Document 2RgJz8qEJMg7d754Gj3GMDGxp

FILE NAME Household Contact HC DATE 1960 DOC HC011 DOCUMENT DESCRIPTION Medical Journal Article - Diffuse Pleural Mesothelioma and Asbestos Exposure in the North Western Cape Province ' } ! 32 32 i 1 3 F a a * : 3 ( i. 4 qs ins Ww . it ~ . ( E * AM AM AM M T * ve 434694 434694 434694 434694 1 ) ( ( ( Witla h am date aT fe Soh alhtuticah ge anit Adal: Ty tkaie cat Oe LAR bs ei ataaes 4 i tA sree ona ek oliers NS Brit J. industr Med 1960. 17 260 ted F 1C Be N REEEN e GSEIa tects at, Tee pian att 3, ne Rimniacimesrteas NY A SEAS lite D ys Soe bas aon t S4z45 ec Ris tire Ee-al aNie 5 ap PS Ft ekeNoe ahs DIFFUSE PLEURAL MESOTHELIOMA AND ASBESTOS EXPOSURE EXPOSURE EXPOSURE IN THE ; NORTH WESTERN CAPE PROVINCE . BY ~ , C. WAGNER ~ A. SLEGGS and PAUL MARCHAND . From the Pathology Division Pneumoconiosis Research Unit of the Council for Sitemine Sitemine and : Industrial Research Juhannesburg West End Hospital Konherley and she 1 Department of Thoracic Surgery University of the Witwatersrand and Johannesburg General Hospital . RH EIVED FOR PUBLICATION PUBLICATION APRIL 24 1980 Primary malignant . Primary malignant tumours of the pleura are uncommon Thirty cases 22 males emales dit~ use 68 ' 11 emales ages 31 mesothelioma to 68 of dit~ use pleural mesothelioma are described all but one have a | probable exposure to crocidolite asbestos Cape blu~ i In majority majority this exposure was in the . } Asbestos Hills which lie to the west of Kimberley in the north west of Cape Province The timour is rarely seen elsewhere in South Africa s is secondly Mesothelioma of the pleura is regarded as an of first Case the lungs of the first case Case H. and t uncommon tumour In the last four years we have 10 of the cases came from a hospital to which seen 33 histologically proven cases 28 of these had suspected cases of tuberculosis were referred from a some association with the Cape asbestos tield and large asbestos mining area This hypothesis could four cases had been exposed to asbestos in industry not be supported at once from the original histories > The tumour is rarely encountered elsewhere in obtained from the patients for they included house- South Africa During the past five years with the wives domestic servants servants cattle herders farmers a exception of the present series no neoplasm of this water bailiif an insurance agent and an accountant nature has been diagnosed amongst 10,000 lungs none of whom were working on the asbestos mines examined at the Pneumoconiosis Bureau in at the time We therefore undertook a detailed | Johannesburg or in the Pathology Department of investigation of their past occupation and place of : the South African Institute for Medical Research residence and the association with asbestos ex- Oettle Higginson and 1957 did not observe a single posure was discovered The cases are suminarized ' case in their survey of malignunt tumours occurring in Table 3. Previous biopsy specimens were re- in the Bantu and Cape Coloured population of Johannesburg and the North Eastern Transvaal examined and asbestos miners new cases diagnosed including In only one case do the relatives Vw Our first necropsy specimen of pleural meso thelioma with asbestosis was examined at the asbestos deny that the patient either visited milies or was exposed to asbestos the Pneumoconiosis Research Unit in February 1956 Case ) During the early months of that year one of us C.A.S. in the Northern Cape Heated six This is preliminary publication and the problem is being intensively investigated patients with gross pleural thickening Pleural biopsies from two of them showed the features of The Asbestos Area of the North Cape mesothelioma In the ensuing two years eight further cases were found from this region and live from elsewhere in the Union During this period C.A.S. had become perturbed at the number of these unusual tumours occurring amongst his patients and