Document wz0yXx0gwKNXn7QgbmKEDzg4

>. O. '-"r. D . S.*fc T l.MMm, M. mul Diiin rf{< I f-z.J. indusir. \1ed., 1965, 22, 261. PLAINTIFF'S EXHIBIT a.j,, u. :> O . Mol^rti -*. *_ ^ * k tk, 14. sn. ^ ct. j<j , i % I MESOTHELIOMA OF PLEURA AND PERITONEUM FOLLOWING EXPOSURE TO ASBESTOS IN THE LONDON AREA BY MURIEL L. NEWHOUSE and HILDA THOMPSON f ront the Department of Occupational Health and Applied Ph\finlogy, London School of Htytenc and Tropical MeJUine (RECEIVED FOR rUSUCATION FEIRUARV II. 1965) ST02792I6 A series of 8.1 paiients from the London Hospital with a diagnosis of mesothelioma confirmed by 1 necropsy or biopsy has been studied for possible exposure to asbestos. The series consisted of 41 J men and 42 women; 27 of the patients had peritoneal and 56 pleural tumours. The earliest death J recorded was in 1917, but only 10 of the series died before 1950 and 40 (48%) between I960 and 1 1964. In 76 of the series full occupational and residential histories were obtained. Forty (52 6%) gave a 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 diseases (p < 0001). 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 evposurcs 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 (r < 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. lo recent vears, the association between exposure among the women. 25 had pleural and 17 peritoneal asbestos dust and cancer of the lung and other tumours. ralignant neoplasms has been the subject of much The aim of this study has been to establish the research (leading article, 1964). Wagner, Sleggs, and occupational histories of these patients and to trace vlarrhand < 1960) described the occurrence of meso any other possible exposure to asbestos. There were * thelioma of the pleura in those exposed to croddolite four surviving patients at the outset of the investiga tsbestos in the mining districts of South Africa, and tion, but these have subsequently died. The earliest \ cis has stimulated further studies of the occupa- date of death in the scries was 1917; 10 died before oonal histories of patients suffering from this tumour 1950, 33 between 1950 and 1959, and the remaining > lOwen, 1964; Fowler, Sloper, 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, and nearly half were Ahem mesothelioma had been diagnosed at the dead before the ege of 55 (Table 1). London Hospital during the past 50 years. After i- examining the necropsy and biopsy specimens held Clinical Features -.t the path.-'logy department, Hourihane (1964) con- -rrr.cd a c-agitosis of mesothelioma in 83 patients, The ward notes of 65 of the patients were available ;f w horn - j wfre men and 42 women. Thirty-one of and give a picture of a disease with a consistent ,-ic men hac pleural tumours and 10 peritoneal; symptomatology Among those with pleural f BRITISH JOURNAL OF INDUSTRIAL MEDICINE MESOTHU / Tu I *<>* -" o;a:h or *: ^at:csts vmth mesotheljal TL MCLRS Mi 4 No U 4 ^ *4f * j" :i i >:i44 1m F*m*k No. 1 961 j 24 2u14) It !| 412990 irr. :ur-. ne commonest presenting s>7nptom was re -a pi c ns*.! of extreme shortness of breath due r .- f .rrr-jiien of a massive pleural effusion. Pain -ax a p-or-::nenl feature, either described as a dull a:hc. s:rw. due to invasion ef the ribs or 'trievrc. cr sometimes sharp and radiating, sug- gr>u-g -.er-e .nvolvement. Tumours in the chest wail *re no: uncommon, occurring either in p:."' 'u; op-rranon scars or by direct invasion of the C"e: The symptomatology of the peritoneal tLT'c jrs wij rare varied. In some patients the pre- ve~.:i:-g svi-ptom was pain on defaecation or rr- t_ -- 11 'n. D.fiuse upper abdominal pain was very co-pi- or. ar-d spelling of the abdomen due to ascites ;. ;:vkivs present terminally. The methods of trrat- cr' i.-.-'liJcd pneumonectomy, decortication j: !