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1., ind Mucntii -ittt oi Toluene. rieconccntrunun / Colour CA?mrt/r` 5wtB K, i7 11 i I i 4 ! : . 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 end Tropical Medicine (RECEIVED FOR PUBUCATTON FEBRUARY 11, 1^65) A series of 83 patients from the London Hospital with a diagnosis of mesothelioma confirmed by necropsy or biopsy has been studied for possible exposure to asbestos. The series consisted of 41 men and 42 women: 27 of the patients had peritoneal and 56 pieural tumours. The earliest death recorded was in 1917, but only 10 of the series died before 1950 and 40 (43%) between 1>60 and 1964. In 76 of the series full occupational and residential histories were obtained. Forty (52-6%) gave a history of occupational or domestic (living 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 < 0-001). None of the 17 suspected cases of mesothelioma, rejected on pathological t grounds, was found to have had any exposure to asbestos. There was also evidence that neighbour' } hood exposures may be important. Among those with no evidence of occupational or domestic i exposures. 30-6% of the mesothelioma patients and 7-6% of the in-patients with other diseases ! lived within half a mile of an asbestos factory (p < 0-01). Out of the 31 patients with occupational ; exposures only 10 were in jobs scheduled under the Asbestos Regulations of 1931. The interval ` between first exposure and the development of the terminal illness of mesothelioma ranged between I 6 and 55 years. 1 In 47 patients in the mesothelioma series, lung tissue or sputum was available for examination, j -. In 30 (62-5%), either asbestosis or asbestos bodies were present. i _Ia recent years, the association between exposure among the women, 25 had pleural and 17 peritoneal to asbestos dust and cancer of the lung and other tumours. snlignant neoplasms has been the subject of much The aim of this study has been to establish the watch (lading article, 1964). Wagner, Sleggs, and occupational histories of these patients and to trace Marchand (1960) described the occurrence of meso any other possible exposure to asbestos. There were thelioma of the pleura in those exposed to crocidolite four surviving patients at the outset of the investiga ttbestos in the mining districts of South Africa, and tion, but these have subsequently died. The earliest this has stimulated further studies of the occupa date of death in the series was 1917; 10 died before tional histories of patients suffering from this tumour 1950,33 between 1950 and 1959, and the remaining (Owen, 1964; Fowler, 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 ti&om mesothelioma had been diagnosed .at the dead before the age of 55 (Table l). London Hospital during the past 50 years. After camming the necropsy and biopsy specimens held Clinical Features nitbe pathology department, Hourihane (1964) con firmed a diagnosis of mesothelioma in 33 patients, The ward notes of 65 of the patients were available afwhom 41 were men and 42 women. Thirty-one of and give a picture of a disease with a consistent e men had pleural tumours and 10 peritoneal: symptomatology. Among those with pleural 261 t* Table 1 ACE AT DEATH OF 83 PATIENTS WITH MESOTHELUL TUMOURS , < 3J45."5- 6< - Mats No. 1 \ 7 ! 17 l 13 : .** 10 7 1 17-4 | . Femal# No. / 1 l4 6 14-3 * :i * 18 1 *19 1*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 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 L was always present terminally. The methods of treatment included pneumonectomy, decortication ot the lung, deep .t-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 oattenrs suffering from oleural mesothelioma died within one year of the onset of symptoms, a further third within two years, and only one patient survived for more than three years. The course of those with peritoneal tumours appeared to be equally rapid. Eight of the patients died within six months of the onset of symptoms. Scarce* 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 w. 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 hie 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 uu^r their maiden names'had been ascertained from >. tives) were identified without difficulty. The o . dates of employment of these IS patients ami ,, jobs they had done "ere obtained from the record , 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. F:-.interviews lasted for at ieast an hour. To recail c' ci of 30 or -U) years ago it was often necessary . explore the residential and occupational histone* ' 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 (he patients in the medical and surgical wards of the hospital durir.t the early summer of 1964 ('in-patient' series). Ea*. patient in the mesothelioma series who had bev traced was matched with an in-patient of the same sex boro in the same five-year period. As there was a dearth of male patients over 75 yean 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 (he hospital as cases of mesothelioma but in whom the diagnosis was subsequently rejected on pathological grounds by Hourihane (1964) ('rejected series'). A* it had proved extremely diffioiit to locate the rela tives of those who died before 1950, attempts we .' 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 years during which there might have been a substantial change both in the residential \ ^eas and social c: : .ondon Hospital. .as taken from tl jte of admission iSth the patients ir ' 'laces of residence x comparison wit Details of the ? cries are given in ^bout past domest ..ailable for sever '6, 40 (52-6%) gav jjmpared with on cries (Table 1). 1 -YPES OF EXPOSU *,TH vtESOTHEUO T>p* ut" E'ponir ;30l0>cd OBS *St 'jetery , Nfevccd coeds to fsc j Lortorrt odter *st | . StClQfl** t BoaUiort and lausn ' >Kk*n haadlrn* u ' CAT| ' Xo history of or * . 4ocMt ciposur ( UtWM y Tfowo** sspowss t ybMtivo hwoncs ia u cum of am ea tAB i*oIs. - ^statistically hig I'^fpOl). This res1 by the two groc [3ear of admiss "Significant diffe rio the occups _and those adm 'jcri&g the cor jnesothelioma; if the confirm' Save a history This differenc TX* 11-83; i life MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 263 .tas and social classes of patients attending the oadon Hospital. Thus, a third group of patients a taken from the hospital records matched by ite of admission as well as date of birth and sex ;th the patients in the mesothelioma series. Their ices of residence and occupations were extracted :r comparison with those of the in-patient series. Results Details of the 33 patients in the mesothelioma res are given m the Appendix. No information ,:ouc past domestic and occupational histories was ..ailabie for seven patients. Among the remaining j. 40152 6;) gave a history of exposure to asbestos .mpared with only nine (tl-8%) of the "in-patient* cries t Table 2). The difference in this proportion is T\BL 2 '|"-S OF EXPOSURE TO ASBESTOS OF ** PATIENTS iTH MESOTHELIOMA ANO 7A IN-PATIENTS W ITH OTHER OISEASES ...p of Exposure i Mesothelioma ; : Scon No. ; ; In-patientSeries No. 1 *, j( on otbestoa MCIOO .`<jrc4 <ods to factory factored it otner asbestos :tonc* :uuatort and litter* worked wunaiwiot * S 9 :so . j <3 : tOJ ; III 1 t[ i li i3 4 ! Si l : 13 lxm tunoiint uMm arto 0 --i j i :s So hutory of work or 1 domestic exposure to uoestot * 47-4 1 *r f"M-i Pottme tipotures to asbestos in mmotbeliOBii series r*tu ;ow<e iiuwia m la-psiieat mm: . * n it. * <<hi *Sr*n eiio of mtwhtliom comid Mt bo nad sad are emitted ttOB tbts table. statistically highly significant (** -- 27-11; p < WOO. 