTIC EXPOSURE TO ASBESTOS positive history of exposure are scattered throughout the various diagnostic groups, and there is no indiestion that exposure to asbestos could be related to the disetme which had caused their admission. In-prtitot &rtoL---ffK 36 patients with meso- Senas MoomMiow In-pttMst Uwd Withia i mite of Aatanos Fsctoty Liv4edtsMuieorferoTmhen Asbestos Factory No. Ns. u 3W 23 m-4 3 7-3 ns *< - 713, r < (HJI Total 36 67 MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 265 Thus, among those with no occuP*t^?^\ domestic exposures to asbestos, there are 11 (30-6 /.) oatients in the mesotheiioma senes and five (7 /) to the `in-patient' series who Uved wtUunhaif a mde of an asbestos factory in the area (Table 6). ine difference in the proportion of patients m ^ meries who Uved in the vicinity of the factory and had had no other exposure to asbestos is statistically significant (y* ** 7-85; r < OOl). Date of Ffrst ExpMare and Interrei Before Death ia MeaotbsftwMt 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 yean). 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 Tails 7 RELATION BETWEEN TYPE OF EXPOSURE AND LENGTH OF INTERVAL BEFORE DEATH IN SI PATIENTS IN MESOTHELIOMA SERIES Lung tissue was available in only four patients either 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. Table 8 EVIDENCE OF ASBESTOS BODIES OR ASBESTOSIS IN 47 CASES OP MESOTHELIOMA WITH LUNO TISSUE OR SPUTUM AVAILABLE FOR EXAMINATION Hittoty of Abm&t Ls&g Tianao not AvaJlaMffi FOllUVf MaflP&tv* U&tTBAd Total 13 4 4 3 6U 8 13 i0 M 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 both asbestos bodies and asbestosis; he may have had contact either in South Africa or at sen, 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. Typo of Exposure No. Foetory work Domkms Laggure and iaawiaiore Living ia hood ofEtosry U # 8 El Mena Ap at First Expoouft (ymt*> 22-1 17* ` 13* *5 Moos laterrsi bor-- Fine Exposure xa4 Doxth iymnl 2M 37* 31* 484 varied between 29*4 and 48-6 yens, the mean age at death showed less variation; it was 50-6 yean in the group of factory workers and between 55 and 57 yean in the other groups. AsianiM leto aai Aatmtoals to the Mm thciatM Smhm.--Of the 83 patients in the mesothe&nw aeries, lung tissue was available for exiataatioa in forty-three. In four other patients, all certified as suffering from asbestos!*, with no lung rime available, caminatiosi of sputum during life revealed'tbs presence of asbestos bodies (Table 8). Both aatatfos bodies and histolofieai evidence of asbestosis were found in 15 of the 24 factory workers andlanns. A further five showed evidence of either asbestos bodies or asbestosis. 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 of information 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 exposure during the youth of the demised. For sample, one of the patients was eventually identified as having worked at a large asbestos factory for two months in 1941. This was before he married, and his widow did not know of this episode. It is of interest that asbestos bodies in the lungs were found in only four of this group, and it sans probable that among the remainder dwe were those who had had no exposure to asbestos. In the mesothelioma series of patients, both in dustrial and non-industrial ctpowiitem were racognixed. Arnaaj tl>>pi~the atpoww~RM pre dominantly industrial; 22 worked in asSBoa f*rtorieT^~ii~ISners two were etBajeTHTibnie, arid' one lived nsartSeS5toni5airv. Among the women only 10 worked iroabattos factories, and a SBESTOS 265 only four patients > or by living in the ictories. In two, tissue but there OR ASBESTOS1S IN ra LUNG TISSUE OR EXAMINATION