_'#. deep jr-ray therapy, instillation of radio- zc. grid. ani cytotoxic drugs. They were used al;pc or - oor.biaation but had little effect on the o the dxasc. Half of the patients suffering irc'.i -le.ra mesothelioma died withio one year of :n: i ' -e of sv.r.ptoms. a further third within two a.-s. zr.t o' iv one patiert survived for more lhan three ec-v. T. e course of those with peritoneal lurou -v epp c oed to be equally rapid. Eight of the pa <rrt> oev. - thin six months of the onset of r pir rn*. Sources of inr,.rtEjrion on Occupation and Residence I: i :d. .(' tc "ie ward rotes, some of which gave . cc.ra Til histories, there were three other -ource- o' in '--jiicn: the patient's genera! practi: or;- :heri. rc> of an asbestos factory in the area; and perv na i-.ter.Sew-s with patients or their sjoivi.-.p relavves. A> a hrv s:ep. general practitioners were circulated with ar explanatory letter aslung them to complete a fern ct'-ng details of the occupations of patients and the-p ..-n.TJtdiate relatives. Within two months f?*, of ire oners had replied. In two cases a - :h:rv l.-vn.:exposure to asbestos was revealed; t cr.c'i t/e name and address of a surviving relative v-ert ci rn. ru: in the majority the doctor was unable t; g.r f'tT'jiion because, on the death of the patient, the notes had been relumed to the local executive council of the National Health Service, where the) were destroyed within a pcrunl of three years. In one of the asbestos factories a file wav 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 histories of all members of the family. Exposure to Asbestos In Three Groups uf Patients Suffering from Other Diseases For comparison with the mesothelioma salients, 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" series). Each patient in the mesothelioma scries who had been traced was matched with an in-patient of the same sex born in the same five-year period. As ihere w a dearth of male patients over 75 years of ace in the hospital, a sample of six patients of th is ace and older was taken from a neighbouring eeriatric hospital. The second group were those who had originally been filed in the pathology department of the hospital as cases of mesothelioma but in w hom the diagnosis was subsequently rejected on pathological grounds 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 thrte survivors in this group and (he 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 years during which there might have been a substantial change both in the residential areas and social claxw London Hospital. Tl- I was taken from the ' date of admission nv :. with the patients in thi Places ol residence for comparison with'h. 1 "S Detail. of the 83 pi v series are given in the F about past domestic ji I available for seven p:n > f 76, 40 <52-6 %) gave a hi * compared with only mn. * series (Table 2). The d j t types or EXPOSE WITH SII NOtHE.Lin LI26L201S Tmx -r EDmcftbpewltoory<rsr0J ji 'n ^`0' io f*ci< Emfacpttoiend. * InvwiilOfi .*ihJ luMtu Rfljti'd ked 'th k^*'*'*''* Docket lumlltnf *vhcsi" SO TllAI" ' O* *' . dumctiA npouitf Potiine routiNC h 'ii'ffc'i n m-pji'.'1' 'Sawn of mrv'lhv from htx ,jhit. statistically highly mci0 001). Thix result is u.i by the two groups of p. year of admission to ' significant dilferente i r or in the occupations . and those admiued b.-t. Paring the confirmed i mesothelioma group > of the confirmed and n ft *ave a history of exp This difference i' -t > = II 83; P 0 f<H I _JL_ MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 263 re:.mcd the local <--jl HcJ:.' Service, ...it-. a pe-.o- of three , : cv i file ' it *cjx with .. oc- sinee .lined is ,ar it were c-.ec*;ed with . married vorr.cn fafter a-certa-nt; 5-cm reU- Ji~.cult> Trie exact ,< It pstir-'.s and the , -.ci (Vox thj records :iw beir,-.Tg of the ,0 p>:TSOnii;. A few . hut the rc..stives of - . one of J H.T.) at ,n tne Etvl End of . ->ai anal K .ic -y of the aaujhters. ar i fatta .-c a(.o receded. The . rou. To rccaT events often rccosary to .. ..pstior.a! -.I'-.nries of -ix Croups of Patients :i.