Document pe90brZoVGLb26Yd07JbDO62a

* ?t . r4 \ //a'. ./. nulustr. Meet., 1965, 22, 261. '** 'irlWit IW^ j*. 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 FOR PUBLICATION FEBRUARY 11, 1965) A series of S3 patients from the London Hospital with a diagnosis of mesothelioma confirmed by nectopsy 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. The earliest death recorded was in 1917, but only 10 of the series died before 1950 and 40 (48%) between I960 and lOfU In 76 of the series full occupational and residential histories were obtained. Forty (52-6%) gave ;i history of occupational or domestic (living in 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 ihvjases (p < 0 001). None of the 17 suspected cases of mesothelioma, rejected on pathological ,e. minds, 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 h .vd within half a mile of an asbestos factory (p < 0 01). Out of the 31 patients with occupational c'pusures 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, la 30 (62-5%), cither asbestosis or asbestos bodies were present. lii recent years, the association between exposure among the women, 25 had pleural and 17 peritoneal ' .isb tos dust and cancer of the lung and other tumours. `Ir t. nt neoplasms has been the subject of much The aim of this study has been to establish the ' 6:.di (leading article, 1964). Wagner, Sleggs, and occupational histories of these patients and to trace Lire i. nd (1960) described the occurrence of meso- any other possible exposure to asbestos. There were Aci,.i of the pleura in those exposed to crocidolite four surviving patients at the outset of the investiga "'V''.in the mining districts of South Africa, and tion, but these have subsequently died. The earliest " i`.i' stimulated further studies of the occupa- date of death in the series was 1917; 10 died before M.a: I i'tories of patients suffering from this tumour 1950, 33 between 1950 and 1959, and the remaining "'Cl!, 1964; Fowler, Slopcr, and Warner, 1964). 40 in the past four and a half years. The youngest I he present investigation concerns patients in patient died at the age of 33, and nearly half were ''iv, mesothelioma had been diagnosed at the dead before the age of 55 (Table 1). nmlo;i Hospital during the past 50 years. After 'Jmn.mg uie necropsy and biopsy specimens held Clinical Features h'c pathology department, Hourihane (1964) con- 3 a diagnosis of mesothelioma in 83 patients, The ward notes of 65 of the patients were available : "limn 41 were men and 42 women. Thirty-one of and give a picture of a disease with a consistent - incn had pleural tumours and 10 peritoneal; symptomatology. Among those with pleural 261 C/3 o UJ Tl LU T.j3 jintf 9 > tU,` o \-V- I BB 0005587 I 4 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Table 1 AGE AT DEATH OK 8? PATIENTS WITH MtSOTHELIAL TUMOURS Age (yr.) < .u 3545'5565' Male No, C/ 2 4.9 7 17*1 15 36 6 }0 24-4 7 171 Female No- 1 % 1 1 24 6 | 14-3 9 21-4 18 42-9 8 19 0 tumours, the commonest presenting symptom was the rapid onset of extreme shortness of breath due to the formation of a massive pleural effusion. Pain was a prominent feature, either 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. 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 terminally. The methods of treatment included pneumonectomy, decortication ol the lung, deep x-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 third within two years, and only one patient survived for more than three ye 3. 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 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 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 % 1 rtf*1 p 4 >%3 '*t' , 4 :*, patient, the notes had been returned to the lev,; executive council of the National Health Seme.where they were destroyed within a period of thrw years. In one of the asbestos factories a file was kept w.., detailed records of all employees since it started 1:. 