dim n t 1 Loss Tiaau* j not Avulsbk ] 23 13 10 [ 36 n no definite contact ;d, there was one, a Vfrica, whose lungs < asbestosis; he may n Africa or at sea, ; established. There who had asbestos dence of asbestosis. stories could not be es and histological ad asbestosis alone. re are 25 patients in asbestos could llllk nation was a IBP -. A surprising ined, but in some of ay have been defec t of short periods of the deceased. For eventually identified stos factory for two e he married, and episode. It is of ; lungs were found ins probable that hose who had had patients, both in cisures were reco*exposure was pre irked in asbestos * exposed at home, actory. Among the tos factories, and a 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE further 17 had non-industrial exposures, seven in the hdme~andTO living near'asbestos factories. ' ' There is_ no evidence-that me patients with peritoneal tumours differed in thetr 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 mesotheiial 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 (Leathart, 1964) and its uses are more widely diversified in industry. The increasing proportion of the popula tion exposed to asbestos during the past 30 years may be expected to give rise to an increasing occurrence of mesotheiial tumours. The choice of groups for comparison with the mesothelioma series of patients was not ideal. The number of patients it was possible to trace in the `rejected' senes proved to be very small. The `in patient* series, 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' 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 mesotheiial 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 m con tact with asbestos or to live in closer proximity to asbestos factories. ' There seems little doubt that the risk of m^n. theiioma may..arise from both occupational and domestic exposure-to~asSistds. "Wagner and other* (1960) dcsmBetTpatients with no exposure than living as a child in the vicinity of the mijMS^. A high incidence of asbestos .clagues;.of the pleura has beenloundlnlhe population living near an anthophyllite mine in Finland (Kiviluoto, I960). 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. Fiaveil, 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. ' References Fowler. P. B. Sloptr. S. C.. and Warns?, E. C. (19641. Hr,,, mtd. 2. 211. Lesdina aruda (1964). IM.. 2. 202. Hounhanc. . O'B. (1964). INnu, 19. 26*. Kivtlucto, R, Act* rmki&i. (Stock*.), Suspi. 194. Lcsihart, G. L. (1964). Occup* Hltk, (Load.)* It* 119, Owm, W. Glyn (1944). Srit. iM. /,, 2.214. Wigaor. J. ., StewL C A., and MarcfeiAd, r. (I960). Brtt. J tokmtr. A*5Tl7. 260. Appendix opposite * MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 267 APPENDIX EIGHTY'THREE PATIENTS WITH MEJOTHEUAL TUMOURS C** No. Site of Pnmery Tumour I Dura* Year i non Year of of Year Sea of Fine Sim* Of s`nJk E*pe MM Dosill surt (ysn) How Dunms& Aabata* Mien in Iwians Pst looses! Evtdoam of As- in Luaf Tita* Survival front initial Symptoms (months) Retevaat History S&cttots A: Ferrer/ workers 0 Pleura M 19 Peritoneum M 1901 im 1921 1919 17 u 193* Neeroewy Pocttivs 1941 Nttnw Pensive Positive Ponttve t Peritoneum F 1905 192S $ 1947 Poesstve N/A (HMMtMl) 24 Pleura M 1800 1928 n 1950 Necropry Pealeive Negative 14 Peritoneum F 1893 1917 ? 1951 Necropsy Nersctir* Nepittve it Pmtoaeum F 190d 1922 7 1951 Hew {5St, N/A 13 Pemerwura F U Psettonemss F IS Peritonoum F 9 Peritoneum F 11*4 1915 ins 1917 I90| 1197 1918 1919 S 1955 Necropsy Foisaiw Poeitive l 1955 Kopiy fssfe N/A (tpmai) 11 1955 Positive N/A (apuaeel 1 1954 Nscropsy POSBSIVS Negative 2! Pleura M 1893 1928 8 1937 Kopey N/A N/A n Perttooeum F 191* 1937 2 195* Kopey NfA N/A 5 Peritoneum M 1905 1927 m 195* Necropsy Peassm Wmmsm ? Pentonsum M 1925 1940 4 1938 atom/ 2 Pleura M 1925 1941 i/ 1959 Kopiy N/A N/A NdSljvi Namtmi 20 Pentocvsum F 190? 