*r Disease* .'fhci.'ora raiients, 'u fern from other ::.-u the pa .ems in , I'V-.chot: n during - jih.nl' se-.e. . Each wrie> v,h. h_d been ,-p;-.ier.i c' ire same por jd. A-. ir ere was *5 tears o' a^r in the of i~-i i;e and ..gh-ocrir.; ..triatric reas and social classes of patients attending the luruon Hospital. Thus, a third group of patients ,v> Likert from the hospital records matched by ii*.c of admisvon as well as date of birth and sex a th (he patients in the mesothelioma series. Their . jce> of residence and occupations were extracted ir comparison w ith those of the in-paliem series. Results Details of (he 83 patients in the mesothelioma v-tes are giver, in the Appendix. No information .-out past domestic anJ occupational histories uaj imlahle for seven patients. Among the remaining \-. 40 (53 h*..i gj\e a history of exposure to asbestos -rtipared mill only nine (II 8*.i of the `in-patient' ^ie> iTable 2) The difference in this proportion is Tabli I -Pt> Ot IVPOSLRt TO ASIESTOS OF 76' PATIENTS , IN MtsOtlltLIO'IA AND 76 IN-PATIENTS WITH OTHER DISEASES Typt 1 I'vpt Mjff { fd at JwllCMfH 1 -*. . rd at ttet j'hfTlos 1 jf. -/a .-t ,,*.vl .r* 1 Vrci No I i '!11 I * :s< 1 4 5J 1 | to s 1,,-jii.t w.v.rj * lift uhr*J*>4 j raxcr-x .j't \ h At............. Wvvrt -mot k c 'N">wrr a. ***6' 'Xw tte | Hi I ' 9 1 III 1 0 I i 'lA'CMlM*'!' Unm No. | X ! \i Ij *i 1i )) JJ 1) :i ! 24 *7 it: f.>. vf C\,' >vjit> io ttbettot m metoibelioma wrics 'tiut h-- .TtOh .1 ***<* X* - 2VII. r < 0-001 1rir ,*)"j*' ,i<s rrosrthpliomj could no< be traced and are oihind " o ha; or pirally Jo.-jniTiri of the 13 nut ir. *r om the .ate; or. puhological re reied series'). As io loca-a t-.e rela* !'<pV. atirrp-.s were - . i jrS ir. :n: group psr re;. w ere aO I e ra.en'-> with i:.e lire hospital ".ch fere might :: ntne-es der.tial i I .uiisiically highly significant (y* = 2711; P < I c-0011. This result is unlikely to be unduly influenced t the two groups of patients not being matched for .ear of admission to hospital, since there was no smificant difference either in the areas of residence .-.in the occupations of the patients admitted io 1964 i.-.d those admitted between 1917 and 1964. Com- 1 -irirj the confirmed and rejected patients in the ,-escthelioma group who died after 1950, 36 (50*) c: i>c confirmed and none of the 17 rejected cases j pie a history of exposure to asbestos (Table 3). This deference is statistically highly significant ,v- - II 83; p < 0 001). T*au J EXPOSURE TO ASBESTOS or CONFIRMED AND REIECTTD i*secases op mesothelioma surviving after January Eiiwiin io Asktfiot Dugnotit of M%cihdM*rru CoUnntd i Rejected Eipnwirc pout*** No ofk ot ioirtoiik cooioet ftmo4 Umraccd Mi )5 0 14 i * - 11 . P < 0 (tot Mesotheliooa Series 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 amositc in >926. 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. Ail of the 17 for whom details were available had used crocidolite asbestos. Five of the occupations listed are not scheduled as Tasle 4 lOtlS OF 17' PATIENTS WITH MESOTHELIOMA tMI'LOl I l> AT ONE ASBESTOS FACTORS OSMiktu|iiiiWoM) Surbejegcutlitiioofu. Not MbfOCI IO Job Spuming Car4in| Oocthomvigngend Diadnteopgerntiinng| Male 2 FilMfcoeerimlAtaRki.nPg. MaoptMnrfpumpefraeincfoaturumrlinewgd Malounftuinfga*cbtruarkineg Rupbobuenrdcinogm* Gelanbeoraulrer 2 0 l-emale Material 4 Crnctdolitc . CtocialoJiu 0 CCrfaconcarhchcnfwiriurddyx*no9ajniotloliteteitiieicikk.,.. 0 Crocidolite Crocidoltie 0 Crocidoluc CrcohcriydaonliuteW. 0 Crcaobmcriyodsaooiltutctcle., `EmaVoyiKM kauvy not available for on lamak patient. ST0279 2 18 n THE l^-fATieVT Citirn n * *. Mjk V J fl !I i. in the '.n-patiem' upatienjl exposure . .-.sire wording with - ;n-cd to asbestos dust . mediate vicinity of an c t.-.an one-fu'th of the t <-iploytd, opened in .c ntarer ihe centre of v..cr >eart. There were , -i> .ntng within half a i - ; t.me it was in produc er! opened they were vejrsold. At ihe present , *.t ivi.