1913. The names of all patients were checked wit: these files. Nine men and nine married women (af:L: their maiden names had been ascertained from reu. tives) were identified without difficulty. The evi;dates of employment of these 18 patients and t. jobs they had done were obtained from the recf-.v. of the factory. The four patients alive at the beginning of ih investigation were interviewed personally. A fc relatives were contacted by post, but the relative,. : 68 patients were interviewed by one of us (11 l'.i a their homes situated mostly in the East End London. Not only was an occupational history of 1: patient, the spouse, sons and daughters, and fa;\taken, but past addresses were also recorded. ]L,* interviews lasted for at least an hour. To recall ev err of 30 or 40 years ago it was often necessary a. explore the residential and occupational historic' all members of the family. * * ' * , [ > * ` i ' t Exposure to Asbestos in Three Groups of Ratio-.. < Suffering from Other Diseases j For comparison witli the mesothelioma paticir.'. i tlrree further gr-mps of patients suffering from ou.r- 1 diseases were i digated. ; The first grot,- was selected from the patient,.. s. the medical and surgical wards of the hospital duriti ' the early summer of 1964 (`in-patient' series). Ea-i, patient in the mesothelioma series who had her; j traced was matched with an in-patient of the sat: - ! sex born in the same five-year period. As there w.o i a dearth of male patients over 75 years of age in i! . hospital, a sample of six patients of this age am < older was taken from a neighbouring gcriatr. hospital. The second group were those who had origins , been filed in the pathology department of !. hospital as cases of mesothelioma but in whom h diagnosis was subsequently rejected on pathology grounds by Hourihanc (1964) (`rejected series'). A* 1 it had proved extremely difficult to locate the tives of those who died before 1950, attempts w - made only to trace the three survivors in this gioc. and the 14 who died after 1950. ; The in-patient series, already described, were 3 ; admitted to hospital in 1964. The patients vu; mesothelioma were admitted to the same hosp1'- , over a period of 47 years during which there mig' have been a substantial change both in the resident!. i ;-4v Ur\ivi r ru 1 u:j | i ,.:s an ! . m Kike C 'C I'f .! .. :.i the ot 1 - comp t X-tails A'v aie ml piu o.liable 10(52 . iparec. v V", ( fa .is or I II Ml,S' I > |>S- , i '`li'VutJ Jt ' s!tr> I' * iMcii yot > : **'> l'cI ai ` wltlflfs 1 ' ` l ilt'll JIlL ^ iiixc workv 1 ' 1 cfs Ijjiu v` hi$tor> -1 -mu`Miw, 1 `MCJVC CS, live Imun *Vven cjbc ' ``HI ihi;> 1 1 IjL statistically ui'01). Tin b> the two war of ad1 si'-'nificant 1 i'i mi the OC' and those a paring the mesothelioi "t the conf. gave a hist Tliis differ. i.V - U S' 4 o- ^ ' ! y V ... -'-. - . +* - . L.'g?^-..-'.. . I I a-- ocal vice. hree with :d in with after rdaexact J the cords T the \ few ,cs n( T.) at td of o( the father The e.cuK tr> to ri^s ot I ' i ii iI , 1 i , Jtlli ititmtv, 1 other eilts in during Fach 1 been .- same re was in the :c and .riatric lumalW of the iom the ologica! .-s'). Aj :ic relaus wen s groo? were ah us with hospital re might sideT','a! MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 263 a'Oi'ts and social classes of patients attending the Lot <J on Hospital. Thus, a third group of patients wa- ttaken from the hospital records matched by detO iof admission as well as date of birth and sex wim :the patients in the mesothelioma series. Their -pl.h.v of residence and occupations were extracted lO! ccMUparison with those of the in-patient series. Results LV vci ic'. arc given in the Appendix. No information t.ibcnl past domestic and occupational histories was u \ P.1. :ble for seven patients. Among the remaining 7ti. > (52-6%) gave a history of exposure to asbestos mred with only nine (11-8%) of the `in-patient' V. ! !' ' (Table 2). The difference in this proportion is Table 2 or exposure to asbestos of 76* patients v\ , i : ; MESOTHELIOMA AND 76 IN-PATIENTS WITH OT1IF.R DISEASES i, pc of Exposure ved at one asbestos 1V .J goods to factory at other asbestos 1 ICY iTy and loggers c worked with asbestos 5 handling asbestos *vior> of work or .>uc exposure to Mcsotl clioma Set JCS No. /. 18 3 1/ 250 4 5-3 8 10 5 9 HR 0-- 36 47-4 `In-pa tient' Sei ics No. /. 