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 rejected patients in the mesothelioma group who died after 1950, 36 (50%) ' - confirmed and none of the 17 rejected cases history of exposure to asbestos (Table 3). Thi. difference is statistically highly significant i 1 83; p <0-001). Table 3 EXPOSURE TO ASBESTOS OF CONFIRMED ANO REJECTED CASES OF MESOTHELIOMA SURVIVING AFTER JANUARY 1930 1 Exposure positive , No work or domestic contact : foued | Uritraceii ' Diagnosis of Mesothelioma Coaftraed : Rejected 4 0 )5 16 i1 - It S3, t < 0-001 Mesothelioma Series Occupational Exposures,--There are details avail able for the IS mesothelioma patients who had worked at one asbestos factory which used crocidolite 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 elective), 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 showo 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 Tabu 4 JOBS OF |7* PATIENTS WITH MESOTHELIOMA EMPLOYED AT ONE ASBESTOS FACTORY Statutory Obligations Subien to regulations Not tubiect to regulations Job Male Spinning Carding Clothing and we*ving ObiMrgrMiag and opening 0 1 t 2 FQter mskiat for A.R_P. aiitfci Manufaettirioi ofpreformed pipe insula tion Manufacturing of brake )teicg Rubber com pounding General labourer 2 0 1 Female Material 4 Ooctdoiite 1 Crocidolite Croddolit*. 0 cbryioui*. estoaue Crocidolite. 1 chrysouk. aaotns 0 Crocidolite Croddolite 0 Crocidolite Crocidolite, f chryiouk Crocidolite. 0 chryiouk.. UBostte Eejployimot fetscerr ao available for oat female ptunt requiring medical supervision under the Asbestos 7able 5 Regulations (1931). DISEASE CROUPS OF PATIENTS IN THE IN-PATtEST 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 io 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 Diseaao Croup Cardiovascular MetaOOlie ftcueuio*ndotfcclial (including snaemiaei ' GtJtro-toutunal (excluding cancan) Respiratory (excluding cancers) AU neoplasms Older J No. of ' No. with 1 Psbcats ; Exposure t.s i Asbcstus 21 > 19 J j1 * l 1 3 1 l 1 11 l V i a power station, one installing hospital sterilizing Toui i re a equipment, and one installing central heating. All \ were consistently employed on this type of work for 1 more than 10 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 two men, whose relatives worked with asbestos, are of particular interest. The most usual asbestos, might have been exposed to asbestos 4-ist because they lived io the immediate vicinity of a.t asbestos factory. 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 One factory, where more than one-tifth of' :he mesothelioma patients were employed, opened 1913, having been situated nearer ..the centre London for the previous seven yean. There were yean and his wife brushed him down. The two men in this group, when boys of 3 or 9 years old, had sisters who were working at an asbestos factory. One three affected female patients living within half a mile of the factory during the time it was in produclion at its first site. When it opened they were 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 1943 when he worked as a loader children between i and 7 yean old. At the present site, there were eight patients living within a half mile radius of the factory. One man was bom 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 an : of groceries in the docks for five years (bur never on dusty cargoes) and then returntxi to sowing iron girders. He died in 1956 of a pleural mesothelioma. | remained in the same house until she died 43 year 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* series, one patient lived near the factory at its previous site and four others 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 lived near its present site. One patient was 22 years old when she moved into the neighbourhood in 1915. She disliked it and. when interviewed, complained impartially about the dust from the asbestos factory and the rats in the house. histories of handling asbestos cargoes from time to time throughout their working life. The diagnoses of these patients have been grouped into seven categories (Table 5). The patients with a Tabu 6 RESIDENCE OF PATIENTS WTTN NO OCCUPATIONAL C* DOMESTIC EXPOSURE TO ASBESTOS positive history ofexposure are scattered throughout the various diagnostic groups, and there is no indica Sew Lived Within l mU of Asbeatos factory Lived More Thao i 1 ouia freot ) Asbestos Factory i Toiai tion that exposure to asbestos could be related to the disease which had caused their admission. McwrMioflU No. , !! I % JO* no. i 23 | /. : *9-4 i J* Neighbourhood Exposures of Mesothelioma and la-paum In-patient Series.--The 36 patients with meso- 5 | 73 2 j ' 93 3 ; x - 7 SS. t < 0-01 Thus, among th : Jjmestic exposures t :atients in the mesc a the `in-patient* se: : h an asbestos facte : iifference in the pr ; dries who lived in ti * sad no other expc wr$nificant " 7 } Date of First Ext ; .a Mesothelioma Se ; -ad been exposed ived near the mair . of exposure varied :o over 50 years. : txposure and deal: i '.mean 37-5 years) ; mrken, where exi ` interval was shor ; poup living in th ; 'ictories, where 'qwest. Table 7 s - it first exposure a death in each grot DELATION BETWEf ! OP INTERVAL BE! | " Typo of Expesur* | Ftooey work t Ptximuc [ U(t*n tad lamiator > Una* ia neighbour\hood of factory Varied between dath showed 1* group of facto? jm. n in the oti f-Asbestos Bo IheUooia Series :.4hdioma serie joamination in i& certified as s ^tissue availabli Revealed the p &oth asbestos isbestosis wen md laggers. r asbestos bodi< MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 265 Thus, among those with no occupational or emetic exposures to asbestos, there are l 1 (30-6 %) rients in the mesothelioma series and five (7-6%) : the 'in-patient' series who lived within half a mile / an asbestos factory in the area (Table 6). The ,,fence in the proportion of patients in the two nes who lived in the vicinity of the factory and had i no other exposure to asbestos is statistically .^lificant (x3 * 7-S5; p < 0-01). - Date of First Exposure and Intern! Before Death - Mesothelioma Series.--Fifty-one men and women been exposed to asbestos, including those who .*d near the main asbestos factory. The duration ;exposure varied widely, ranging from two months *y<f The interval between the first ^rosure and death varied between 16 and 55 yean -.an 37-5 yean). Among the group of factory orkers, where exposure was probably heaviest, the .'.ervai was shortest. It was longest among the rcup living in the neighbourhood of the asbestos aories, where exposure to dust was probably Table 7 shows the mean age of each group .t i. xposure and the mean of the interval before ^ath in each group. Although the length of interval Table 7 ELATION BETWEEN TYPE OF EXPOSURE ANDLENGTH .`S INTERVAL BEFORE DEATH IN Jl PATIENTS IN MESOTHELIOMA SERIES Lung tissue was available in only four patients exposed either through relatives or by living in the neighbourhood of asbestos factories. In two, asbestos bodies were present in lung tissue but there was oo evidence of asbestosis. Table 8 EVIDENCE OF ASBESTOS BODIES OR ASBESTOSIS IN *7 CASES OF MESOTHELIOMA WITH LUNG TISSUE OR SPUTUM AVAILABLE FOR EXAMINATION History of) -ta | Asbestos \ Positive 1 Xesattvt ! Uiuraetd 1 Tots! ' Asbasosts or Asbestos Bodies Present Absent 6 4S 43 30 17 Lust Tissue act Avnl4bi i3 13 i) 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 sea, but his early history could not be established. There were three others in this group who had asbestos bodies in lung tissue without evidence of asbestosis. Of the seven patients whose histories could not be traced, three had asbestos bodies and histological evidence of asbestosis and one bad asbestosis alone. Type of Exposure Mean Ass at No. First Exposur* (years) .`-fleuc ->Oks sad insulators -TTBS ta RCSC&bOttf* bead of factory 23 f_l < u 225 17* t* SS Mesa Interval bet sen First Espotur* aad Dusts (years). 34 ii-9 3S-4 .AS* - {ratted between 29-4 and 43-6 yean, the mean age at } feath showed less variation; it was 50*6 yean in the igoup of factory worken and between 55 and 57 f jean in the other groups. j - Asbestos Bodies and Asbestosis la the Meso- | ttROoma Scries.