1921 10 1959 Neeropcy Nppidni Ws-a-srs 17 Pleura F 90S 1924 8 1942 FoeWM Nagntmt nettra M 1907 1942 10 1942 Necropsy Mtiw Pnithni 10 Peritoneum F 1899 1923 a 1983 Kopey Poaklvs Negatsve ! Pleura M 1*7*3 1934 at 1943 Necropsy Posesrve Psoittivc 23 Pleura M I9M 1925 4 1943 Necropsy Peeklve NsgMtvs 3 Fermnwa M 1911 1930 2 1943 Necropsy PeeatlM PoUve 4 FemoMasa M 1917 1937 27 1944 Necropsy Ptem POSBtSVS Smlea M: Lflgpm east immiman -23 iptman Ml 1874 S3 1915 Necropey Nejjijtrl Hmpsh nm M mj 1910 22 1955 IHfnmmi N/A N/A 22 men Ml 1921 1937 22 1959 Neeropup Paaicivs PamiMve M min MI 190S 1922 1941 Btepsy N/A N/A 2? totanm Ml 1909 1922 M 1941 MffiCTnfflipgy Panatta HFfStmttmHHJrUil.nirinat 2ft-- PartMUM M 1911 1927 M 1941 Paite PMtttM 31 mean M 1197 1918 41 1942 m*mv N/A N/A 2$ Pleura M 1912 1927 M 1982 Kopey N/A N/A | Brake iiner boder eoverer. 1M factory; memly cromdoltw | Disintegrator end other k*c I tiocttcc factory; amoutc, erso- * doiuc. chiyeotile Sectional pipe maker, aeboetoc ' factory, certified aibesotic; mam- ty croctdolite 9 [ Used catnMoa boarding in railway I carnage conecnicttoa AabaKsc factory, jes unknowe ? Opener and Mcuosal pros maker, ubetot factory, certified uaa- totac; amoaite, croodolttc, caryao- ftlt 12 Spinner. ubastoc factory, certified Mbemwie; mainly croodotna 3 Snettonei pipe mate, ubeuot factory, ceniAod asbestotic; memly crocuiolite $ Spinner, ubettoe factory, cammed ubastotic; mainly cracidoUte 3 Diuntegrator. aatattoi factory; amocne, crocidoMte, cteyioule 18 Aabestoc mixer, north England aabeetot factory i* Carder, actatae factory; mainly eromdoiita , i* Clothing and weaving, .asbeatoa factory; matt, croadetae. duytotile 3 Filter maker far A.R.P. maika. aabmcoa factory; mainly erect- ttoiite a Filter mete for A.R.P. matki. aabesioa factory; mainly crocs- 4> dolite Electrode eoverer; crocidolite V Spinner, aatato* factory; mealy crocidolite Delivered ctenkal* to attaetos factory; amoana. croctdolte, earyaotile s SptatMK, tibem* factory; meaty erocidolita ? Labourer, work* and buddinga, aabanoa factory; amonte. croo* dote, dtrytotUe Worked in yard of iniulattag coturactorx 8 Carder, aslneiUM factory; mainly croddsiite 24 Dieatacmtor and other iota, eternal factory; amo*,;!*, ate- dolite. chryeotia 12 Worked la dene proxmMy to boitar repute in dockyard* 24 ndier eh*** and etr^pv. tab* yet* t Dote amwar and lagpr to vanaiae Urns 25 Erect** sad fining ranurai heating (2 oiler cower and pipe mattes*. contracting find 11 Lapp* and boil*r cower, varim ftrme t InurmittaMly boiler lagger, ship to Inautletfem of twaptul uerilixMf _Jgliaj|BWl S8ESTOS 267 ftricvsnt History ' ter, boiler eoverer, ashes* ory; mainly erocidolite aior and other jobs, v factory; tmcsitc, croohryiotiie p?oe maker, asbestos certified asoestotic; mam- Joint nsatof boarding tn railway construction factory, job unknown md sectional pipe maker, factory, certified asbesnostit, croodoitte, chryso- asbestos factory, certified -ic; mainly erocidolite pipe maker, asbe&cs certified asbcstotic; mainly itte asbestos factory, certified ic; mainly crocidoitee ator, asbestos factory; . erocidolite, ehrysottie mi**rf north England t factory asbestos factory; mainly lite and weaving, asbestos ife amositt, erocidolite, taker for A.ft.P. masks, t factory; mamly eroct- laker for A.R.P. masks, t factory; mainly croc*- e eoverer; erocidolite 'Jam*.