1 1*3 1 1-3 4 5-3 1 1-3 2 26 67 88-2 "wc exposures to asbestos in mesothelioma series versus 'u histories in in-patient scries: x* - 27-11, p < 0*00! wn cases of mesothelioma could not be traced and are omitted 'i.ii table. u.' nically highly significant (y2 = 27-11; p < 11 b >1 j. This result is unlikely to be unduly influenced h\ the two groups of patients not being matched for >w: of admission to hospital, since there was no MV 'ificant difference cither in the areas of residence i>: i n the occupations of the patients admitted in 1964 :ti'2! 11 lose admitted between 1917 and 1964. Com r-o ing the confirmed and rejected patients in the me 'othelioma group who died after 1950, 36 (50%) of ihe confirmed and none of the 17 rejected cases g.i i e a history of exposure to asbestos (Table 3). rii n difference is statistically highly significant '.\- 11-83; p < 0 001). TABLE 3 EXPOSURE TO ASBESTOS OE CONFIRMED AND REJECTED CASES OF MESOTHELIOMA SURVIVING AFTER JANUARY 1650 Exposure to Asbestos Diagnosis of Mesothelioma ---------- .----------------- Confirmed Rejected Exposure positive 36 0 No work or domestic contact found Untraced 35 1 16 1 x* - 11 83. p < 0 001 Mesothelioma Series Occupational Exposures.--There are 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 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 17* PATIENTS WITH MESOTHEI.IOM A EMPLOYED AT ONE ASBESTOS FACTORY Statutory Obligations Subject to regulations Not subject to regulations Job Male Spinning Carding Clothing and weaving Disintegrating and opening 0 i 1 2 FUtcr making for A.R.P. masks Manufacturing ofpreformed pipe insula tion Manufacturing of brake lining* Rubber com* pounding General labourer 2 1 1 0 Female Material 4 Crocidolite 1 Crocidolite Crocidolite, 0 chrysotile, amosite Crocidolite, 1 chrysotile, amosite 0 Crocidolite Crocidolite 0 Crocidolite Crocidolite, chrysolite Crocidolite, 0 chrysotile. amosite Employment history not available for one female patient. CO OS iJZ\ csUL____' t r. ''M 6-' 1 I-- Uj -;~ oo gg i`7n rraMTHw Utmsssrr 264 BRITISH JOURNAL OF INDUSTRIAL MEDICINE MESOI requiring medical supervision under the Asbestos TABLE 5 Regulations (1931). DISEASE GROPES OF PATIENTS IN THE IN-PATIENT Four patients were working at other factories SERIES 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 Disease Group Cardiovascular Metabolic Reticuloendothelial - .ncluding anaemias) Gastro-intestina! (excluding cancers) Respiratory (excluding cancers) AH neoplasms Other No. of Patients 21 9 8 6 3 18 11 No. with Exposure to Asbestos 3 a 2 0 1 1 a power station, one installing hospital sterilizing Total 76 9 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. 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 Domestic Exposures.--The group of nine, seven women and twm 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. 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 ;h_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 halfmile radius of the factory. One man was born within a quarter of a mile of the factory and remained a: 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 4S 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. In-patient Series Among the `in-patient' scries, one patient lived near the factory-at its previous site and four other:, Occupational and Domestic Exposures.-- Two of this series 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 lived near its present site. One patient vvas 22 yearold 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. histories of handling asbestos cargoes from time to time throughout their working life. Table 6 The diagnoses of these patients have been grouped into seven categories (Table 5). The patients with a RESIDENCE OF PATIENTS WITH NO OCCUPaTIONAI Os DOMESTIC EXPOSURE TO ASDESTOS positive history of exposure are scattered throughout the v arious diagnostic groups, and there is no indica Scries Lived Within 1 mile of Asbestos Factory Lived More Than ? mile from AsbcMos Factory To !.: tion that exposure to asbestos could be related to the disease which had caused their admission. Mesothelioma No. 11 V. No. I j30*6 25 69 4 36 Neighbourhood Exposures of Mesothelioma and In-patient 5 7 5 62 J 92-5 e7 In-patient Series.