stimulated an investigation At this stage there were two reasons to suggest than asbestos might be implicated First asbestos was found in According to Hail 1990 1990 asbestos was discovered discovered by Lichenstern near Prieska sluring his travels be- tween 1803 and 180n Stace then it has been established that the asbestos deposits extend from 20 miles south of Prieska meittewards through the firn part of the magnteral district of Hay to the eastern portion of the m gisterial district of Postmasburg and finally to the western area of the 280 Pe Pel ettgih ov Me os an, nee Geer ance are NOSE Te 7 Nf EA w Osc Tad a ay be oat ream Rennie Goneeeetr ete oy a2 at Spree ts es: Ke Oe Peasx^' es CEN Come ona? seunrraeypentcnnivey AWE aya ee a REG ts! uae arin rng Arh xis Ke) 4 Tee gee et & nnn 0 ee eta w ~ eM DIFFUSE PLEURAL MESOTHELIOMA 261 a | . ' i) 1 i MOLOPO RIVER \ | 1 i ye ur | a ORANGE RIVER ENT + EE Tr ond Cried oil oe meee ASBESTOS HILLS erm met UNON OF SOUTH AFRICA ; Eo C )i C : from a a fe Nl . could | stories 2 | cen FIG 1 - Map of Griqualund West asbestos fields house- ners a untant :j ee etailed = e . mines lace of district of Kuruman Fig ) These deposits occur In 1908 production had begun in the Kuruman dis- | in the slopes of a range of hills covering an area trict Between 1916 and 1918 a large number of approximately 8,000 square miles Known as the claims were taken up This northward trend has 05 CX- Asbestos Mountains these hills extend more or continued and in about 1950 mining started at marized ere re- less longitudinally between 22-30 and 23 E. The whole area is semi sparsely populated and Pomfret near the Bechuanaland border ( Table 2 Initially the ore was quarried in numerous small luding . apart from mining cattle ranching is the only open cast workings This was followed gradually ee several i important occupation the Kuruman area sbestos i on wer inhabitants sbestos large tracts of land in or abutting these mountains SHLE 1 ee have been reserved for the aboriginal CHEMICAL ANALYSES OF CROCIDOLITE AND AMOSITE -o-bolebmlem ! and here whites may only reside in the immediate from Vermaas 1932 ~ ape overed eles ls be been from gh the lay lay to rier ( ' vicinity of the mines { The type of asbestos mined throughout this area . is crocidalite better known as Cape Blue Asbestos The chemical analysis of fibre Table chemical analysis analysis fibre the given in is given in Table . \ Crocidolite is the fibrous form of riebeckite and all . stages of transformation from a massive riebeckite | rock through lamellar riebeckite to asbestiform Magnetite : crocidulite occur in this region frequently associated with the crocidolite Vermaas . 1952 ' Mining Mining of of asbestos asbestos first first began in thethe Prieska i Prieska district in 1893 and gradually spread northwards ty 5,0 1,0 Feu, teu Mg ha H.J 10 SHA - luth Crocidalite 51.94 0.20 130 130 19.39 1.37 017 31 a 160 Vanchite 47 203 +19 1563 57 oH 3% ras! UN - 100 40 4 ol bon te Vin ee eng) vw lettin RTE Te ck Ad RY eT Pet eel et i A MORAN la COP I: : ote . Pars : , at 3 qn, PSO ea wh g 3% ST Ae rangi%a,e ets 4 is 38 ! oe ie AE 4) PEELE sovasens TSNYY Sao A ws eddoves x ees iY SateZ 262 BRITISH JOURNAJOULRNAL OF INDUSTRIAL MEDICINE ae, POPULATION OF THE TAULE 2 MAGISTERIAL DISTRICTS IN WHICH THE ASBESTOS Itaken from Laivu Census 1921 una 19511 FIELDS FIELDS ARE SITUATED District Prieska Kurum Has Postmasburg -- Whites Population 1925 1925 wt mee whtles Ls, . Total 3.430 4.79 4,499 Included +877 16 698 8,814 in the fla 8,309 8,309 21431 21431 13301 Dist^nh a oes Whis J.361 4813 1757 +357 _ Population 1952 meeree Nontal les wee beer oe flfl 10847 10847 , 14.208 21.774 ' 28.597 9.631 12.388 21.019 25,906 laki m by a type of shallow mining inclined shafting be- today the white prefers to live came more common after 1930 as close as un possible and the children play on the dumps from 61 According to Frood 1915 the quarrying was