--Of the 83 patients in the mesoielioraa series, lung tissue was available for semination in forty-three. In four other patients, UI certified as suffering from asbestosis, with no lung fesue available, examination of sputum during life totaled the presence of asbestos bodies (Table 8). V 'bestos bodies and histological evidence of A 's were found in 15 of the 24 factory worken &Ci$gen. A further five showed evidence of either ubestos bodies or asbestosis. Discussion In the mesothelioma series there are 25 patients in whom oo evidence of any exposure to asbestos could be found. A chief source of information was a history taken from a surviving relative. A surprisin Hiamount of Information was obtained, but in some 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 wontea at a large asoestoinactarv iarvsm 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 seems probable that among the remainder there were those who had had no exposure to asbestos. In the mesothelioma scries of patients, both inHiKtrial and nnr^.jndUStrial CXPOSUTea WCTC reCQgpized. Among the men the exposure was pre dominantly industrial; 21 worked in asbestos factories or as taggers, two were exposed at home; and one lived near the asbestos factory. Among the women only 10 worked in asbestos factories, and a j* ,\V f ** y . ' I a - * M, farther 17 had non-industrial exposures, seven in the likely than the mesothelioma series to work in con. home andJO living near asbestos factories. tact with asbestos or to live in closer proximity to There is no evidence that the patients with asbestos factories. peritoneal tumours differed in their type of exposure' (r There seems little doubt that the risk of mcs<% from the patients with pleural tumours. The propor I thclioma may arise from both occupational and tion of positive findings of asbestos bodies or \domestic exposures to asbestos. Wagner and others asbestosis was similar in both groups. A higher pro* desenoeo patients with no exposure other portion of women, particularly among the factory than living as a child in the vicinity of the asbestos workers, was affected by peritoneal tumours, but the mines. A high incidence of asbestos plaques of - .> difference between the sexes was not statistically pleura has been found in the population living significant. The recent increase in the number of patients diagnosed at the hospital may be partly due to an increased interest in mesothelial tumours and partly to the long interval between first exposure and development of the tumour. Those exposed between an anthophyllite mine in Finland fKiviluoto, 196<.-. More evidence is required of an increased risk to tru* population liviog in the neighbourhood of asbestos factories or other areas, such as dockyards, where asbestos is used in quantity. 1915 and 1925 might be expected to die from about NVe should like to thank Dr. D. O'B. Hounhans for 1950 onwards. Asbestos imports to the United Kingdom have mounted steeply since l932(Leathart, 1964) and its uses are more widely diversified in industry. The increasing proportion of the popuia* 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 ail were admitted to hospital during 1964. Neither of these groups could be interviewed without know ledge of the disease from which they were suffering. his co-operation and for making the results of h<> investigations available to us. Our thanks are also due to Professor C. 'ViUon. Professor V. \V. Dix. Dr. N. L. Rusby, and Mr. c; Flaveil, F.R.C.S.. of the London Hospital and Dr. C. ' Silver of Sl Matthew's Hospital for permission to view their patients; to the general pracutioners who laborated in this enquiry; to the managements of iiie asbestos factories for arranging access to their record*: to Miss Joan Walford for statistical assistance, and to Dr. i. C. Gilson. Professor R. S. F. Schilling, and Dr. SV. 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 m October 1964. end will be published in a shorter form in the proceedings of that conference. This could have led to bias with underreporting of exposure to asbestos in the in-patient series. How Riiuencu 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 ofmesothelial tumours. There was no evidence that, because of their more recent admission to hospital, the in-patient series was less Fowler. t. #. Sloper, J. C.. end Warner. E. C. (1964). Brit. mm. /.2.211. leading eruele 0964). Ibid.. 2. 202. Hounkase. D. O'B. (1964). Thorax. 19. 261. Kiriluoea, R. (I960). Act* radio!. {StockhX Sup*. 194. LeuklR.O. L.0964K Ocny. HUk. (Load). 16, 119. Owan,W. Giya U964). Bru.mtd.J.. 2.214.Wegner, i. C. Sleggh CA.,ud Meickaad, P. (I960). Brit. J. ittdmur. .We*., 17. 260. Cut No. Site of Primary Tumour Sex Stain A: Factory oorktr. 1 Pleura 'M 19 Peritoneum M IS Peritoneum j F 24 Pleura M 14 1 Peritoneum ` F 16 j Peritoneum 1 F 'i IJ Peritoneum j F U . Peritoneum | F 15 : Peritoneum j F 9 ! Peritoneum t F :i : Pleura 1N 12 1 Peritoneum , F j 5 l PmtMtum \ Peritoneum pleura . :jo i i 17 Peritoneum i Pleura Appendix opposite / MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 267 APPENDIX UCJITY.TimrC PATIENTS WITH moothcual tumours I Sir* of Piimarr Tumour Dura* Yt*r fIM Year of Ytsr Sts A< Rum of Bulk lEvp^i suit 0*aik ***** ______ : O.a*. noted Ashestao Bodies in loo* Tittut Path** tnrwal Evidence nf A* bcstOSit in kf Tittut Survival * from Initial Symptom* Imooihtl Relevant History t Pleura M 1901 1921 It 1911 | Positive *| Peritoneum M im 1919 22 1941 Necropey Povtrvc Positive 1 11 Prruaoevm t 1901 19a 3 1947 Positive HU u Pturt M lua 192* 12 1950 Neempty fwiliU Neastite ( u frrnnnetmi F iri 1917 4 I9M Kv'fi<f*)r Negative Negative Id Pcroocum r 19a 7 1951 NU 4 4 9 1} Peritoneum f tl Peritoneum r im 1913 ms 1917 3 1933 1 1933 Positire 'HU 13 Peritoneum t 9 Peritoneum r ( 21 Pleura M 1 n Ptruotvcum f 1 Penioncum M 7 Peritoneum M 1901 im in) 1911 1901 19ft 1919 19a 19)7 1927 1923 1940 !| 1933 HU 1 1934 Neernpvy Positive Negative 1 1957 2 1931 NU HU HU NU 20 1931 PositKm * 4 1951 NU HU 12 3 4 3 It It It 3 1 2 Pleura | 29 M 1923 1941 1/3 1939 Nt^ino Heaatire r 1907 1921 10 I9J9 Narepir Negative Negative Pleura r 1901 1924 1 1942 Biopsy Poiitim Negative Pleura M 1907 1942 10 1942 Positive 1 i Rfuinnm F IW 1923 1) 194) ! Positive Scplilt ! * Plmtra M 1199 19)4 2* 1943 Necropsy ; Pasture Pmtuve { J- a Pleura M 1901 1923 194). ! Positive Nrrttnt ) Ptriiootum M 1911 19)0 2 1943 VrosKT! Petiint Positive 1 i 4 Pwvtooeum M 1917 1937 27 I 1944 KcCTO0*r I Positive - I1 Positive Smtom 8: Lofxrrt mod iotmlmoot > 23 |PWu 1 Pleura i 21 j M 1174 | [ 1X9) M 19X3 ; 19)3 1910 ! 22 | .933 Nccropry Biopsy * He^irve NU Nesatne NU s PlctM 1 \ kl : 1921 1937 ! *s ' 1939 Nvcrorsy Positive Positive .14 ! Pleura , M - I0X 1 a 1 Pmtoocum ^ | M ; I90S 1922 1 1941 .99 1 1922 ! 1941 Biopsy HU Necropsy Postiire N/A Positive 24 ' Peritoneum 1 M ; 1911 C 1927 1 14 | 1941 WitfOfiT PesMne Positive )l ` Hcura 4 ' kl IS97 1914 j 41 1 1*42 N/A i N/A a Pleura . M 1912 1927 ' .14 1942 i*x*r N.A i N/A 1 11 7 4 4 3 7 t 4 24 12 24 9 23 13 13 Brahe liner, boiler comer. ilo* ins factory; mainly croenJolMo Dmmegrsinr tod other robs. ashestos factory; am^uc. erneo doliic. chrysosilc Sectional rre maker, athestoe factory, ccrttAcd avbestnsie: main* fy rroeulolite L'vnl avhevtn* hoarding in railnay Cirri*ft fnmincin>4 . Avhsiis fn'tia), y*h ninwt Oiener-aoU vevtnnwl rnr nuher. atoestos factory, certified atnes* love; amotne. crocadolMc. chrysa* tile Sfiirtocr, sshesuvs fitetetrv, crrtiAed ashesteiic: nvaioty croeidolitc Sccuooal rr* mahet. athesue factory, certified ashestove; mamly crocidolifc Sninocr, ashesim factory, certified avhcsioie: nwinlv crocidolite Divinietraior, avhesim lavtory; aoMiuic. craeidivlitc. chrysmile Ashesius miser, north Unjland asbestos factory Carder, athesiot factory; mainly crncMloiM* Oethtof and seavmu. asbestos faoory: amotne, crocidmuc. Chrysould Filter maker for A.R.P. masks. ashestos factory: mamly cie*f doliic Filler maker for A.R.P. masks. ashotod factory: mamly ooen doltta Electrode coverer: crocidoluc Spinner, asbestos factory; mainly erncidoine Delivered chemicals to asbesioa . factory; ammitc. croctdoiua. ChrysmiH Spinner, ashestm factory; mainly crnevdoliic Labourer, nevrks and building. asbestos factors-; amosiic, 000deitte. chrysotdc Worked m yard of msulatin( contractor* Carder, avhestoe factory; mainly croeui-eiitc Dttiniefrater and other jobs. asbestos factor*; amrxtic, croo* doiitc. Cftotovile Wnrked i dote pr.miiy 19 boiler repairer m dockvards Boiler deans and ttnpper. dock* vardl Boiter eovrrrr and latter to rarvota ! Erretm* and Atnnf central hcaiuvg | Boiler cm ever and pipe msulaior, . contracture Arm Uattcr and boner coverer, various Arms InicTiniiicutH- hotter Latter, thip repair* Installation of knpiial ttcriluuvf ctu'rmmt_______ __________ fil , !u ' }% . r'% &' * i I F*-' fc.Li;ST' Fr.V JfV. ' mr' Wyv'. 