--The 36 patients with rncso- NOTE: MOT M* Ui a iwf'ai f fG FILES 1 Thus, among ' domestic exposure patients in the me ' in the `in-patient' I oi an asbestos fa. dutereiice in the | | vj :cs who lived in i had no other exp | significant T Hate of First Ex I in Mesothelioma Si ( ( hail been exposed lived near the maiim` exposure varied m over 50 years, exposure and deal! ('.'lean 37-5 years), workers, where exj iipc'-val vvas short juoup living in the t.ictorics, where c l.n.esl. Table 7 sit at iitst exposure an. i death in each group f * f i )it to I ATION BETWEFN 'I interval liLte: M t St' I 1 - PC of Exposure f 1 ' ',-,criyiicwork I j vfv and in$u!jlor& 1`''o m neighbour- mJ of factory 1 at ed betvveen 29-4 death showed less v; ao't.-p of factory wt v ` s in the other c; i Vsbcstos Rodics ! tliclionia Series.--Of : theluima series, lu evimination in forty all eei lifted as suflerit j tissue available, exar | 'w aled the present ' doth asbestos bodic - ad'estosis were fount! >m! laggers. A furthe 1 'she .tos bodies or as 'll 47b4 l SB 0005590 j TT - S^PATIEXT No. with i \posure to Asbestos 3 0 -i 2 0 1 I n-paticnf exposure ring wirh cstos dust iity of ail th of the iprned in centre uf here were .in half a n produc- he^^.nt m a half,irn within mained at even were when the of age and 18 years neither a whom :crops>. at lived r others 22 vears in 1915. nplained ;os factory 7IONAL OR *23 i'y I Total 4 j 36 5 ~~j 67* MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 265 Thus, among those with no occupational or Lung tissue was available in only four patients i domestic exposures to asbestos, there are 11 (30-6%) exposed either through relatives or by living in the p.iticnts in the mesothelioma series and five (7-6%) neighbourhood of asbestos factories. Tn two, i ii, the `in-patient' series who lived within half a mile asbestos bodies were present in lung tissue but there I of an asbestos factory in the area (Table 6). The was no evidence of asbestosis. ' difference in the proportion of patients in the two sci ies who lived in the vicinity of the factory and had h.id no other exposure to asbestos is statistically Table 8 i -:;j ,,'ficant (x,a = 7 85; p < 0 01). EVIDENCE OF ASBESTOS BODIES OR ASBESTOSIS IN 47 CASES OF MESOTHELIOMA WITH LUNG TISSUE OR SPUTUM AVAILABLE FOR EXAMINATION i Date of First Exposure and Interval Before Death History of in Mesothelioma Series.--Fifty-one men and women Contact < had been exposed to asbestos, including those who with Asbestos Ir.ed near the main asbestos factory. The duration Positive ' of exposure varied widely, ranging from two months Negative | to over 50 years. The interval between the first Untraced Asbestosis or Asbestos Bodies Preseni Absent 21 6 48 43 Lung Tissue not Available 23 13 0 exposure and death varied between 16 and 55 years Total 30 17 36 i (irean 37-5 years). Among the group of factory workers, where exposure was probably heaviest, the ' interval was shortest. It was longest among the Among the 12 patients in whom no definite contact j group living in the neighbourhood of the asbestos with asbestos could be established, there was one, a ' f.utories, where exposure to dust was probably merchant seaman from South Africa, whose lungs i Invest. Table 7 shows the mean age of each group showed both asbestos bodies and asbestosis; he may 1 a; first exposure and the mean of the interval before have had contact either in South Africa or at sea, ) death in each group. Although the length of interval but his early history could not be established. There were three others in this group who had asbestos ^ Table 7 bodies in lung tissue without evidence of asbestosis. Of the seven patients whose histories could not be KTl ATION BETWEEN TYPE OF EXPOSURE AND LENGTH Ot INTERVAL BEFORE DEATH JN 51 PATIENTS IN MESOTHELIOMA SERIES traced, three had asbestos bodies and histological evidence of asbestosis and one had asbestosis alone. 