-ig wii.nin a half' >-ic run was horn within . tjst.cy and remained at . - '"he other seven were At e children when the - ; 23 .'ears of age and u-iit she died 48 years ^tieni who had neither - c'pos-ire but in whom , 11 :-.i lures ai necropsy. -cr..s. one pjiient lived . ,.u. site and four others >jr; pativni wjs 22 years . n; ghbourhood in 1915, .nurxiiwed. complained . . -n- the ashe-los factory >< -.o occl r vtional o* I TO ASSESTOS Iti M r i.rcai *' *. o> Tottl 1 MESOTHELIOMA OF PLEURA FOLLOWirmINuG EXP> O--S--U---RE TO ASBESTOS 265 Thus, among those with no occupational or LLuunngg ttiisssxuuee wwaass aavvaaiillaabbllee iinn oonnllyy ffoouurr patients domestic exposure* to asbestos, there are 11 (30-6%) exposed cither t"hr-o--u--g>h -re*>lati*v;e* or bvy liviing in the neighbourhood of asbestos factories. In two, pstiems in the mesothelioma series and five (7 4%) asbestos bodies were present in lung tissue but there m the "in-patient' series who lived within half a mile was rso evidence of asbestosis. of an asbestos factory in the area (Table 6). The CO difference in the proportion of patients in the two s series w ho lived in the vicinity of the factory and had had no other exposure to asbestos is statistically signif-i-c-a-n-t (X,, s " 7-85; r < 0-01). Date of First Exposure and Interval Before Death la Mesothelioma Series.--Fifty-one men and women had been exposed to asbestos, including those who Uaul q EVIDENCE OF ASBESTOS bodies or asiestosis IN f\3 <t casessrtomfjMmaevsaoitlhabellieomfoarweitxhalmuinnagtTiiossnue or a,.J ----------------------------- vO LMwi.r*WW J Ln*Tiy* |\> ' i 4'W*M 1 ikM AM* , lived near the main asbestos factory. The duration of exposure varied w idely, ranging from two months to O'er 50 .'ears. The interval between the first evpoiurc and death varied between 16 and $$ years (mean 37 5 years). Among the group of factory wMien, 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 ir each group. Although the length of interval Among the 12 patients in whom no definite conUct 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 sea, but his early history could not be established. There were three others in this group who had asbestos bodies in lung (issue without evidence of asbestosis. Table 7 Rli.vIO'. SCTWEES- Ttn OF EXPOSURE AND LENGTH or ivTi HVAL Herone death in si fatients in mesothelioma series Of the seven patients whose histories could not be traced, three had asbestos bodies and histological evidence of asbestosis and one had asbestosis alone. Discussion In the mesothelioma series there arc 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 survit mg 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 deceased. For J between 39 4 and 4! 6 years, the mean age at 'jn; showed less variation; it was 30-6 years in the --at :p of factory workers and between 55 and 57 erf. vcirv m the other groups. example, one ofthe 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 interesi that asbestos bodies in the lungs were found Asbestos Bodies and Asbestosis In the Meso in only four of this group, and it seems probable thai thelioma Series.--Of the 83 patients in the meso among the remainder there were those who had hat thelioma series, lung tissue was available for evimmation in forty-three. In four other patieats, noJenxpthoesumreetsooathsebleiosmtosa. scries of paiicnts, both in all certified as suffering from asbestosis. with no lung dustrial and non-industrial exposures were recoi uc available, examination of sputum during life nixed Among the men the exposure was pn ti ealed the presence of asbestos bodies (Table Sj. rneo- th asbestos bodies and histological evidence of Basobtehstosis were found in 15 of the 24 factory workers aar.td loggers. A further five showed evidence ofeither dominantly industrial; 22 worked in asbesu factories or as laggers, two were exposed at horn and one lived near the asbestos factory. Among ll women only 10 worked in asbestos factories, and asbestos bodies or asbestosis.  