1%; E# F&: u. - "J- L'c. r Zt?r &-? # t.-Tei-'.. VtfTi. :*> I.V-. ili/t fc 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE MESOTh APPENDIX (nntiniudi EIGHTY-THREE PATIENTS WITH MES0THE1IAL TUMOURS Casa No. 1 Sit* of 1 Pnm*ry S*i Tumour | Oura-I Year tlOA ' Year of of ! Year of Pint E.teo-i of 8irth Expo sure ' Death sure (yarn j How Diagaosed Asbeetoe Bodies m Luog Tiuue Path logical Survival Evidence from of At- Initial bestosis Symptoms n Lung i months) Tissu* Relevant History Stcuem C- E.tposyet of rttauns jo i pleura : M 1912 1929 It : 1956 Biopsy N'A N/A 27 Elder sister worked a* spinner - 11 1 asbestos factory, died . - certified asbestotie J4 Pleura ; F 191J 1919 1957 Biopsy N'A N/A Elder sister employed as spinner looked atter patient as child 38 pleura ' F 1199 1919 41 : I960 Biopvr N'A N'A ts For Kveril yesrs husoaad worked 1 id ship a engiae room. aio> proximity to ugging operation* J7 Pleura F 1905 1925 14 ` I960 Biopsy N'A N'A 3 Husband worved as ooticr coherer- 1 overalls brought home tor washing !S Peritoneum F IS90 1921 21 I960 Seeropsy < Pewiv Negative 24 Hus&and foreman and execute* -t asbestos factory il Pleuta F 1916 1 1910 * ' 1961 Seoopsy 7 Husband t docker: frequently handled `white asoestos 39 Pleura M 1919 1929 2 1961 Biopsy N/A N'A IS Elder sister worsed as spinner * asbestos factory and suffers rr.-.n asbestosts il Pleura F 1 1900 i 1941 1 5 1963 Biopsy S/A N'A 19 Daughter worked ut asbestos i.uto*. tor 5 years; patient warned overalls 36 Peritoneum F 1119 1912 18 ' 1963 Biopsy n;a N'A 15 Hushand railway carriage build.-; i lined compartments uli stool - ii ; ; sheeting; work clothes warned ;. ! i` home 1 7. I 7. E 0 S Stctioa 0: .Veighbourhood e*ut M | Pleura 49 Pleura F ! 1905 1913 I 7 - 1939 Biopsy M 1922 1922 | 16 , 1960 Biopsy | N'A i N.'A N/A , N/A 42 Pleura JO Pleura 43 Pleura F 1919 19(3 | 49 1961 1 Positive Negative j F 1905 1909 I 6 1961 Biopsr 1 N/A N/A F 1905 1913 | 13 1961 Biopsy | N/A N/A 47 Pleura 64 Pleura F 1917 1917 [ 10 1961 Biopsy I N/A \ F 1999 1907 | 6 1962 Biopsy j N.'A Negative 7t Pleura F >999 1907 j 6 4| Plewa 45 Pleura F 1900 1913 | 32 i F 1900 1913 7 46 Pleura F 1907 1913 1 7 1 Smio* : ft* kutory oft*m*ct with **6ost*t 1962 Biopsy 1962 Biopsy 1962 Biopsy 1963 Biopey ____ i N,'A 1 N/A j N/A ] N/A J_______ WA N/A N/A N/A 9 Lived withio \ oil* of present sitt of asbestos tactory IT Lived within t nule of present sue of asbestos factory 13 Lived within 100 yards of present site of asbestos factory 13 Lived wittUB t mile of old sit* of asbestos factory Lived within 3 mil* of present sue of asbestos tactory 16 Lived within 200 yards of present site of asbestos factory 5 Lived within fr mil* of old sue asbestos factory 12 Lived wuhia t mile of old site . aibenoi factory =, Lived within > mil* of present site of asbestos factory 9 Lived wuhia fr nui* of present sue of asbestos factory 7 Lived within \ mi of present sit* of asbmtes factory 65 Pleura F 69 Feriwnw F 1900 1901 1947 nvopif Positive Negative 1954 Necropsy Negauve Wepsav* 7 Worked as fiamamasd to manager of gas works in East London: stbestoe insulalion used in works S Shorthand-typoi and haueewue; 49 Pleura M 1193 1954 Biopsy ^N/A N/A ? Baker's roundsman, army, general labourer. publican for 30 yean a 75 Pleura F 1999 1955 Biopsy N/A N/A ? KTi.MtiioQs work before marriage. then housewife: lived Waltham 74 Prritoocsim F 1909 1935 HiBopiy Negative Negative 27 Tailorau sad housewife in Ess: 62 Pleura M t999 1935 Necropsy Negative Positive 2S Employed as linemen and greaser. Beckton gaa works 36 years: perststsat discharging sinus * side of cheat toUowtng empyema 1923. acute chest infection 1953. subsequent thoracoplasty but deteriorated from this date i j! Cats ; NO. i* Site of Primary Tumour 1 ! Sea . : 61 ; Peritoneum . M 24 : Pleura *6 ; Pleura 1 a i Pleura 66 11 Pleura M F ; n | Peritoneum ( M ; R " Pleura jM 63 ' Pleura ; . 51 i Pleura ` 39 j Pleura !M : ! ; V !V U 1-.19 1 i 4 .* i.53 j Fleurs j j Pleura ; ji ; Ftmoneum i 1 | Pleura | | 1 F F F S teeni/eeeu* MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS APPENDIX (eemiinurii) EIGHTY-THREE PATIENTS WITH MESOTHELIAL TUMOURS 269 *i Sit* Of Primary 1 1 Dura*| Year ; non | j Sea | Year 1 of of | of 1 Fim ; E.tpot Year i of ' Wow Dias* 1 l | i 1 Psth^ 1 Asbestos i logical Bodies | Evidence 1 Survival from l io Lung i of As* ; Initial i Tamour Birth! ixpo! sure - Death' noted | Tissue ` bstosis j Symptoms i ! 1 sure ^yearsH i its Lung i ttaootflt) Tissue . Relevant History Peritoneum ' .St 191J I - Pleura Pleura ii M ; 1904 ' i f 1916 ' Pleura * Pleura Si :39i F 1391 1 Peritoneum i St 1379 ' : Pleura Pleura i * i Pleura Pleura o Pleura u 1390 1 M 1904 | l i M , 1910 | M < I9U i F 1387 P 1888 Peritoneum F tm 13 Pleura M 1888 * Peritoneum M 1913 S7 Pleura i* Pleura F 1*97 M 1912 Peritoneum * 1901 . i 53 Pleura M 1892 1953 Oiopjy | NA i 1936 S Biopsy 1937 Biopsy 1937 Biopsy 1938 Biopsy i N'A i n<a i ' N'A N'A N. A I N'A N' A N-A N'A I . . 1938 ' Biopsy N'A NA . 1939 Biopsy ' N'A N-'A I960 Biopsy ; N.'A . N-'A ! 1960 - Necropsy Negative . Negative I9C0 Necropsy Positive j Positive 1942 Necropsy Negative Negative mi Biopsy Negative Negative 1962 1962 1962 1963 1963 Biopay SfK N/A 1 Necropsy Negative ` Negative Necropsy \ Negative Negative 1 Biopay N/A N/A Veptr N/A N/A 1964 Necropsy Negative Ncgiiive 1964 Nsmopsy Positive Negative ; Merchant seaman, cargoes from S. Africa 1930-3 2. no definiter>tdenca of contact with asbestos: subse quently employed on crot<haancl boats 12 Labourer and builder. Anally aployed ia tunnelling; lived in East End of London 19 Employed remaking old tacks in Sow, previous content oftacks not ascertained: lived East End of London 11 Gsrags hand, chautfeur. mechanic; lived Wolverhampton and Epptng 6 Worked as printing maenmist before marriage, then as housewife until destn: lived East End of London Stereotype? md printer: lived originally w East London, men moved to Ipswich 12 Van boy. regular army, cutter and grinder: lived N.E. London and Dagenham 18 Bricklayer, cement worker, post* man; lived East End of London, moved to Hamauit. Esses in 19)1 18 Fitter and turner; lived principally m East End of London Coloured S. African merchant sea* ' man. stoker at glass factory; possible contact with asbestos in S. Africa or at sea 10 Lived until marnage ia Wales, then housekeeper in S.w. London JO Machinist of celluloid collars, housewife and canteen worker; lived East London to Machinist in hosiery trade. Notting* bam. housewife: moved to London I960 Labourer. merchant seaman, docker, earned only meat 34 Apprentice printer, barman, cook, and butcher. For 23 yean before death lived East End of London 29 Dressmaker and housewife: lived East End of London then Somerset 24 Steel erector, army, site! erector, labourer and port*; lived East End of London 42 Employed as packer ia pharma* ceuucal few for 12 yean, then housewife until death; lived in Dagenham 24 Fisherman, fireman, docker. 191^ 39 at Tilbury dock*, fireman and finally storekeeper: contact with asbestos oot probable at Tilbury docks; lived Tilbury area Loin* F; L'Htractd eases 78 Pleura 83 Pleura M 81 Pleura M 80 Pleura M 82 Pleura M 77 Peritoneum F n wura F 1193 I860 1877 1900 189} 1910 187! 