1 >pc of Exposure No. ^ *ork fV rustic and insulators 11\ nf m neiphbour- 1 ooit of factory 23 9 8 11 Mean Age at First Exposure (years) 22'5 17-9 15 6 85 Mean Interval between First Exposure and Death (years) 29-4 37*9 384 48-6 I j varied between 29-4 and 4S-6 years, the mean age at death showed less variation; it was 50-6 years in the j group of factory workers and between 55 and 57 | y.crv, in the other groups. ; Wiestos Bodies and Asbestosis in the Mesoj ilklioma Scries.--Of the 83 patients in the meso| thelioma series, lung tissue was available for ' examination in forty-three. In four other patients, j certified as suffering from asbestosis, with no lung 1 t'^-uc available, examination of sputum during life fexhaled the presence of asbestos bodies (Table 8). H 'th asbestos bodies and histological evidence of j asbestosis were found in 15 of the 24 factory workers j and. laggers. A further five showed evidence of cither I Jibcstos bodies or asbestosis. P Discussion In the mesothelioma scries 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 front a surviving relative. A surprising amount of information was obtained, but in sonic 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 deceased. For example, 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, an3 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 seems probable that among the reniainder there were those who had had no exposure to asbestos. In the mesothelioma scries of patients, both in dustrial and non-industrial exposures were recog nized. Among (he men the exposure was piedominantly industrial; 22 worked in asbestos factories or as laggers, two were exposed at home, and one lived near the asbestos factory - Among the women only 10 worked in asbestos factories, and a <73 -- " ijJ P ___ j ` -J J ' *-* - '* * -,\i-1.i. ; -' r -f - -- >-aae. :.'jj.'--- --a--- 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 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 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 1932 (Leathart, 1564) 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 mesothelial 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' series 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 w'ithout 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 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 meso~ ` thelioma may arise from both occupational and domestic exposures to asbestos. Wagner and others (1960) described patients W'ith 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 anthophyllitc mine in Finland (Kiviluoto, I960). ' More evidence is required of an increased risk to the ; population living tn the neighbourhood of asbesto., I factories or other areas, such as dockyards, where i asbestos is used in quantity. t We should like to thank Dr.- D. O'B. Hourihanc for ! his co-operation and for making the results of h' j investigations available to us. Our thanks are also due to Professor C. WiNon. Professor V. W. Dix, Dr. N. L. Rusby, and Mr. C; Flavell, F.R.C.S., of the London Hospital and Dr. C. I'. Silver of St. Matthew's Hospital for peinlission to inter j * 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 rcconb. to Miss Joan Wulford for statistical assistance, and tu 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 J Conference on the Biological Effects of Asbesto-.. arranged by the New York Academy of Sciences it: October 1964, and will be published in a shorter fom, in the proceedings of that conference. ( 1 j RErERENCES ( Fowler, P. B* S,, Slopcr, J. C,, and Warner, E. C. (1964). Brit. /. 2, 211. Leading article (1964), Jhid,, 2* 202, Hourihanc, L>, O'B. (1964). Thorax, 19, 268. Kiviluoiu, R. (I960). Acta rudtot. (Siorkh.), Suppl. 194, Lcaihan, G. L, <1<G4). Otuip. Jflth, (I.ond.), 16, 119. Owen, W, Glyn (1964). ilnt. mcd. J,, Z, 214. Wagner, J. C., Sieges, C, A., and Maryhand, P. (I960,). bn:. J wduitr. 17, 260, , vt nsnTUI ? H'" ' v -i i ij MHT r-' IS'Ji -J : . i I G FILES Appendix opposite CO Mftfj MESOTHi ( NO. Site of Primary Tumour Se\ V '[ion 4. Factory u orkcr'i K Pleura M 19 Peritoneum M IX Peritoneum F :j Pleura M M Peritoneum r 16 Peritoneum p IJ Fcritorn'-urn F Peritoneum 1' !