I2Z6UG1S BRITISH JOURNAL OF INDUSTRIAL MEDICINE funner 17 hid non-indusmal exposures, seven in the hjrre a-d 10 l:v ing near asbestos factories. There is na c'-idcnce that the patients with pern rr.es! t_maur> differed in their type of exposure from :ht pai.er.a with pleura! tumours. The propor tion o' pc-viti.e findings of asbestos bodies or a-:os i was similar in both groups. A higher prop -; n if -o-ier.. particularly among the factory v* jf^erv was afected by peritoneal tumours, but the d ''erence between the sexes was not statistically sumr'ca::. The recer.t increase in the number of patients d'-ie'-. n-cc a: the h-ospttal may be partly due to an irpci-cc interest m mesothelial tumours and partly to the !;.ng ir.terval between first exposure and de ei. p~en: of the tumour. Those exposed between IItI? in5 I9Z5 might be expected to die from about 19:0 or.arcs. Asbestos imports to the United K.nyc nr h.a : mounted steeply since 1932 (Leathart. 19--tj ji-: i - lw. are more widely diversified in injj-t-j The increasing proportion of the popula tion c.pence to jnnestos dunng the past 30 years me;, be expecit-J to give nse to an increasing occurrence o' mesochelial turrours. The chiice of groups for comparison with the -nc-othel.cma series of patients was not ideal. The -lu.-ihrr of patients it was possible to trace in the reected' series proved to be very small. The `inoaiient" serie*. although matched for dale of birth ind sex, cLfened from the mesothelioma series in that all were admitted to hospital during 1964. Neither of these groups could be intentewed without know ledge c! the disease from which they were suffering. Thi; could ha-e fed 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 obtabed than was passible from the relatives of those who had died of mesotheliai 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 lo asbestos. Wagner and others (1960) described patients with no exposure other than living as a child in (he x icinity of the asbestos mines. A high incidence of asbestos plaques of the pleura has been found in (he population living near an anthophyllile 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 Hcurihanc fot his co-operation and for making the results of his Investigations available lo us. Our thanks are also due to Professor C. w.I.-on. Professor V. W. Dix. Dr. N. L. Rush;., .md Mr. G Flavell, F.RC.S., of the London Hospiul anj l>r. C. P. Silver of St. Matthew's Hospiul 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 Watford for statistical iSM-tance. and to Dr. J. C. Gilson, Professor R. S. F. Schill ng. and Dr. W. Smiihcr for (heir 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 (he proceedings of that conference. Retcxencxx Fewtar. P. . S.. Soper. J. C . end Werner, E. C.II9MI)).. BfU. > A, 1,211. Leadkia ankle (1964). HM..U301. Uoenkane. D. O'B. (1964). Three. 19. 261. Kixiluaco, k. (I960). Acts rMKW. iSioekA.u Suppt. t**. UalHArteO. L. (1964), Octxp. HHkALm^X 16. 119. 0*n. W. Clin (1964). Bru. m*4. 2. 214. Wafner. J. C,, Steffi. C. A., and Mtrchlod. P. flttO). But. /. imdsstc. A/rW.. 17, 2*0. MESOTHEl I Caw Sue t>( No. j Pf' mar> Serfka 4 f.len wire. s Pleura M 10 Poiifttruii) M It Pr-ih-neitm r 24 1 Pleura m 14 ferui'nctjm . f 16 PcrtW'noum ! K 13 p, Iit.vrseuni j II Pc'K*rttUH ' 15 9 P.'fiux*kn 21 Pleura 12 P.-fiti*rum 5 P.'fllt'MUtn 7 pL-ritoneum Pleura j 30 Pcfitenflifi' 17 (Mrura 4 | |*1*UTJ ! I- 10 rern<vmim ; I : Pleura 23 IMcut j 3 9rtuivnxjm Vr,i,*<xeum Appendix opposite i r 2} Pleura 21 Plejra 22 Pleura JO Pleura 27 Peritoneum ' 26 Pet tioneum 21 Pkurj 29 Plcut J N1 M M M M M L MESOTHELIOMA OF PLEURA FOLLOWISC EXPOSURE TO ASBESTOS 267 V ;nk icrio 10 orit in con,.e in ciorr ^rotimity lo '..at iht r.jk of idoo b;ch o=y;jitionl and v. fctnc-*jsd othen tjo CTpcxt^e other ic ctnr.v ' * ubeuot ir asrc.3 rlijue* of tbe - p??cau>r. Iking near I'.itrd (Ki 'lu.