a the mine and mill family affair undertaken by the local inhabitants The men quarried the rock which was sorted and then hand cobbed by the women and children Case Histories Hand cobbing consists of separating the tibre from The following eight case histories illustrate various ae the banded ironstone by striking the rock cob with a small hammer As the market was selective a aspects of the disease and the different types of exposure to asbestos dust ona rotary sieve was sometimes used to grade the libre and eliminate the small particles of dust After grading it was bagged and weighed The asbestos was then transported by donkey wagon to the nearest Cuse I. - P a Bantu male 36 years of age born 1920 was at mine labourer and was the first case diagnosed as a mesothelioma with evidence of asbestosis He was born in the Kurumau district but is not known He | head Before the establishment of the railway whether he worked in the asbestos inin~ s He was in this area between 1923 and 1930 such a journey employed on the Witwatersrand munes underground could last as long as 10 days This transport was for two years and in the change rooms for a further 11 years generally undertaken by white youths farmers sons under contract The white inhabitants A radiograph taken at a amine hospital on August 18 little in actual played very 1955 showed a masave sided pleural effusion on part recovery of the tibre being nearly and 3,000 ind of fluid was withdrawn He always employed in the role of managers or over- was adinitted to the Witwatersrand Native Labour Association seers issuing stores and supervising the grading and Hospital on August 24 1955 and two days later aspiras weighing of the fibres Farming activities were and tion yielded 1,000 ml of thick ggelatinouselatinous pus which are still carried out round the mines could be pulled out in threads H ' was treated with Since the 1939-1945 war the demand for crocido- frequent aspirations and instillation of varidase but sky acwny lite has enormously increased The lucrative clums without unproveinent and he died on February 15 have been bought by registered companies others 1956 Martiny 1956 have been abandoned As deeper and richer At autopsy the right thoracic cavity was occupied by estes deposits have been found vertical shafts are being a large gelatinous tumour which displaced displaced the mediasti- sunk However the mines with num and compressed the left lung The tumour had large shallow infiltrated the pericardium The right lung was com deposits are still using the inclined shaft and tunnel pletely compressed by neoplastie tissue Fig 2 hit the and quarrying is still used by the few remaining right bronchial tree did not show any evidence of a Fr smaller producers With the building of more milis hand cobbing has diminished In 1915 the first primary brunchogenie carcinoma Histological sections of the pleural growth showed a papillary mesothelioma crushing mill was established at Koegas in the south Fig 3 There was evidence of asbestosis in both FIL This was followed by a large mill at Kuruman lungs Fig 4 : operated between 1926 and 1931 where it was situated within 300 yards of the main street close to which cobbing was also done for a few years 1927-1930 This was followed by a mill at Priesku in 1930 which was completely rebuilt in 1957 Griquatown had a small mill in 1928. The practice today is for one mill to serve several mines in the immediate vicinity In the early days the manager and labourers lived within a few yards of their place of work and even Case 4. II a white femiale ^ n^ n years of age thorn 1898 was a social worker who could could only have had a short exposure to asbestos asbestos as child and probably a further slight exposure as a young woman She may have pant several short visits to the nunes with her husband at later pered She was born in Grigadtown she was years of age Her Kimberley where tum 1916 to Clerk in an asbestos