< Peritoneum r 0 Peritoneum r Pleura m 12 Peritoneum F 5 Peritoneum M 7 Peritoneum M Pleura M '0 Peritoneum f J 7 I PJtura 6| Pleura r M 1 HI | Peritoneum F 1 | Pleura M ! Pleura |M Peritoneum M 1 Peritoneum j M nun // Loggers and a. w. Pleur.i M 'v Pleura |M Pleura 'M " Pleurj jM Peritoneum ! M Peritoneum ' M Pleura Pleura M jM i | BB 0005592 \ y > if i -T' -. .a^Eto^-gl-a >---- Ttirff - ^ NOTE: THIS DOCUMENTDID NOTCOMEFROMPPGFILES MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 267 coniy to ne>oand Kbcr> other icsios f the : near I960). to the lestoti where APPENDIX EIGHTY-THREE PATIENTS WITH MESOTHEUAL TUMOURS 1 \ J ( ST Site of Primary 1 umour Dura- Year lion Year of of Year Sex of First Expo- of Birth Expo- sure Death sure (years) How Diagnosed Asbestos Bodies in Lung Tissue Pathological Evidence of Asbestosis in Lung Survival from Initial Symptoms (months) Tissue Relevant History S' :,.,r -IFactory workers s Pleura M 1901 1921 J7 1938 Necropsy Positive Positive I 19 Peritoneum M 1895 1919 22 1941 Necropsy Positive Positive IK Peritoneum F 1906 1925 5 1947 Biopsy Positive n/a (sputum) Pleura M 1880 1928 12 1950 Necropsy Positive Negative 1 : Peritoneum F 1893 1917 1951 Necropsy Negative Negative 7 Brake liner, boiler coverct, asbes tos factory; mainly crocidohtc 7 Disintegrator and other jobs, asbestos factory; amosite, croci* dolitc, chry&otile n Sectional pipe maker, asbestos factory, certified asbeslotic, main ly crocidolite 9 Used asbestos boarding in railway carriage construction 7 Asbestos factory, job unknown ne fin of liis ;!<.'ii. 1r. Ci. . C. I\ > in:.to of .eoriT and io Dr. W. 1 1'. Peritoneum r 1906 1922 7 1951 Biopsy Positive N/A (sputum) ! Peritoneum F 1894 1915 X 1955 Necropsy Positive Positive 1 ; Peritoneum F 1895 1917 l 1955 Biopsy Positive N/A (sputum) 1 .> Peritoneum F '' Peritoneum F 1901 1918 1897 1919 n 1955 Biopsy Positive N/A (sputum) 1 1956 Necropsy Positive Negative Pleura M 1893 1928 1 1957 Biopsy N/A N/A i: Peritoneum F 1918 1937 2 1958 Biopsy n/a n/a Peritoneum M 190S 1927 30 1958 Necropsy Positive Positive 7 Opener and sectional pipe maker, asbestos factory, certified ashes* totic; amosite, crocidohtc, chrysotile 12 Spinner, asbestos factory, certified nsbestotic; mainly crocidolite 3 Sectional pipe maker, asbestos factory, certified asbestotic; mainly crocidolite 6 Spinner, asbestos factory, certified asbestotic; mainly crocidolite 3 Disintegrator, asbestos factory; amosite, crocidolite, chrysotilc 18 Asbestos mixer, north England asbestos factory IS Carder, asbestos 4factory'! mainly 18 Clothing and weaving, asbestos factory*; amosite, crocidolite. to the bestoe. i;es in form ' | j j Brtf, J. Peritoneum M 1925 1940 4 1958 Biopsy N/A N/A Pleura M 1925 1941 1/6 1959 Biopsy Negative Negative ;ii Peritoneum F 1907 1921 10 1959 Necropsy Negative Negative P Pleura F 1908 1924 1 1962 Biopsy Positive Negative Pleura M 1907 1942 ,0 1962 Necropsy Positive Positive in Peritoneum F 1899 1923 H 1963 Biopsy Positive Negative Pleura M 1S99 1936 26 1963 Necropsy Positive Positive Pleura ' ` M 1908 1925 ,* 1963 Necropsy Positive Negative Peritoneum M 1911 1930 " 1963 i Necropsy Positive Positive Pc-ttoneum M 1917 1937 27 i 1964 Necropsy Positive Positive ; 3 Iiltcr maker for A.R.P. masks, asbestos factory; mainly croci dolite 11 Filter maker for A R.P. masks, asbestos factory; mainly croci dolite 7 Electrode covercr; crocidolite 7 Spinner, asbestos factory; mainly *> Delivered chemicals to asbestos factory; amosite, crocidohtc, chrysotilc 5 Spinner, asbestos factory; mainly 7 Labourer, works and buildings, asbestos factory; amosite. croci dolite, chrysolite 8 Worked m yard of insulating contractors 6 Carder, asbestos factory; mainly crocidolite 24 Disintegrator and other jobs, j asbestos factory; amosite, croci| dolitc, chrysotilc ` R Loggers ami insulators Pleura M ' 1874 Pieura M 1893 - Pieura M 1921 Pleura ! M 1908 Peritoneum ! j M 1908 , Peritoneum i M 1911 , ------ Pleura Pieura M |M 1 1897 1912 1888 1910 1937 ' 1922 ` 1922 1 1927 ; 1916 | 1927 53 1935 , 22 1955 22 1959 3Q 1961 36 ! 1961 34 1961 41 1 1962 34 . 