^to, I960). ; -r, rvcrexrisk to the ufjCKiI cf atbestot .. i o.ci.i.-is, when :) OB. >: .hi.Te for i, :rc of:;.o :n hb < t*- "dS<>t C WUon, r jsrry. me Mr. C. If fJ Ur. C. P, - crr-'ns...n *.o ioter- ><..'.itjanrs 'v'hoeoi* . >..r.iftrc7''- of the . .c- tr ihtrr .-scottb; and to ^ f.c Or. W. `o the V *CMo c` S; e--n in * `h'rre- fo-m i-*.T;. M APPENDIX EIGHTY.THEE FATJEVTS WITH MESOTHEUAl. TUMOUES . ;; j~ IUkil Hi>ior> \ZZ* a | PlBl* ipoi ; It 1 11 i t*9J t*l* 1 K ll 1 Sacropey I<M1 Naeropef Km<~* Porilh. j *** lM7 j 1 '1 19S0 i |9St l 1931 Biopsy Nacrctpsy NscrooT B*otny poHiv< j N*A (,pu,ll<nl Po.Ui N-i-; Potilix S * (ptuun) ( t Brake liner. boiler go**rer, nbn* | lot (actor)'; mainly crocidoliic ) PiiintipMOf and other join, aab--es factfury: amoute. ernci- I doliiA chryioitk < twiatlt (lipe maker, 1 factory, Ctn<icJ avKot^tiv . 1 ly crooMtu ( Uid atbatto* boardin# m r-Uj> j carriage coo(ric(on | Aibmw fviv>, : Opmar and Mctumal r^or m^kvr, uNnnt factory, Ofitfettl avt>o> tock; tmoaac. crocidolfte, ebryv1- 1955 brncromr Pouuvt BMtpsjr Fmilivc j N"A j Upturn) } 1 I95J j Biopsy 1 ( NA . I (p*rtutnl 1954 j Necropsy 1 Pos**"* Ned*'*1** 1957 I BiW 1951 1 Bop*y N/A NA KA 1951 J NCrW Pe<tt pa*'ltv* j' Slpitewmr. nbc9tt factory. ccrtiUcd a , attantotk; mainly crocidolnc - Sactional pip* make*, ikbt^toi 3 ) factory.crntAcd abbotmt*c; mainly , ScprioflaMafM. atetbdloi fb.'iory, ceniliol 6 ubcaatk. mainly crocnSoluc OttMM|rter. i^bntci fcistr>; nuUrtd3 amwtr, erocdoliK. thowuW AlbCUM fr.ivcr, north E 1* Ciaihrdcaar.oiaftabcctvoirsyn factor) . mjml> It * Orio9hri<kfflitrand sNvtos It fbCiory: armnftr. cnodolDc. Petitiv-c.int 1 M pruf j i St y\ pkjia 1 f M p NA j'*;?1 1940 l i 19?* ] Biopsy I > I 1959 : 8<cp*> N7A ! Negative J Spau> : 1 ! i . :t925 1941 ! 1 t ) j 1959 j Nocrofn) j Negative ( Ne**tve j tv07 1921 j 1 , 1942 | EUofny | Bourne ] Negative J |'K)7 1924 ' 1942 I l 1P99 1923 j ^ PoutlS* ( 0 ' 1942 N'ec*or*y f Pcntm* I NcgMl"* i U j 194) ! feopsr ! Positive i6 ' 1962 j Necropsy ! Positive positive 1 2 II ? * ? 5 ? Fcihltevyrtmmilacker lur A R.P. m-skA. aAbcaioa factory; m*inV ciooFJioltelurc maker for A.R.P. avhotot (actor); nuirl) 4<4ite Liectrode c>cr. crociJoltir Sptntier, Abet<o factory. mainly croctdolitc Dcliveecd chcmKAlt to / factory; ammiic, croCHit'tot. 1 Scphinrynwerm, la* tbritu* factorym.nniy croodotnc i} Labourer. *erki and buildin*'. asbccoa factor): amotiic. v'iki* Pku' a M 11-99 1936 1 ! j | {J 1963 j Necrops) j Po*ilue j Negative JP Ifu * si Z1925 1 j1963 Necropsy j Positive Positive Pc*ii*nrum M in 1930 ' 1 27 1944 1 Necropsy j Positive Positive p<'.i.*ftA jrr M (917 1937 t 1 Wdoorikiue,dchirnyaoytaikrd of m^ul.mng 6 Ccaornduear,ctoatrbt cuot rectory; mjnly . crocadolite 24 Dittmefrater and nth.-r asbestos factory; ifrvnitc. crin;u dolitt, chryimik 23 1935 Nacropey ' N*ativ* r^ur- Vieu'J - M M |$74 lull till 1910 19.17 ' <> 22 : I9JJ Biopsy N/A 22 t 1959 Nocrckpey Positive NA Positive 1901 1 1922 1 " i 1961 M 1| 19*1 ' ay N/A ' N.A Powitv* SI 190S 1922 y* p,Mi'V;um P<cat PlCJl* M M 19U 1547 1912 1927 I91A , 1927 14 1961 Nacropn j Po*ni' 41 | w: Biopsi 34 1962 ! Rmhmi VA nfa Pemttve Na SA Worked in close prt#*mn> t* hokr repairer in dockvardt ' Boiler <kn*r md t(rt*er, \^u,u\24 9 ByoairkdrsCoirfcf and lagircr to (Efirramc*tifff and fiding cemM hutmg 25 Boiler coterer ji J pr< inhuiatof, 12 coott*ciirg ftrnt ' Lag#cr and btukr crsrre*, sjri(Hj\ 13 firms Intecnuicrt!) ho*kr Ufpc', i: p t InrenpaalliArsliktr -f ,icilu>ng 10 ZZ26L20J.S 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE APPENDIX ImW) EIGKTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS i'4 S x . ' rr. r> k - . 1 Dvr** i Vo,* *>en >CM of ^f Year c ' First Expo- of B tpo- urc Death tgrr t>c4rt Ho* Diasnosed i . i.m " f. T.