warchatne warchatne asbestos intre from 1933-1940 1933-1940 where where she lived until tarmix then moved to 1922 she worked as a Het luisband owned owned an iad . a 1 . eta co Saga th Set ALS Ren 4 8 op san 3 aaah A owe . nately oP a eordien 3 Ew i , ay 5 re pernang yaa: . es A 4 . kates atheSees : , . tease! ; A pales IOS phe datie . { eee - oN ia ted cr) t t - 3 % - sw i se as from ' . { irious \ osure born | case ' ' losis losis nown was ound .rther .rther DIFFUSE PLEURAL MESOTHELIOMA 263 te 3 ' hd = . ~~ Ley h ' . i] AK a en Sey ot Te,~ +7 be Wee gE oe S- e, wo oD ee! Ste, aM tg ve ; y) >. Le % 4? y 7 oe the, : 2? Me diy ote Swgtr,as tan,, 1 Sant ? i b-s* n,ew be . o. 2 . t A] ut va a 1 ~ a ee 3, y rs Ld ope. +6 - 4 v . heOk 4 me - Ug ot 3 . PF mee 4 J ar m > &. ar Ca 1 g a a . sy 49 oe N 4 \ . a jaey rm Ee Ah ag a af ae f %. apa o wy. , ? se of sita . re 3 ' ck re | + i 4 U a tke i th tf > {7 oan [ Rat 3? a 2 OO RE aT . . ey a GEST, ee ? ry. " 2 tawp ga o,f & es a - . A r f. # ,. P, ee et a i , ne * i Thich Thich : with but 15 : vasti- vasti- vastii had Flu 2 ae t Pg or 1M er : ore a i . a TB Le % ee a. 3st if d e ot* . ~EM Ma alt Woes: ad Oe DER : Se RLY p Dt* _* - Ny Ce : sg ap au . an ode sf i a . Se ' . es . . * a .?. b4 vy t ; ( the og AL hes tee Pay . 4 . t 3 : 2. Case a> if av, Fig 2. -Right lung of Case I compres ing showing a tumour compressing flie aw te OM vous i lung substance ~ * tions i i *, a ae x . r on ot Toma both y . : : bui * ee Fig 3 Cellular structure of tuni^ urof Case 1 1 40 Haematusy gk 1 and usin Yeo 7 Of : - ', <a Qe %. e ) Fwy 4 , 2 . jd jd ly may her ae. . Fi^" 4 Sectionsof lung from Case I showing asbestus b^"sties mIets % oeAa ay af F ; S 40 Haematoxylin and eosin ty nes . ~ , v ' . ~ 7 2 Gy . 3 - os el? , cee e . bay . . \ . 3 e i to 18 . Jan | ry see, . ae H ore oie I ron 3 , 4 ~ fe o : . ota t . fu. 3 oe e.. Ri co 4 $ 7 n 4 * ay ay ees ve Be 4 . 4 SS =e is s a oy ae en Ss 5 eS Ra us me 2) Ee Das ws i: oei 2 i ES one ts me 7 *h B [3 wt. ms 7) a LF ate fs h$ae 12be: af - 0 fe oa ari Sy tes pt ad a fs . = . : 4 . 3 x u , fe st i &: te b- <= - be . it 4 te Soren uaianewee os, i 3 2:Q ihe EAE iS; Chesed we ries bs bs one Ns rs ee Ot 1 gee Se SPONSES . Ce Ra) Lae ee FEELa RN SRN be . ee . Wao 4 Fig On July 21 1954 E36 6. On July 7 1955 . Ay Fig 01 March 1916 Fleis . 8 " JJ >- '> - '>-' In B On Jul 1 1955 R. diograplis sitowing Jurcroposed Jurcroposed on your your kass Jie AM Rare sae RSs aatiire st Tass Set Ea sees ris caneags Seta aha Ar ay wear e . AE Paty : tp Ma) LE SEB OAEANE et OT Ss EM ey 9 gy Ty Are Hash sie ee OS Si me ts ite hes, et De IN & } Cable int dtr 4 howe ie Me Aine ritremsre Forte Me : p. Eytan BOS aay TE icoyt aye pss riie: < viel. NTE BNO Nie oY on ARLES TYME eet, motme n may 8 WC TRae Sy 4 ants be PA DS yf Le a RT Oey ae 5 eg EN Pahas tyese Cals . _ paperen = ye SS i AE ~ ' DIFFUSE PLEURAL MESOTHELIOMA 265 ie ey aan 3K 4 h fn ay ra Leste vl dg re 4 tae {.@ H Ba oe pra - *, Bek \ * isi Si Wik,Yo.. 3 "1 Mad . BS . ey: fe. =, An Ee ., ai re . cay ut.g "f a. Gxt ' Wik oatisd 6B.3e R/s i BS ny a 9% i + ; sfi 4 q are ' Pm * oh ee Wise 't wa hs a 6 <> s%, * oe es an Baty | up " ' He a. BS: ee, . tS ey ve en 2 S tgNeee wr, -; se os ms z. a | ys Ie dialf ae y wy a) H 4 *y > ad ed 392 Py J 7 i) val ph : cy sige] NS fo Wid : pS C \ / 4 i Fig 9. Right lung of Case 14 aS a. av ate Pay aan) ee $ asin 18, Fr. 10 --Histological sections of fimtuar from Case 14 +4 HiematoxylHiiematonxylin and eosin ; She was referred to the West End Hospital Kimberley returned to the Kurumsan district in 1943 when he on July 19 1954 because of dyspnoea and right chest worked as a farm labourer until his final ulness discomfort of acute onset The chest radiograph He was admitted to the West End Hospital March 3 showed a loculated pleural effusion at the right base 1959. He had been well until July 1958 when he coloured fluid was aspirated which on examina- became