1917 i Necropsy 4 1922 Necropsy Negauve 1923 Necropsy Negative 1934 Necropsy Newuve 1938 Necropsy Positive 194} Ncmopsy Pouuve 1933 Necropsy Positive Positive Negauve Negative N*t*uw Pouuve Positive Positive Not traced Not traced Not traced Not traced Not traced Not traced Not traced N/A " tissue not available. $*irb*ly. J. l, ) . and Miichcii -<r$ oi Tolwcn*. r!cdftcntrji.un ' Colour Chrmitn' It*. .nciwoflh. K t. .*7. j jrit. /. industr. Med1965, 22* 261. i ! 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 Phvsioiofy. London School of Hyjiene and Tropical Medicine (RECEIVED FOR PUBLICATION FEBRUARY 11, 3^65) A series of 83 patients from the London Hospital with a diagnosis of mesothelioma confirmed by necropsy or biopsy has been studied for possible exposure to asbestos. The series consisted of 41 men and 42 women; 27 of the patients had peritoneal and 56 pleural tumours. The earliest death recorded was in 1917, but only 10 of the series died before 1950 and 40 (48*;) between 1960 and 1964. In 76 of the series full occupational and residential histories were obtained. Forty (52-6%) gave a history of occupational or domestic (living 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 i diseases (p < 0-001). None of the 17 suspected cases of mesothelioma, rejected on pathological { grounds, was found to have had any exposure to asbestos. There was also evidence that neighbourj 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 j jived within half a mile of an asbestos factory (p < 0-01). Out of the 31 patients with occupational ! exposures only 10 were in jobs scheduled under the Asbestos Regulations of 1931. The interval ! between first exposure and the development of the terminal illness of mesothelioma ranged between | --J 6 and 55 years. I In 47 patients in the mesothelioma series, lung tissue or sputum was available for examination. 1 In 30 (62-5/{)* either asbestosis or asbestos bodies were present. ] -In recent years, the association between exposure } asbestos dust and cancer of the lung and other arelignam neoplasms has been the subject of much research (leading article, 1964). Wagner, Sleggs, and Maxchand (I960) described the occurrence of mescv tietioma of the pleura in those exposed to crocidoiite asbestos 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, Sloper, and Warner, 1964). ->Tbe present investigation concerns patients in ttom mesothelioma had been diagnosed .at the Undon Hospital during the past 50 years. After Oamining the necropsy and biopsy specimens held ft the pathology department, Hourihane (1964) con fined a diagnosis of mesothelioma in 83 patients, whom 41 were men and 42 women. Thirty-one of $e men had pleural tumours and 10 peritoneal; t: among the women, 25 had pleural and !7 peritoneal tumours. The aim of this study has been to establish the occupational histories of these patients and to trace any other possible exposure to asbestos. There were four surviving patients at the outset of the investiga tion, but these 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 past four and a half yean. The youngest patient died at the age of 33, and nearly half were dead before the age of 55 (Table l). Clinical Features 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 I' 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Taiiuc 1 patient, the notes had been returned to the loal areas !J ACE AT DEATH OF 5 FATITHTS WITH MESOTHEUAt. executive council of the National Health Service, TUMOURS where they were destroyed within a period of three Londi was t A* lyt.) <14 >}- <}33- Msk No.. 2 13 10 V. 4-9 n-t )* 34-4 n-t Female No. *; 1 24 t I4-) 21-4 ta 42-9 years. In one of the asbestos factories a file was kept with detailed records of all employees sinee it started in 1913. The names' of all patients wCrc checked with these files. Nine men and nine married women (after their maiden nam& had been ascertained from rela tives) were identified without difficulty. The ena Idatc < with place for ct tumours, the commonest presenting symptom was the rapid onset of extreme shonnes of breath due to the formation of a massive pleural efTusion. 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 wail were not uncommon, occurring either in previous operation scars or by direel invasion of the chet wall. The symptomatology of the peritoneal tumours was more varied. In some patients the pre 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 iasted for at least an hour. To recall events D scric aho avai 76. con seri v TV ; wi senting symptom was pain on defaccation or micturition.- Diffuse upper abdominal pain was very common, and swelling of the abdomen due to ascites was always present terminally. The methods of of 30 or 40 years ago it was often necessary in lexplore the residential and occupational histories of all members of the family. treatment included pneumonectomy, decortication of the lung, deep .r-ray therapy, instillation of radio active gold, and cytotoxic drugs. They were used Exposure to Asbestos in Three Croups of Patients Suffering from Other Diseases 0 alone or in combination but had little effect on the For comparison with the mesothelioma patients. E course of the disease. Half of the patients suffering three further groups of patients suffering from other - from pleural mesothelioma died within one year of diseases were investigated. { !' the onset of symptoms, a further third within two The first group was selected from the patients in. * years, and only one patient survived for more than the medical and surgical wards of (he hospital during } t three years. The course of those with peritoneal the early summer of 1964 {`in-patient* series). Each . tumours appeared to be equally rapid. Eight of the patient in the mesothelioma series who had been t patients died within six months of the -onset of traced was matched with an in-patient of the same i symptoms. . sex born in the same five-year period. As there was a dearth of male patients over 75 years of age in the Sourcesof Information on Occupation Residence hospital, a sample of six patients of this ace and older was taken from a neighbouring geriatric In addition to the ward notes, some of which gave hospital. good occupational histories, there were three other . The second group were those who had originally sourees of information: the patient's general practi been filed in the pathology department of the tioner; the records of an asbestos factory ir. the area: hospital as cases of mesothelioma but in whom the and personal interviews with patients .or their diagnosis was subsequently rejected on pathological j' surviving relatives. ' ' grounds by Hourihane (1964) ('rejected series*). As As a first step, general practitionerrwere circulated it had proved extremely difficult to locate the rela- j with an explanatory letter asking them to complete lives of those who died before 1950, attempts were a form giving details of the occupations of patients made only to trace the three survivors in this group and their immediate relatives. Within two months and the 14 who died after 1950. . 65% of the doctors had replied. In two cases a The in-patient series, already described, were all hitherto unknown exposure to asbestos was revealed: admitted to hospital in 1964. The patients with in others the name and address of a surviving relative mesothelioma were admitted to the same hospital were given, but in the majority the doctor was unable over a period of 47 years during which there might to give information because, on the death of the have been a substantial change both in the residential / ,,* A-V***"+mn mu-v-- wi t~*t Vir^ mviH am. MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO ASBESTOS 263, csi m$ and social classes of patients attending the a, llcndon Hospital. Thus, a third group of patients rtt 'ns taken front the hospital records matched by , ate of admission as well as date of birth and sea uh hh the patients in the mesothelioma series. Their in '.aces of residence and occupations were extracted ilh ^ ircomparison with those of the in-patient series. 