*** factory; mainly | cals to asbestos 'site, erocidolite. asbestos factory; mamly itte r, works and buildings, s factory; amosite, crocs* ehrysottie in yard of insulating tors asbestos factory; mamly lite rater and other jobs, * factory; amouse, eroeihrysotile n dose proximity to boiler in dockyards finer and stripper, dock- erer and lagpir to various and fitting central besting overcr and pipe insulator, ting firm md boiler eoverer, various tentIy boiler lagpir, ship on of hospital uerilixing ent__________________ 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE APPENDIX IWMI EIGHTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS Case No. Sll Of Primary Tumour | Dura- : Year uon Year of ! of Year , S , of Birth First 1 Expo- of Expo 1 iura Death sure tCyean) How Diag nosed Asbestos Bodies m Lung Tissue Fatten- logical Evidence of Asbeetoeas m Lung Tissue Survival from Initial Symptom* (moeiliul Relevant History Srcrifflt CJxpomrr of rtlmtirti 14 Pleura 38 'F i F 1913 1895 1925 1 - 1919 | 11 2 1919 1 41 1936 j Biopey j 1937 Biopsy f I960 1 Biopey N/A N/A N/A N/A N/A N/A 37 F 35 Peritoneum t F f 33 F J9 Pleura M 32 Pleura F 36 Peritoneum F 1905 1*90 1916 1919 1900 1189 1923 1 1921 i 1930 ! 192S i ' mi i 1 i 1*12 ! ! <* 21 4 2 s ss 1990 i Biopsy NIA I960 1 Neeropay Potitiva f 1941 1 Necropsy Negative 1991 Biopey .993' Biopsy 1 NIA N/A N/A Ncfauve Neputive N/A N/A 1963 ! Biopey n/a N/A 27 | Elder sister worked as spinner at ftshee&oe factory, &mm5 t*44, certiM aetaMStK 14 Elder suter employed is tpinner. looked after patient as child 15 For several years husband worked m ship's engine room, dose proximity to lagging operations 3 Husband worked as boiler eoverer; overalls brought home for washing 24 Husband foreman and executive at V j asbestos factory Husband s docker; frequently handled `white* asbestos II Elder sister worked as spinner t asbestos factory and suffers from IS i asbestosts Daughter worked in asbestos factory for 5 years; patient washed her overalls IS | Husband railway carriage builder; ! lined compartments with asbestos sheeting; work clothes washed at home Season D: Neighbmtrhood costs 44 Pleura i a Pleura j F 1903 tW>nftf 1922 1913 1922 7 16 42 Pleura { F 1U9 1913 4* SO Pleura , F 1901 190 6 43 Maura 1 F 1903 1913 U 47 Pleura ' F 1917 1917 10 M Pleura j F im 1907 9 71 Pleura F 1(99 1907 6 1 41 Maura I F 1900 1913 32 43 Pleura F 190 1913 7 44 Pleura [ F 1907 1913 ____________1 7 Section E: No history of commt with osbestos S3 Maura F 1900 !959 Biopay 1*90 Biopsy 1991 Biopiy 1961 Biopey 1961 Biopsy 1991 Biopey 1992 Ropey 1992 Biopsy 1992 Biopsy 1992 Biopay 1993 Biopsy N/A N/A Positive N/A N/A N/A Naatava N/A N/A N/A N/A N/A N/A N/A N/A N/A Namtiva N/A N/A N/A N/A 1947 Necropsy Positive Naggptiva - P-fto-aum F 1902 49 Pleura M 1195 1954 Necropsy Negutiva Naamtlvp 1954 Biopey N/A N/A i1 i 73 Pleura F (933 N/A N/A 74 Peritoneum IF 92 ME 1955 Necropsy Naonlive Natmtiv* 1933 Necropsy Namtiva Poaisiv * Lived within | mile of present site of asbestos factory 17 Lived within t mile of present site of asbestos factory , IS Lived within 100 yards of present site of asbestos factory 13 Lived wittem | mile of old site of assesses factory 4 Lived wtthin 1 mile of present sice of asbestos factory 16 Lived wuhm 20 yards of present site of asbestos factory ' s Livid withia t auk of old rite`of astaHos factory !2 Lived wittem k mile of old sue of asbestos factory 29 Lived wittem | mile of present site of asbnssoe factory 9 Lived wittem k mile of present site of asbestos factory 7 Lived within k mile of present site of asbestos factory 7 Worked as mmemacd to managm of gaa works in Eaet London; asbestos insulation used in works 5 Shorthand-typeK and housewife; V IM Ilford ana Bakar'a rouadiaun, army, pattm! labourar. pufciieaa