aware of pains in the right side of his chest In tion was found to be negative for M. tuberculosis but addition he had a slightly productive cough and short- _ contained mesothelial cells arranged in acini Al ness of breath on exertion Chest radiograph on _ thoracoscopy in Johannesburg on August 11 1954 tumour nodules were seen on the parietal pleura Histo- March 9 1954 snowed ubliteration of the right lung field Asbestos bodies were found in the sputani logical examination of the biopsy specimen showed Needle biopsy showed histological features consistent mesothelioma Deep therapy and active gold with a mesothelionia instillation in September 1955 caused initial regression of both the pleural fluid and nodules but did not arrest the progress of the disease She received a further course of Autopsy -The right chest Wita occupied by a huge whitish tumour which infiltrated ine mediastinuin ray therapy without improvement and died in January 1957 The liver was enlarged and nodular before death but no necropsy was done Figs 5 6 7 and 8 show the radiological development of the tumour in this case extending through the diaphragni onto the superior surface of the liver A coloured effusion was present in the left pleural sae but the left lung was not affected The mediastinal cervical and aortic abdominal lymph glands to the level of the renal artesTOS were infiltrated with tumour Case 14. S. a Bantu male 40 years of age born 1918 was an asbestos miner He was born in the Kuruman district and as a child often played on the asbestos dump near an asbestos mine He subsequently worked with asbestos for several years being employed at an asbestos mine weighing libre from 1938-41 In 1942 he worked on a Witwatersrand gold nine mut in the right lung it was found that the tumour mass had rafiltrated along the interiobar lissures The lubes of the lung were compressed into three small segments Fig 9 On histological section a papillary type of pleural mesothelioma was seen Fig 10 which had infiltrated into the lung potenctyma in some areas There was marked ~ ,,mplatsepread throughout the aS f Bes ge wr Be fe aye . pat reP: Bk > al Se Nt aachat ES Be an 7 v To OMe, ER re HE aa. a s fo v pat ~~ Te @ ors - ( ter oe ZA ders $m " % oe a ae 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE lung substance Numerous asbestos bodies were present in the air spaces and occasional bodies and fibres were seen in the interstitial tissue The lung self was markedly atelectatic Evidence of asbestosis WALS observed in the left lung Case 15.-S.S.V. 15.-S.S.V. a white female 42 years of age born 1916 is a housewife who lived on a mine near Johannesburg and was treated for tuberculous pleurisy for six months It was only after the histological diagnosis of a mesothelioma had been made that her previous history was obtained In addition it was subsequently learnt that her father Case 22 had been born on the asbestos field and had a long mining history The patient was born in the Griquatown district and went to school at Kuruman She spent most of her youth in the asbestos belt She has lived near Johannesburg for 20 years In March 1958 this patient developed right chest pain and rapidly increasing shortness of breath She was admitted to hospital and 2.500 ml of slightly bloodstained fluid was removed from the right chest A thoracoscopic examination was carried out on July 27 when a small biopsy was taken but this consisted of fibrous tissue Bronchoscopy was normal and no neoplastic cells were observed in the bronchial washings M. tuberculosis was not cultured from numerous specimens ef sputa pleural fluid nor from the bronchial washings She was admitted to a Johannesburg nursing home on October 16 1958 Radiographs then showed massive thickening of the right pleura with fluid in the right chest At thoracotomy Mr. Dennis Fuller the parietal pleura was cm thick hard as rock and stripped with great difficulty from the