'jcr :to- 1 Results aa I -. the | Details of the 83 patients in the mesothelioma rdv * tries arc given in the Appendix. No information 1 ifioui past domestic and occupational histories was the ' nailable for seven patients. Among the remaining cv * 74, tQ (52-6 %) gave a history of exposure to asbestos of ompared with only nine (11*8%) of the `in-patient* at <ehes (Table 2). The difference in this proportion is of the net The rm to Tabu 2 rrrts ok i^xrosuRE to ashrstos of rvnt-NTS vrw MESOTHELIOMA AND 7A IN-PATIENTS WITH OTHER DISEASES nf Tyre cC Etpoaur* Mvnx)>oma ! ` Sctia j *1n.ptit' ' S<ra0 - iaNn*v.l at ont atOatm Cmon* orrfti o factory No. '!) * 23*0 No. > % 1*3 m*,v her s in ring aeh cvn :me was me anj .me (n>trmS a wiw umia lactone* RwHioh lateen tflatn ch >.-U tK aaAcmm Drum hardline uneunt ctrfo fimory of wk "f >mimn rapouire to afcotoi 4 * * 0 J* 3.-J IO-S lit 1 t * I a 47*4 47 1*3 5*3 1-3 2*4 112 InKni cipeatirci 10 I'OrMOl in mnoiMlima una 'tnui (ant trmvffjA uvmhoh uns; < r* 27*11, r < O-OOt |7 *Ve C3W5 or moAihtlKwn* couM noI b* iracrO ao4 arc omitted ! tfe* taOtc. 3v *hc j!! aatisiically highly significant (jf1 * 27*11: R < te :icai Av eta* verr oup r all with ?ital light attal * O-OOi). This result is unlikely to be unduly influenced i by the two groups of patients not being matched for ' jar of admission to hospital, since there was no yjnificani difference either in the areas of residence or in the occupations of the patients admitted in 1964 ind those admitted between 1917 and 1964. Com paring the confirmed and rejected patients in the mesothelioma group who died after 1950, 36 (50%) a of the confirmed and none of the 17 rejected cases 1 pve a history of exposure to asbestos (Table 3). * This difference is statistically highly signiflamt (r- 11-83; * < 0-001). ., Table 3 , EXPOSURE TO ASni'-STOS OF CONFIRMED AN REJECTED cases of mesothelioma surviving after January - - .. tvso Dia|itm>t ot Mcaoihclwwno CMlitlNlI ^R*K*U rotim* e No *rk or imam ermtao (nmm* . 33 14 . Unmet* > i ti*>. r : omi ' Mesothelioma Scries 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 amositc in 1926. Eleven started work before 1933 (the year when the asbestos regula tions controlling the manufacture of asbestos goods and the protection or 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 are shown in Table 4. AH of the 17 for whom details were available had used crocidoiite asbestos. Five of the occupations listed are not scheduled as ' Tau 4 JOBS OF 17* PATIENTS WITH MESOTHELIOMA EMPLOYED at one asbestos factory Sfsivtot? 0k>CstMMa Sobfcci to rflwiSIKMU Not aubivet to tetuliuo** Jo* Mai* SpiAAHR CirOn<c Ooifiinc -cavmf Od4Afr<(in( A0op<niA| 0 t 2 Filter makint for a.R^. masAa Marntfaeturinc of pfcfortnn |Hf IA4tlU> (Of) XVonwfseturma of br4 luwOfO RuhNr itwo. rwwAduig Gmcral laboow 2 0 F*fi* Material 4 CaecidMitc 1 CrncidoUtc CroeSOeliic. .0 Chryrwttil*. immif CrocMoiitc. 1- chryttttJi. ameow 0 Crootfoiitc Croc*otit 9 Cfoctdfkiiat CrrwiUoin*. corjAeoi* Crr;idftl>t. 0 CkrpnMc, *>! mploy<*>em hnxwy wot available fo* w frmal* pai<*nc i TTW--T I: 3n rs . tv.- 5* n?rr& ftktr. & | * 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 arc not known. The eight heating engineers and loggers were all men. Three had been employed in dockyards on ship repairs, two in various types of laggings one in a power station, one installing hospital sterilizing equipment, and one installing central heating. AH 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 giris worked as a spinner from 1925 to 1936. Jn 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 relumed to sawing iron girders. He died in 1956 of a pleural mesothelioma. Jo-patient Series Occupational and Domestic Exposures.--Tw.o oI this series had worked in asbestos factories and four .sad been employed as loggers. The husband of another was employed at an asbestos factory for three years, and two dockers in this croup gave histories of handling asbestos cargoes from time to time throughout their working life. The diagnoses of these patients have been grouped into seven categories (Table 5). The patients with a positive history of exposure are scattered throughout the various diagnostic groups, and there is no indica tion that exposure to asbestos could be related to the disease which had caused their admission. Neighbourhood Exposures of Mesothelioma and In-patient Scries.--The 36 patients with meso- ` Tjwu i DISEASE -- CROUPS or . Oituu Grew)* rATJf.NTS SERIES - IN THE Hf>. of NiKMt tN.PATlt*T -- No. Hk A&bCM** C*rdir>culr Mciikolit Rcsm,ii%>n4r>Hel<at (mciudmt iiutnai) G*tifO->ntcMin*l (deluding (iMBl) Rcipirsiory (cteiudmt catn) All ncopUtm* Oibcr * at 9 J 0 t aa Je IS i tl H ----1 Total IS 9 f ; ( I thclioma and the 67 patients in the 'in-patient* \ scries, who had neither an occupational exposure t nor n relative living in the home working with ; asbestos.'might have hern exposed to asbestos Just ' because they lived in the immediate vicinity of an ' asbestos factory. -j One factory, where more than one-fifth of the i 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 wets in produc- * tion at its first site. When it opened they were . children between 5 and 7 years old. At the present site, there were eight patients living within a half mile radius of the factory. One man was born within a quarter of a mile of the factory and remained at . the same address for 16 years. The other seven were f women, and alt except one were children when the ' factory opened. The seventh was 23 yean of age and j remained in the same house until she died 48 years . later. She is the only patient who had neither J occupational nor household exposure but in whom * asbestos bodies were found in the iungs at necropsy. Among the `in-patient' series, one patient lived ' near the factory at its previous site and four others i lived near its present site. One patient was 22 years [ old when she moved into the neighbourhood in 1915. j She disliked it and. when interviewed, complained r impartially about the dust from the asbestos factory j and the rats in the house. 'l Ta*u 6 ( REStOENCE OR PATIENTS wrTw NO OCCXJRATtONAU OR DOMESTIC EXPOSURE TO ASBESTOS UxMS 1 nvitr of Fwtwr Ux4 Miwi Than 1 mile from AimiM Factory NO. | " * - k*. j 2S I r. i-4 12 3 r* ? *j. ir < o ot TmaJ J* -* -- -" - - -- . ' /'f?*-1-- ,, (t N' t* * -.'v* w y <--, .. -i\ - - -- ------ - ---------- --4^* . -v x a - - . ; oT- '- / MESOTHELIOMA OF PLEURA FOLLOWING EXPOSURE TO aTII.hi h . -Thus, among those with no occupational or ' domestic exposures to asbestos, there arc 1) (30*6*0 1 patients in the mesothelioma series ami five (7*6/0 / tn the 'in-patient* series who lived within half a mile ; of an asbestos factory, in the area (Table 6). The difference in the proportion of patients in the two teries who lived in the vicinity of the factory and had bd no -other exposure to asbestos is statistically tignificam (jf 7*85; * < 0*01). . patient* tposure >g with os dust i of in of the :ned in r.ue of re were half a jroduc* .y were present a half- ithin cd at tn were hen the <* - whom eropsy. it lived others 12 years in 1915. plained factory Date of First Exposure and interval Before Death a Mesothelioma Series.--Fifty-one men and women j had been exposed to asbestos, including chose who fived near the main asbestos factory. The duration i of exposure varied widely, ranging from two months I to over 30 years. The interval between the first exposure and death varied between 16 and S3 yean (mean 37*5 years). Among the group of factory workers, where exposure was probably heaviest, the ] interval was shortest. It was longest among the group living in the neighbourhood of the asbestos t factories, where exposure to dust was probably lowest. Table 7 shows the mean age of each group j at first exposure and the mean of the interval before . death in each group. Although the length of interval Table? ' tELATION BETWEEN TYPE OF EXPOSURE AN LENGTH or interval before death in si patients in MESOTHELIOMA SERIES - ! Mean Age ( j Type of Expontra No. Tint Eimuit Uon) ) * Factory work 23 *j Dnntessie Utter* and r*gIatol 9 t. 1 Lem* in neighbour . hood of factory 11 32-3 17-9 13-4 ti Mean Interval between Fir* ape*ur and Death (rears) 23-* 37** 3**4 *14 varied between 29*4 and 48*6 years, the mean age at death showed Jess variation pit was 50*6 years in the group of factory workers and between 55 and 57 years in the other groups. Al * -- . T*"* ^" ------ --. 