-ur* I'r-rkr ver 4*i *U-J M IB.2 1*23 11 1*56 Biapfir 1 P.lho- Asbestos i logical | Bodies Evidence tn Lung of AjTissue , bcsiotls (a Lung Tissue N-A N/A U rCu-4 3* Peurs F i*:) 1*1* 2 l*J7 Biotay F IW 1*1* 41 1*60 tiomr \;a NVA N/A N/A JT fjua F 1*05 1*25 14 1*60 Biogty Six N/A 3? ^riiomeur F ir-o 1921 21 1*60 Necropsy Positive Negative 33 PCUTW F 1*16 It JO 4 1*61 Necropsy Negative Negative J* fnn M i*i* 1931 2 1*61 B*oiay N/A N/A j: Pcurw F 1*00 1*41 1*63 Biopsy N/A N/A m Peri4.:*wew. F i II** 1*12 It 1*6) i _ ow N/A N/A Survival from Initial Symptoms (mosikt) i Retesar: H .i.rs 21 Elder sitter oul u spinner it asbestos dird 1*46. certified ubniote 14 Elder sister cmr`.o)td si spec**. looked after patient i child 1) For several years husosod ssd" in ship*! engine room, d0* proximity la lagging operations J Husband sorted as boiler tovosr; overalls brought home for washing 24 Husband foremae and esecutnc asbcsios factory s Husband a docker; frequently handled 'white' asbestos it Elder abler worked u ir<*'Mr f< asbestos factory and suffers from tlbfUOiU It Daughter worked m sibe^mfactoO for S years; pa:tem washed he* overalls IS Husband ratla cjrrugc buddrr; lined consfwrxmrnii with stbmtc* sheeting; work clothes washed si home S> hhawrAs prf awi 44 PWvrw 41 Prwra 43 Hegra JO - Hewra 43 Prvr 4* Newrs M 7| P-CU*? 41 P.cura 4* PuD 4* *tu% 7F 19C5 1*1) 1*5* BMW N/A N/A 1 Lived witfaio | m:V of puKi site of asbatos factory* M l 1*22 14 i 1*60 Biopty N/A N/A 17 Lived withm | mJc of prwsewt site of asbestos Csctorv F IM9 1913 41 . 1*61 *oy Positive Negative IS Lived withta 100 >srds of proenl 1 F l*C3 1*00 * 1*61 Biop>r N/A N/A site of asbestos factory 1) Lived wtihio | mile of old trtc asbestos faaory F 1*03 i*i) 1) 1*61 Bttpty N/A N/A 4 Lived within | m:le of frotfl! of asbcsios factory F !*;? 1*17 10 1*61 Biopiy N/A N/A 16 Lived within 200 >ads of pi**1 tile of asbestos factory F IF** 1*07 4 1*62 Biopay Negative Negative 5 Lived withia f mile of old sne of asbestos facmo- F It*9 1*07 4 i*i Biotay N/A N/A 12 Lived within | rrulc of old *t* et asbestos factory F 1*00 1*1) 31 ;1 1*62 Biopsy N/A N/A 2* Lived within | m.U of present *4* of asbestos factory F l* 1*1) ^ i 1*62 *opy N7A N/A * Lived whh | rc.k of present u of asbestos factory F 1*73 1*1) 1*63 Biopay n;a N/A 7 Lived within J rr. le of prevent **tf of asbotos factory w. ,r .V* *I,TW r/rn. act i / Mhrrfm A t*fu: i * 1*00 V H-.t 4 feu*. " /e-v 1*"I M IV5 L 1 *' 4 It--t *rve -- l'4 t. Pe-n M ir 1*47 Necrorn> Positive Negative 1 PM 1*54 Necroni) Biopsy Negative NA Negative N/A 1*55 Biopsy NA N/A 1*73 Necropsy Negative 1*55 Necropsy Negative Negative Positive 7 Worked as nur*^-n.i^ tv maoigcr of gav work* n 1 .SI L isbevtin intjijti *n tr*r</ m v**r> 3 Shorthand-ivr*'* h.>u*cJ<- % lived tllofd area Baker's rotr.dvr*in. i*rv.v. graet** labourer. puhl*,jr. JO .'4t East End f* Lc* J-'" V Munitions *ork hr* re msfrags, then hou>c*il'. :..ed >4 al't^m n Abbey. Eaves Tailorcst and h uvc- f< m t-5i - End of London 21 Empkwed *t lu^r-ni- and greaKT. Beckton gas *.rii 36 >"" perstsient dvcK. m-% `g smut B tide of chest tv* <*.ng e*rr'-*^ 1*23. acute chr : -.iec:*on 1,3>. tubvequent ir *... t-Ij''.' deicnoralrJ f..-- I- . MESOTHELh ST0279223 Case No. S ic of Pr 'HUM 7. incur Srv 1 i P 61 Per iiirnm 1 M . I* 54 PWut j 74 Pleura 51 Pleura 66 Ple-jra M F il i jM jF 57 Peritoneum | M | 32 ritjrj 1 1 6) Plrjf. | 31 Pleura 3* i Plcwia ! 1 7) . Pleura 70 Pleura 72 Peritoneum 33 Pleur* 60 * Pe'itoneum v< M 67 ; Pleura 36 PU-ura 69 Periirneum F M F 33 P-eurj M f 1 nttjrrd 71 Pl.-jri 1 1) | Pleura |M II .l Ptcuri |M 0 ' Pifun Pleura 11 !1 M M 77 Peril.neum * 1 7* Pleura 1* 1' 1 r |- :i i\i; : EMa * nr. A -e: Ucury, <i~ w '** w*r<tyt; u - *J *.'ter jva- r.: ,.t ^ jtj- r-: *#llt m*. ' f;c \m ~ u Uq:'< rr-" - *offce <t ile - t m:u sri i: ij"*# fir valuing r,w .ircauj * - e\mvr* ar - 'jCSt^ . a dicar' l*qarm<)> h-Uf' 4*>r,'iO* v.wcr *of^ u immt re <* fa, or> ani suSms {< *orktd n 4. * 'an; pa^ea: raua xi*--ejc | T.pAimem r-ib * nt *ock cotAi*a m _ . `Ill IT> .