chest wall The visceral peel stripped furly easily from the upper lobe but separation became more difficult over the lower lobe where the peel was thicker During the decortication a necrotic mass was found in the panens chyma of the left lower lobe At the base confluent with the diaphragm and perhaps the mediastinum was a hard craggy mass which could not be removed Histolgical Histological sections of the specimen revealed an adenoid form of tubular mesothelioma Subsequently three specimens of sputum were examined for asbestos budies but none were found The patient still alive April 1960 but her condition is deteriorating Case 22.-D.A.B. a white male 68 years of age and a farmer was the father of the previous paticat Although a diagnosis of pleural mesothelioma was made in January 1957 it was not until July 1959 that slerais ot his exposure to asbestos was obtained He was born in Griquatown and went to school there He worked in Kuruman Postmasburg and tiriquatown until the age of 62. Between 1918 and 1932 he worked as an asbestos miner underground and was mostly in charge of blasting Between 1932 and 1944 he farmed in the district but returned to asbestos mu^,,ngtronk 1945 10 1952 In January 1987 cause of sided the patient consulted las chest pain with cough doctor ber and slight haemoptysis He was referred to the Johannesburg General Hospital for investigation The chest radiograph showed gross pleural thickening with a basal pleural effusion on the left side He was admitted to hospital and on June 10 1957 a thoracoscopie pleural biopsy was taken This showed the features of a meso- thelonia On June 24 1957 an attempt at decortication was made The left upper lobe was stripped easily but the grossly thickened pleura was so adherent to the lower lobe that the attempt was abandoned Sections of mesothelioma the pleura confrmed the diagnosis of He died on December 13 1957 Case 16. -A.N.V. -A.N.V. a white niale 50 years of age bom 19061 was a farmer who was born at Griquatown and went to village school near un asbestos nude From 1914-16 he transported asbestos in donkey waggons from Hay to Prieka During these journeys he often slept on asbestos bags In 1914 he worked in an asbestos mine for a month The patient became ill December 1955 with vague substernal pain and dyspnoea A sided pleural ellusion was diagnosed and he was referred 10 Mr. K. Breminer in Pretoria There was no evidence of malignancy in bronchial and scalene biopsies Some apical pleura thickening and a Jense homogeneous opacity ar the base the left lung was seen in the radiograph on August 3 1956. Thoracotomy Mr. Bremmer^ in February 1957 revealed a thickened nodular pleura with a large mass on the left diaphragm A mesothelioma mesothelioma was seen on histological section In April1959 he was examined by Mr. D. Visser in Kimberley who found shall nodules in the subcutaneous tissue over the neck and chest A large nem mass was found in the thoracotomy wound and a mass was prosent in the left bypochondrium bypochondrium There was generalized lyniphadenopathy and numerous nodules were present on the tongue Chest radiographs showed the felt pleural cavity to be obliterated He was one of the few cases to develop widespread metastases A biopsy of one of the subcutaneous chest modules showed a simtar appearance to those seen in the original specimen from the pleura The patient died on May 22 1959. No necropsy was performed nd a f em ge emintmane gg oe - Case D.G. a white male 32 years of age born , 1922 by profession an accountant was born in England but came to South Africa as an infant He spent his early childhood in Kurumian and left at the age of He later qualified as chartered accountant in Kimberley In 1944 at the age of 22. he had been dischargeddischarged medically untit from the army because of a left pleural cafusion Neither then nor on many subsequent occasions were acid bay~-ll~-tonna eithea in sputum or pleural flund