1962 Necropsy Biopsy Necropsy Biopsy Necropsy Necropsy Biopsy Biopsy Negative N/A Positive N/A Positive Positive N/A N/A Negative N/A Positive N/A Positive Positive N/A N/A 12 | Worked in close proximity to boiler ` repairer in dock>ards 24 1 Boiler cleaner and shipper, dock* I yards 9 j Boiler covercr and Idgger to various i firms 25 | Erecting and fitting central healing 12 Boiler covercr and pipe insulator. i contracting fu m 13 ] [.agger and boiler covercr, various ! firms 8 j Intermittently boiler lagger, ship j repairs 10 | Installation of hospital sterilizing equipment (contit *['bT0005593__1 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE APPENDIX {continued) _| EIGHTY-THREE PATIENTS WITH MESOTHELIAKliVlliRS. ' 0\D MES Case No. Site of Primary Tumour i j , Sex Year of Birth Dura Year tion of of Year First expo of Expo sure Death sure (years) How Dias* nosed Section C: Exposure of relatives 40 Pleura 1 M 1912 1925 n 1956 Biopy 34 Pleura 38 Pleura 37 Pleura j F ! !F i 1 F 1913 1919 2 1957 Biopsy 1895 1919 41 1960 Biopsy 1905 1925 14 I960 Biopsy i 35 Peritoneum F i 33 Pleura iF 1890 1921 21 1960 Necropsy 1916 1930 4 1961 Necropsy 39 Pleura i M 1919 1928 2 1961 l3iopy 1 ] 32 Fleura F 1900 1941 5 1963 Biopsy I ' 36 Peritoneum F 1889 1912 18 1963 Biopsy 1 !1 St'ctt'ui D; Neighbourhood coses 44 Pleura F 1905 1913 7 J959 Biopsy 48 Pleura M 1922 1922 16 1960 Biopsy 42 Pleura F ) 889 1913 48 1961 Biopsy 50 Pleura F 1903 1908 6 1961 Biopsy 43 Pleura F 1905 1913 13 1961 Biopsy 47 Pleura F 1917 1917 10 1961 Biopsy 64 Pleura F 1899 1907 6 1962 Biopsy 71 Pleura F 1899 1907 6 1962 Biopsy 41 Pleura 45 Pliura F 1900 1913 32 1962 Biopsy F 1900 1913 7 1962 Biopsy 46 Pleura F 1907 19 J 3 7 1963 Biopsy Senior. E* No kisior. of con tact h / h asbestos 65 Pleura F 1900 i 68 Peritoneum F 1902 49 Pleura : m 189} 1947 Necropsy 1954 Necropsy 1954 Biopsy 75 Pleura ; F 1899 1 74 Peritoneum F 1904 62 Pleura M 1899 1955 Biorw 1955 Necropsy 1955 Necropsy Asbestos Bodies in Lung Tissue N/A N/A N/A N/A Positive Negative 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 Positiv e Negative N/A N/A Negative Negative Patho logical Evidence of Asbestosis in Lung Tissue Initial Symptoms (months) Relevant History N/A N/A N/A N/A Negative Negative n/a N/A n/a 27 Elder sister worked as spinner v asbestos factory, died J9'o certified nsbestotic 14 Elder sister employed as spinner. looked after patient as child 15 For several years husband worked id ship's engine room, close proximity to lagging operations 3 Husband worked as boiler eover,,-r overalls brought home (or ...nlv4s 24 Husband foreman and executo e .n asbestos factory <> Husband 8 docker; frequent. handled 'white' asbestos 18 Elder sister worked as spinner .c asbestos factory and suffers irtr-* avbcMosia 18 Daughter worked in asbestos factor. for 5 years; patient washed U-r overalls 15 Husband railway carriaee biiik!*'*; lined compaumcnK with j-L't-x' sheeting; work clothes washed v home N/A N/A Negative N/A n/a N/A Negative n/a N/A N/A N/A 8 Lived within 3 mile of present 5'tt of asbestos factory 17 Lived within 1 mile of present sit: of asbestos factory 15 Lived within 100 yards of present site of asbestos factory 13 Lived within J mile of old site / asbestos factory 4 Lived within i mile of present v of asbestos factory 16 Lived within 200 yards of prevent site of asbestos factory 5 Lived within i mile of old site of asbestos factory 12 Lived wiihin \ mile of old s*tc >J asbestos factory 29 Lived within \ mile of present -te of asbestos factory 9 Lived within i mile of present sw of asbestos factory 7 Lived wiihm * mile of present v;` of asbestos factory Negative Negative N/A N/A Negative Positive 7 Worked as nursemaid to mannv ' of gas wotks in East l-ond.'"., asbestos msul.ition used m v.oi' 5 Shorihand-tvpiit and houses it.. lived Ilford men Baker's roundsman, nrniv, gene ; labourer, publican for 30 ycirv tn East End of London T Munitions work before m,irri.'y*. then housewife; lived \\alil.J~t Abbey, Essex 27 Tailorcss and housewife rn f-': End of London 78 Employed as luteman and greave.-. lleckton gas woiks 36 persistent discharging sinus K. side of chest following empt-rru 1925, acute chest infection subsequent thoracoplasty N* deteriorated from this dale 1 i ! 