1 Asbestos Bodies and Asbestosis is the Meso' thelioma Scries.--Of the 83 patients in the meso- thelioma series, lung tissue was available for i examination in forty-three. In four other patients, all certified as suffering from asbestosis. with no lung tissue availab/e, examination of sputum during li/e revealed the presence of asbestos bodies (Table 8). t Doth asbestos bodies and histological evidence of ' asbestosis were found in 15 of the 24 factory workers and laggcrs. A- further five showed evidence of either 4 asbestos bodies or asbestosis. Lung tissue was available in only four patients exposed cither through relatives or by living in the neighbourhood of asbestos factories. In two, asbestos bodies were present in lung tissue but there was no evidence of asbestosis. , . Table 8 EVIDENCE OF ASBESTOS BOOIES OR ASBESTOSIS IN 47 CASES OF MESOTHELIOMA WITH LUNG TISSUE OR SPUTUM AVAILAULE TOR EXAMINATION Hitler; ef Contact with Atbetioe Fotitrve Kcsaiivc Untraccd Total Aibc*to*n or Aibeiet Bodie* Finest AtofM ^ 23 4 4* 43 17 Lung THmc not Available 23 13 0 34 Among the 12 patients in whom no definite contact with asbestos could be established, there was one, a merchant seaman from South Afriea, 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 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. Discussion ' In the mesothelioma series there are 25 patients in whom no evidence of any exposure to asbestos could be found. A chief source of information was a history taken from a surviving relative. A surprising amount 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 example, one of the patients was eventually identified as having worked at a large asbestos factory for two months in 1941. This was bcfc'.e 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 seems probable that among the remainder 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 the men the exposure was pre dominantly industrial; 22 worked in asbestos factories or as laggen. two were exposed at home, and one lived near the asbestos factory. Among the women only 10 worked in asbestos factories, and a I f I / X 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE further 17 hud non-industrial exposures, seven in the home and 10 living near asbestos factories. There is no evidence (hat the patients with peritoneal tumours differed in their type of exposure from (he 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 afTcctcd by pcritoneal 'tumburs, 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 mesothdial tumours and partly to the long interval between first exposure and development of the tumour. Those exposed between 1915 and 1922 might be expected to die from about 1950 onwards. Asbestos imports to the United Kingdom have mounted steeply since 1932 (Lcathart, 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 mcsothclial 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 mesothdioma 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 mesothdial tumours. There was no evidence that, because of their more recent admission to hospital, the in-patient series was less likely than the mesothelioma scries to work in con tact with asbestos or to live in closer proximity to asbestos factories. There seems little doubt that the risk of moo- thclioma may arise from both occupational and domestic exposures to asbestos. Wagner and othen (I960) described patients with rvo exposure othe than living as a child in the vicinity of the asbestos mines. A high incidence of asbestos plaques of the pleura has bpen found in the population living near an anthophyllite mine in Finland (Kiviluoto. 19601. More eviden^p 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. . I \V< should like to thank-!7r. 17. O'H. Hourthane for | his co-operation and for making the resolts of ha investigations available to us. Our thanks are also due to Professor C. Wilson, Professor V. W. Dtx, Or. N. U Rusby, and Mr. G. Flavell, F.R.C.S- of the London Hospital and Dr. C P. Silver of St. Matthew's Hospital for permission to interview.their patients: to the general practitioner* who col laborated in this enquiry: to the managements of !lr asbestos factories for arranging accns to their records; to Miss Joan Walford for statistical assistance, and to , 1 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 w-ill be published in a shorter form { in the proceedings of that conference. | References ^ Fowtcr. t. B. S.. Sapper. J. C. and W*rn*r, & C. (1964X Snr. m>4. t Lradtflf article (I9M). Ihid^ a 202. II.KinUM. O. O'S. 7W.t. 19. 26*. ft. (19*01. Ana radjoJ. (Sinri*.). SuOOl. 194. Lcslfurt. C. L. (19*41. Oeryp. Mhh, IS. 119. 0cn. W. Cl* (19W). frw. imdJ.. 2.214. Wj*n*T, J. C-- Slctgv C. A_ And Marctattd, F. (19*0). . imdujtr. >1.260. few. 1. ' , I | j | MuiCUfiUi 3 V Appendix opposite 7 % f.** . % ' /* r *: U / MESOTHELIOMA Of PLEURA FOLLOWING EXPOSURE TO ASBESTOS 267 APPENDIX EIGHTY-THRFE PATIENTS WITH MCSOTIIEUAL. TUMOURS Path^ t Site pf Yit* IMA Year et Year Hr* -Avhrstea Inteal Survival Bodies Evidence from 9. Primary Sci of Fi*tl EipA* of Diag in Lung nf As- Initial 1 7umowf Birth E*r* ftV'f Death tur. 7can) nosed Tissue bestosit Syntpi omt in Lung (months! Tittue Relevant Hruory f rri-- <4; FmtiBty v 1 Pleura M 1901 1921 17 1938 Neerorup Positive Positive 1 17 Peritoneum 1I9S 1919 22 194| Necropsy Powtrve Positive It Peritoneum f : Pleura f u Peritoneum V 1901 1923 3 1947 Biopsy Petitive N/A (sputum) 192* >* 1930 Necropsy Pmii i<e Negative im 1917 1951 No-nipt)' Negative Nrcimr A * A 9 A Brake liner, boiler eovetcr, tthrv tot factory; mainly erncidnitte Disintegrator ind other jobs. ashmtot factory; amgsne, erne* dnlitc. ehrysotile Sectional pipe maker, asbestos factory, certified asbcsimic: maim 1y crncidoiMe Used avhevtrw hoarding in railnay car*tae . Avhsiis liKItVt, pdv niilvis* it Peritoneum F % o Peritoneum F n Peritoneum F 1900 1922 im 1913 1I9J 1917 * 1951 Biot*y Positive N/A (sputum) 3 1953 Necropsy Positive Positive 1 1933 Biepty Positive * N/A IS Peritoneum F 1 9 Peritoneum F f 21 Pleura M 12 Peritoneum F S Pemencum 61 1901 1097 1193 1911 I90t 1918 1919 I92S 1937 1927 >i 1933 Positive N/A fspnttmA t 1956 Neeropty Positive Negative i 1957 N/A N/A 1951 Biepty NfA N/A 30 1931 Neeropty Positive Positive 7 Peritoneum M 1923 1940 4 195S Biopty N/A N/A 1 1 2 Pleura M 1923 1941 1/6 1939 Biepty Negative Negative J 2D Peritoneum F 1907 1921 to 1959 Neeropty Negative Negative A Opener-and ui'ImuI pipe sulo. ttfietos factory, certified ashes* iamc; amesne, ereodAinc. chryso. tile 12 Spinner, asbestos factors. certified asbevietic; mamiv croctdolttc 3 Sectional pipe maker, ashestcu factory, certified ashest otic; mainly erocidnine 6 Spmner. ashevim factory, certified avhestntn;: nwmlv crncKpdiic 3 Disinteerainr. phoim tusinry; immiic. ciKMji'iitC. chrysmde It Asbestos oMsce. north England asbestos factory It Carder, asbestos factory; mainly crocidelite It Clothing and vcaving, asbestos factory; amoiitc. crocidnliit. chrytettle 3 Filter maker for A.R.P. masks. asbestos factory; mainly crocs* doliic 11 Filter maker for A.R.P. masks. asbeios factory; mainly eroc Oolite 7 Electrode covercr: ereeidolitc Pleura F 1900 1924 1 192 Biopty Positive Negative Pleura M 1907 I' i 10 Peninncum F 1899 1 Ploun M 1199 i 23 Pleura M 1901 3 Ptoioncum M 1911 4 P*mioneum M 1917 ! jmm B: Ltfffn innr/ai^ > 23 | Pleura 4 3 Pfevra 61 1874 j| iM 1893 PWur f 61 j 1921 .30 ! Pleura . 61 ' 1908 27 1 Potionswm ^ M ' 1908 1 26 . Pvruorwvm < 61 : 1911 % 51 rtm 29 Pleura * 61 ^ 61 1197 1912 1942 10 1962 Neoopty Petitive 1923 1936 1923 1930 1937 U 1963 Biopty positive ' 26 1963 Ncvopty ; Positive s 1- A 1963. Nepers'.' ' Positive 2 1963 Necreery 1 Positive I 27 1964 Nccrop*r 1 Petmve |1 - 11U ; 53 1933 1910 t - 1933 1937 ! 