*S 'cov ioAUr- . m :`.im i mic c,r v UJKry ; - -."lift }Oti >ar-y of : aibew.:* Ucto*-* . ->r. i nat* t'< set wy he ef f OUC *_` pim facto'* *.un 2ft.' of ` .iPCStaS fluToP" k . *.*' .m`jCiLS|fxmx a! ok I ot . *: *.'A t **< a * 9< ,7 . .> iA.v> - --*.m y ru p-m p| ffcCU^* ;! t true c*` pr -wv 4 . <vi;n rtu* e* 'fVwt t*ctcr< I of r. L *m--atur w-stf i.-Vl he ' I'ti rwr.^t f . K; . : Lor.^tr '" *r\c tc:' ?*- f*` X k^c . Itic; -nd b.iin Lx ndrm at i-uenar .urvd f <L*Cb.-|<'4 l*rin i ft. ' x*e>: '* - f ewgjsn-- __e cars x:i<ai Itf X, . T- ' Ak*i MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS APPENIKX (awM) EIGHTY.THREE PAT1ENT1 WITH MESOTMCUAL TUMOURS 269 ^ s or ^ Pnmar* e Pentoneam fir.: j > Pie.- Plr.-rf - Pte.j - Femone.m Fk.-a Pkw.'j Vle^ j e rie.'j Plrjfj - Pkc'j - Per cone _m r Ptc_'- ! Per.t'Vic tm Plr-rj Pkj*j Personr-m r Pk^j ,/ l atr. PIcitj c Pleura * Plr--'a . PhC^t . Pie.-j - Pcr.t.'nc .n -4 YW-J* ' ; Year Scs of | link ! M 1913 1 M 1904 1 1916 M 119) 1 IK9t M 1179 M 1(90 M 190* M 1910 M 1911 F HIT F I SKI F 1191 M 1181 M 1915 F 1*97 M 1912 F 1901 M 1(92 Dura- Year lioo of of Year First ipo of Eapo- sure Death sure (years How Dm#- aeeed 1931 tiovr " 1956 lir 1957 fiiopsy 1957 Biopsy I95S Biopsy 1951 mtoptf 1959 Biofnr 1960 iopty I960 Necropsy 1960 Nerov*f 1962 Nnwr 1 1962 R*of< 1962 1962 Necropsy 1962 Necropsy 1965 B,op*r i 196) (<o|I 1964 Nacrofwjr i 1964 Necropsy Aabevee Bodies to lareo Tane N/A NA NA NA NA S'A NA NA Kfun Poaitivt Nepatnw Nefatree NA Negative N1M NA NA Negauve Positive PshotlEL of A*in Lareg Taetre N/A N. A NA N7A N,*A N/A Si a N/A Ntpihv fouiw Nepthc Ncpthe N/A Hipiae Nepihs N/A N/A Nc^rtve Negative Survival from lartvai Symptoms (reoothe) Kttrrmi Hmofy i< Africa 19)^32, no definite evidence of COWm villi asbestos; suhte- liwHly smployed nri cratKlunMf boati Labourer and builder, final])- em ployed in tunnelling; lued m F.jvt End of London 19 Employed remaking r'd nek* in i Bow, prcvHitix cimunl <f v-ickv ih*i ascertained; loed I ju Cud of London ; i GllaieradgeWhl|a|nlcdfl,t4cmhjpuilifMcut '..IImmI 'Ik|h*fjMnfulK', 6 forked ** pnung nuwhmtM before marriage. then a> Ik>ui( tie until death: lived Cni End of London J Stereotyper and printer, load ortfinatty in East London, then moed to Ipiw icfc 12 Van boy, regular army, cutter and Kndcr; lived S.E. London and >penbam IK Bricklayer, cement worker, ptp-i- man; lived East End of London. moved lo Hainault, Eases in |vt| II Fitter and turner: lived principally V in East End of London Coloured S. African merchant tea man. stoker at plau factory; isible contact with asbevtov in rAfrica or at tea 10 Lived until rrumaie in Wales, then housekeeper in S.W. London 50 Machinist of celluloid colUiv. 1 housewife and canteen winker; lived East London 10 Machinist in hosiery trade, Notting ham, bousowife; moved to London 1900 j; Labourer, merchant vejm.it>, docker, carried only meal 54 |I Apprentice printer, barman, cook, and butcher. For 25 years before death lived Easi End of Ixvndon 1i Drcaanukcr and housewife; lived East End of London then Somerset 24 <i Steel erector, army, steel erector, 1 labourer and porter; lived East 1 End of London 42 | Employed as packer m pharma! eeutical firm for 12 years, then Housewife until death; lived m Dagenham 24 Fisherman, fireman, docker. 1915- 59 at Tilbury dockv, fireman and finally storekeeper; contact iih asbestos not probable ai Tilbu') docks; lived Tilbury area F 1,93 i M 1160 j i M IS77 j M 1VI l9) j F 19)0 | jF ; >:* i 1917 Necropsy i 1922 Necropsy Nefjtrvc 1925 Necropsy Negative 19)6 Necropsy Negative 1931 Necropsy Positive 1945 Necropsy Positive 1955 Necropsy Positive Pohicrvc ( 1N* i .Nc0Dc . Ncgstrvc Postivc Powtivc ( POVD ve Not traced Not traced Not traced N*H traced Not traced Not traced Not traced N'A (issue not ssaiUbk. ST0279224