1 > i ' f ! ! i i ! * / l I1 i i i \ > i I'lxC 1 Site of \o Primary Tumour, M Peritoneum 1 ! j Pleura -.0 Pleura ^ j Pleura 1 Pleura -7 Peritoneum < * Pleura Pleura Pleura w Pleuta 71 Pleura Pleura 72 Peritoneum Pleura Peritoneum l7 Pleura U, Pleura i Peritoneum Pleui ,i i s > non h, i r.tmerit c 78 | Pleura * i ! Pleura ! Pleura 0 l Pleura s; ! Pleura 77 i Peritoneum '' I Pleura (continu*-1*1 j BB 00Q5594 7 imm *" ......... **- ^ -- L~- ^ .-. MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS APPENDIX (continued) EICHTV-THREE PATIENTS WITH mesothelial tumours 269 NOTE: THIS DOCUMENTDID NOTCOMEFROMPPGFILES 1 I5 1 ~ i .* rp ' lc J ( ...ly 1 r ... 1 >,,v ' i1 \ a: __ 11 ' W - 'V'lil of i : sits _ -f'n; * e of J t vi:e vie | MU w. ) i K-r ! f -.:c; ! if r.-i *VJ" . ,N U ,fc\vs 1951 but * 1 { Site of V, Primary Sen 1 umour " Ecnioneuivi M ' Pleura Pleura M F Pleura Pleura M F Peritoneum M Pleura i,> Pleura Pleura Pleura M M M M Pleura H\ Pleura F F Peritoneuni F Pleura M f,r, Peritoneum M h: Pleura P.eura F M L-t Peritoneum F : Pleura M ' / L ntrtured cases Pleura ; P'eurj F M i Pleura M V,, Pleura M i: 1'iaura M Peritoneum F 'v Pleura F Year of Birth Dura- Year non of of . Year First "Txpo- 1 of Expo- sure Death sure (years) How Diagnosed 1913 1955 Biopsy 1904 1916 1891 1898 ira 1S0 W(H 1910 1911 1887 1888 1898 im 1915 1897 1912 1901 1892 i I 1 1956 Biopsy 1957 Biopsy 1957 Biopsy 1958 Biopsy 1958 Biopsy 1959 Biopsy 1960 Biops> I960 Necropsy I960 Necropsy 1962 Necropsy 1962 Biopsy 1962 Biopsy 1962 Necropsy 1962 Necropsy 1963 Biopsy 1963 Biopsy 1964 Necropsy 1964 Necropsy Asbestos Bodies in Lung Tissue n/a N/A N/A N/A N/A N/A N/A N/A Negative Positive Negative Negative N/A Negative Negative N/A N/A Negative Positive Pathological Evidence of Asbesiosis in Lung Tissue n/a N/A N/A N/A N/A N/A N/A N/A Negative Positive Negative Negative N/A Negative Negative N/A n/a Negative Negative Survival from Initial Symptoms (months) Relevant History 8 Merchant seaman* cargoes from S. Africa 1930-32, no definite evidence of contact with asbestos; subse quently employed on cross-channel boats 12 Labourer and builder* finally em- ployed in tunnelling; lived in East End af London 19 Employed remaking old sacks in Bow, prev ious content of sacks not ascertained; lived East End of London 11 Garage hand, chauffeur, mechanic; lived Wolverhampton and Epping 6 Worked as printing machinist before marriage, then as housewife until death; lived East End of London 3 Stereotyper and printer; lived originally in Last Loudon, then moved to Ipswich 12 Van boy, regular army, cutter and grinder; lived N,C. London and Dagenham 18 Bricklayer, cement worker, post* man; lived East End of London, moved to Hninauit, Essex in 1931 18 Filler and turner; lived principally in East End of London 7 Coloured S. African merchant seaman, stoker at glass factory; possible contact with asbestos in 3. Africa or at sea 10 Lived until marriage in Wales, then housekeeper in SAN'. London 30 Machinist of celluloid collars. housewife and canteen worker; lived East London 10 Machinist m hosiery t rade, Noltiug- ham, housewife; moved to London 1960 2 Labourer, merchant seaman. docker, carried only meat 54 Apprentice printer, barman, cook, and butcher, l-'or 25 years before death lived Ea*l End of J-ondon 29 Dressmaker and housewife; lived East End of London then Somerset 24 Steel erector, army, steel erector. labourer and porter; lived East End of London 42 Employed as packer in pharma- ccutical firm for \2 >ea?s, then housewife until death; lived in Dagenham 24 Fisherman, fireman, thicker, 191539 at Tilbury docks, fireman and finally storekeeper; contact with asbtxios not probable at Tilbury docks; lived Tilbury urea 1893 1860 1S77 1900 1893 1910 1878 | i i ! l 1917 1922 1925 1936 1938 1945 1955 Necropsy Necropsy Negative Necropsy Negative Necropsy Negative Necropsy Positive Necropsy Positive Necropsy Positive Positive Ntlsative Negative Negative Positive Positive Positive Not traced Not traced Not traced Not traced Noi traced Not traced Not traced N/A *- tissue not available. gg nrtn ] ~rr -v -----05595~j