1939 1922 i Jf 1 1961 1922 36 1961 1 1927 1 34 t 1961 1 1916 , 41 j l62 1927 ' .14 1962 Nceroguy Biopsy Necropsy Biopsy Nctrff*rf Necropsy Butpsy 8*opry Nc^uvu N/A Positive N/A Positive PosHtve N/A HA Positive Negative Positive Negative Positive Positive Negative i N/A j F914mt | N/A | Positive j Pcnitrvu j N,A | N/A j A A 3 7 1 6 24 12 24 9 23 12 13 t 10 Spinner, asbestos factory; mainly crncidolnc Delivered chemicals to asbestos . factory: amoutc. crocidolttc. Chrysolite Spinner. sxHcstot factory; nvainiv crneislolitc Labourer, sorts and buildings. asbestos factors-; amositc. croo* doine. chrv-vMite Worked in sard of insulating contract Carder, avbestot factory; maintv erectdoiitc Disintegrator and other jota. asbestos faetorv; amoutc, croo* doiitc. chrysoule Wnrked in dene prostmity to boiler repairer in doewurdt Bmier cleaner and stripper, dock* vardi Boir eowm end bftef t* v*no*m Ertctmg and fitting central heating Boiicr envreer and pipe insulator. contracting firm Lacgcr and better etnrrrr, various Arms Intermittently hotter tagger, ship ImulbiiAA of bnHuf M<nlaiA| I /V.1 ' ' rv' 'J* r*;,-.V'\x t ;-f-:-V'- t it Kr . EftK&r. i. Lf:rj.<~ HP py.- CfeJ>f`cVr** r^J t. r'-fi-Y s&z* . i'-* :V.*2 f* J-f.s sl';> * v-ri.j -Zi c?m& ,?Vj ES?r /y<t --liy ia 'a: ^rT rv-]; 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Afrf.NOJX l'MMwrt`1 CICWTY-TMRCE TATINTS WITH MUXOTHCUAL TUMOURS Cam Nu. Primary Tumour * Our> Yof non Year M ef Year Sea of Ftrsl E*ro Ot Birth Espo- Ittfc Death iv> [years) - -- Host Dtaf nosed Asbestos Andies in Lun( Tissue fathm logical Evidence nf Ay. hesiosii in lung Tissue Suriita) from Initial Swnpinirn (months) Relevant History Sretio* C. Ejpemtr */ reJattma ` 40 Flews M ten 1923 It 193* Biopsy N/A NfA . 27 Elder titter worked at spinn asbestos factory. died . 34 Pleura 33 Pleura F 191) 1919 2 1957 Biopsy N/A F ms 1919 41 19*0 Biepsr N.'A N'A NfA certified asbctioctc (4 Elder sister emolojed at *f leaked after patient as child 13 For ic'eial years husband in ship's n>tiM f.wxm. prnsimity 10 Ukiiai "rrnn 37 Pleura F 190$ I92S 14 IhhO Biopsy NfA N'A J llusNahd wmkrd as hmser <r nseiatls humthi home (to * is Fernnnevm F 1390 1921 21 19*0 , Necropsy Pivsathid Nrealise 2* llwban<J fmeman and eseeu 33 Pleura F 191* 1934 4 19*1 Necropsy Neyatrue Neyativt * atbriio factory Husband a decker*, frea handled 'white' a'boioi 39 Pleura M 1919 1923 2 19*1 Biopsy NfA NfA 13 Elder sixer worked as arm asbestos factory and iufle** Mbninn *. 32 Pleura F 1900 1941 S 1963 Bmpsy N/A NfA 11 Daughter workedinavbesto* for S years; patient wain oseraite . 36 Peritoneum F 1339 1912 it >963 Biopsy N/A NfA IS UiKhand railway camuge * lined cooscsarifoersis nh a sheeting; work clothes wa home Smio D: A'rif**<wfJ c nrt 44 pleura F 1905 1913 7 1939 Biopsy N/A N/A a Pleura M 1922 1922 1* I960 Biopsy NiA N/A 42 Pleura F 1339 *1913 43. 1961 Biopsy Positive . Ncjiitve SO Pleura F 1903 1903 * 19*1 Biopsy N/A NfA 43 Pleura * 47 pleura F 190$ 1913 13 1961 Biopsy N/A F 1917 1917 10 mi 8iorsy NfA N/A NfA *4 Pleura 71 Pleura F . 1399 1907 F 099 1907 * I92 Biopsy 1962 Biopsy Negative NfA Ncgamd NfA 41 Pleura F 1900 1913 32 >962 Biopsy N/A N/A 43 Pleufa_ F .1900 1913 7 1962 Biopsy NfA NfA 4* Pleura F 1907 1913 7 $mi .- A'# fuworj / i*#mrt vn* tubesin* 43 Pleura F 1900 1*63 i. 1947 Biomy ` Necropsy NfA Positive NfA Negative 63 Peritoneum F 1902 49 Pleura M 1393 1934 I9S4 Necropsy Biopsy Nctaitvt NfA Negative NfA 73 Pleura F 1199 1935 Biopsy N/A NfA 74 ' Peritoneum F 1904 63 Pleura M 1399 1933 1733 Neeropsy Negative Necropsy Ncaatisc Negative Positive 3 Lived within * mile of pre* of asbestos factory 17 Lived anhm J mile of pre of asbestos factory 13 Lived nhin 100 yards o< site of asbestos factory 13 Lived within l mile of ol. asbestos factory 4 Lived within 1 mile of on of asbestos factory >4 Lived within 200 yards o site of asbestos factory S Lived >inii f mile &f uairiestos factory 12 Lived within j mile ef o asbestos factory 29 Lord ithio ; mile of p* of asoestos factory 9 L/sed within f mile of p* of asbestos factors 7 Lived *uhm * mile of p of asbestos factory 7. | Worked at nursemaid >r of (as works m East Iasbestos insulation ue< . . Shoethandxypisi and lived tlfnrd area Baker's roundsman, snr labourer, publican for East End of London Munitions wore before then housewife: lisee Abbey. Esses 27 | Tailoreia and houses n End of Lonoon 5# 1 Employed as luteman a {Section cot w oi kt porstsieni dischatgint side of cheat (oHv*m 1913. acvtc chest mf. subsequent iMritm deicrinraird from th.> ySQTHCUOMA OF FLlUFa /vuu-.-w ....... ............ appp-noix <<<wi ttCHTY-THAEC PATIENTS WITH MESOTHCLIAL TUMOUKS --. 1 j'-** Ml Year Year Set Fun C*W- of Hn 0.f ** OUf Epo*l ure Death note* ture |(ycar*1 Aeheciot UAdiC* n Lung Tivtuc Path forxal Evidence of At* bttieN n Lung Tiuue Survival from Inmel lympinmt (months/ Relevant Hrttoty "J Peritoneum M I9IJ pleura Pleura M IPO* F 191* l Pleura Pleura M 1191 F mi .7 Perotwum M 1179 Pleura M 1190 1) M 190* J> Pleura Pleura M 1910 M 1911 Pleura Pleura F 1*67 F III* 72 Peritoneum F vr* M mi . iicncum M 1913 *7 . *uf Pleura F 1*97 fcf 1912 Periinnewm F 1901 n Pleura M 1*92 1953 Wiorny '1 , * 1936 Hiopvy j 1937 8omr N1A N/A N/A N/A N/A N/A X 12 >9 l ; i . \ ! i 1 1957 1996 Bi<mr 0icr*r N/A N/A N/A N/A tl 6 1936 Biopsy N/A N/A 1999 1960 Bioper Sippiy N/A N/A N/A N/A 1960 1960 Necropsy Negative Nccrogcy Povkiv* Negative Positive .3 >2 16 16 1962 )962 Neernpvy Negative Biopey N*ativa Neptive Neptivc 1962 lieyiT N/A N/A 1962 1962 Neeromy Nrpiiie Neoopty Ktpu Negative Negate 1963 1963 1964 Bvopey Siopay Nccropey N/A N?A ' Negative N/A na Negative 10 30 10 3 34 29 24 42 1964 Neooety Poutive Negative 24 Merchant veaman. eargnev front 8. Africa 19.tO>32 no definite evidence of contact with ivbevtm; ulg*** duently employed on <mv<haoe< boat* - taPou'cr and builder. Anally cm* ployed m tunnelling; lived in OAl End of London Employed remaking old tacLa m Son. prcvmwt content of tack* not txcnained: lived a*i End of London Garage hand, di.inilrvr. mechanic: lived Wotverhamiumv and 1 pptng Wiirkcd it prinime m.vliMni before marriage, then at hiiutcvi/t until death: lived att End of London Stereotyper and printer; lived originally in Ealt London, then moved to Ipvuieh Vn Soy. regular army, euner and grinder; lived N.. London and Oagenham Bricklayer, cement worker, punt* man; lived liau I:nd of Loodim. moved to Mamault. iiitev in 1911 Fitter and turner: lived principally in Ealt End of London Coloured S. African merchant wa* man. ttokcr at glaia factory; petviblc eomaci with atbcsioa m S. Africa or at tea Lived until marriage in NVata. then howeteeper >n S. vv. London Maemniat of Celluloid collar*. housewife and canteen worker; lived East London Machinist in hosier* trade, Notring* ham. housewife; moved to London J9 Labourer. merchant seaman. docker, carried only meat Aoprentice printer, barman, cook. and butcher. For 22 year* before death lived Sort End of London Dressmaker and houses. i1; lived East End of London men iameraet Steel erector, army, tied erector. labourer and porter; lived ul End of London Emotoved aa packer in pharma* ceutical Arm for 12 years, that hmiaewife until death; lived it Dagenham . Fisherman, fireman, docker. 1915* .19 st TiJftury dock], hitman and finally storekeeper; contact with tlbeiet not preoaoic at Tilbury dnckg; lived Tilbury area intitm F: l'error rd retr* n I PWura F U i Pleura M 1 j Pleura M 10 : Pleura M c Pleura V? Periiiwum M F 1"V t 1*93 1*60 i*n 1900 1*93 1910 1*76 1917 Niuopiy V Pmrtive >922 Neeropey Negative Negative ' * 1923 Mttrcny Negative Negative . 1 <936 Necropsy Nigrint Nrgatiee ' t936 Necropsy Positive Poemvu >943 Necropsy Potiiim Pmnrvc 19J3 Nveti*p*y PftttltVU hwine Not traced Not traced Not traeed Not traced Not traced Not traced NM irjceU N/A litM not available. _*-i , . -. ** r.. v 1 IH'MUWl PlbPJ mrAiPrirw^ - o; i' fer-.r* Is- BTV> K Sv kv -