for 30 yarn is East Ead of Loadou Munitioo work before marriam, titan hooanri&i livad Waltham Abbey. Emms 27 Tattomaa and housewife in East End of London 21 Empkryad as hmnaa and tnmmr, nekton sat works 39 yarns; partammt dtocharsias two* IL Me of chaat foUowta ampyaam 1925, mam ebon infection 1931, MthMUiat tboracoptnity tat deaarterawi Itom-th-- data umum*d) -- MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS * - APPENDIX cwUMMft EIGHTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS 26< ' 'Cw No, Tumour Sax U Peritoneum M 54 Pteura 76 Beura 51 Pleura * 66 Pleura M F M F 57 Peritoneum M 52 Pteura M 43 Pteura M SI Pleura 39 Pteura M M 73 Pteura TO Pteura F F T2 Peritoneum F 35 nsors M 60 Peritoneum M 67 Pleura 56 Plourtt F M m Perttoomisss F S3 Pleura m -testae F: llmmcvd eaan 78 Fleurb P 83 Pham M 1 Ham M 8* naira M a -Man M 77 F 79 Ftooffh r Dura* Yaar two Year of of Yaar of i First Expo- of Binb ; Expo* sure Death sure (years) How Ota*. noeed ! Path*' AatattM [ iomcai Bodies IB Loaf Toswt Evidemc of Aa bama* in Lung [ YlSSWS Survival from Initial Symptoms (montk*) Relevant History 1913 1904 1916 1191 1896 1879 1890 1904 1910 1911 1887 itss lift 1888 1913 1997 1912 193! 1892 ! I \ 1 1955 Biopsy N/A MIA s Merchant min, carysa from S Africa 1930-32, so <Mnta momaa of eamaa entfe aibeNae; iuw quamiy etnptoyitd on eromathana* 1954 Ko**y MIA MIA boats 12 Labourer ana builder, Anally am ployed m tuane&ing; lived ia Eat 1937 wpsT MIA N/A Sad of London 19 Employed remaking old sacks tr Bow. previous content of sacks no etewiained; 1`vad Emu End o London 1937 eiopey MIA MIA U Ganna band, chauffeur, mechanic 1938 B#$wty MIA N/A lived Wolverhampton and Eppin* 4 Worked as pnnuag mackmts. before mamagt, thea as housewife until death; lived East End ot 1938 Biopsy MIA N/A London 3 Steraotyper and printer: Lv* engmaity in East Loaded. ther 1939 Biopsy MIA N/A moved to Ipswich 12 Van boy, regular army, cuttar and ffmder; lived N.E. Leodoa ana Dagenham - I960 iooay MIA MIA It Incblayar, cemu worker, sect- man; lived East End of London, I960 Naeropey Nafttna Negative moved to Haioauit, Eases sn 1931 It Fitter and turner: Uved principal!) in East End of Loaded * I960 Necropsy Positive POQSStV* ? Coloured S. Afneaa merchant sea, man. stoker at tlaiw factofy poesthte eootaes with asbestos ir 1962 Necrspny Negative Nejattv 10 S. Africa or at sea Lived until rnarmea ia Wales, ther 1943 Btepey Negative Negffitiv* kouaekssper m S.W, London Machauat of ostluloid collars housewife and cameast worker 1962 Blew MIA MIA lived East London 10 Machinist in Hommy trade, Nome* ham. housewife; moved to London 1940 1962 Necropsy NtfitNa Mtmnm s Labourer, merchant seaman. 1962 Necropsy Niuive Nanniaa docker, carried only meet 34 Apprentice printer, batman, cook. and butcher. For 25 yean before 1943 Biopsy MIA N/A death lived East End of London 39 Dressmaker and housewtfe; lived East End of London then Somerset 1963 Biopoy MIA MIA 24 Sami ereetor. army, tteei erector. labourer and pomir; lived Emm 1964 Neeropey Nsgnstve Napumi End of London 42 Eatptoysd as packer in pharma- nuucai Ana for 12 ymn, thm housewife until death; lived m Dn#inH]flmw 1964 Nocropey Mi Narihi 24 Ftthsrmea. ftftmaa. docker, 3915- 39 at Tilbury docks, dramas and finally storekeeper; contact with aslmtes not probebfa at Ttlhury docks; lived Tilbury area 18*3 18*9 1*77 1MB 1*93 I91B *( 1917 1922 1923 1934 1938 1943 1933 V Necropmy Neaptfwe NBWflray NBMtfo NttEffp8f Nugedra Neenipv PdeWse Naerapqr M8n Wftoa-iwy Fe*ihw Ne--tira Neppithns Napufilw Puteiva WriinMiimfinBilwniin FdWw# r Not tramd Not traced Not traesd Not traced Net traced Nettncad Not traced MIA -- timm am avniMt, H