His uni subsc juent contact with isbestos was the auditing of the books ol an amesITE guns in the Transvaal Transvaal la September 1983 de complained of ichtesidled ichtesidled chest pains and shorlikesy of breath A radiograph radiograph the chest showed flattening of the diaphragm un tie felt side with obliteration obliteration of the costuphrenie costuphrenie angle and thickering of me oblique fissabe He was was satoosnatoon satoon NanttouS NanttouS DECISIONS e from 19 showed shadow . the de l on the . develope develope biopsy in malign Secti . the hist thelion not perli Case 1909 Exposur Fields He The sys factory volunt tinuart remati pipes cough age hi capaci centr..t contac factor 3 thy Koes agce ee athe aa ssrahe eee aay ts sia ay eas Peeae ap see. aes try ea g rages as T$on; vue ay rtb ti keyne 4 ah % ' PaNe . Mi wast (PF RN (wets? Oe, g tee Ae: - SageGaPye geet at hes! tt ae scare Sn er Mee pisi.! et 2 DIFFUSE PLEURAL MESOTHELIOMA 267 7: ga- yume ee gwar omn _ o FK 11 On September 11 1956 Fig 12.- On August 25 1957 Frus 11 and -Radiogr-Radiograa phs phs skuving skuving development of tumour ink C'est 24 fom 1953 to 1957. A radiograph taken early in 1956 showed the development of a left superior mediastinal ! shadow which enlarged progressively Fig 11 and later the de elopment of diffuse nodular pleural thickening on the eft During 1957 similar but less marked changes i developed on the right side Fig 12 He consented to & biopsy in June 1957 and at operation a diffuse pleural i malignancy was present . Sections of the parietal pleura only were removed and { the histological appearances were those of a meso- t thelioma He died on October 6 1957. A necropsy was not performed Case 30.-G.F. a white male 50 years of age thoin ; * 1909 is a storekeeper with a history of industrial ! exposure He has never been near the Cape Asbestos + Fields | He was born in South West Africa and lived there until the age of 21. From the age of 21 to 26 he worked in a factory in the Cape as a maker and titter He . volunteered the information that he had worked con- tinuously with asbestos lagging pipes and boilers He + remarked that the removal of asbestos lagging from vl^ pipes created very dusty atmosphere and that he wouldh cough a lot at such work Between 26 and 32 years of me age ne worked in a factory in Jonannesburg in a similar capacity but was not exposed to such heavy dust con- centrations For the past 20 years he had not been in contact with asbestos Enquiries were made front tie jo factory the Cape as to the nature of the asbestos used ) and these have revealed that slaring the relevant relevant periodis Cape crocidulite was exclusively in use He was first seen on March 14 1959 complaining or cough pain the right chest and recent onset of breathlessness Three pints of fluid had been aspirated from the pleura and cytological examination showed the presence of malignant cells The radiograph showed marked pleural thickening and pneumothorax On March 17 1959 a thoracoscopy was done The pleura felt thickened and the lung was collapsed and immobite = Several biopsies were taken These showed the presence of a mesothelioma The underlying lung showed the presence of asbestosis He was treated with nitrogen mustard pleurally and his condition temporarily improved When last examined he come plained of increased breathlessness Discussion In 1924 Robertson denied the existence of primary malignant tumours of the pleura and considered them to be secondary in origin Since then on the one hand Willis 1948 1953 and Smart and Hinson 1957 have supported Robertson's views while on the other hand pumaty neoplasms of this nature have been described by many authors in recent seatS These includ ' Tablassen 1955 in Sweden Belloni and Bovo 1957 in Italy Godwin 1957 in the United States and McCaaglicy 1958 ihe f . Z vrv ate , PF . f . 5 * g Bay . 2 A r 4 base q err . a 7 caters ~y athe rane Se t att Bn opee orate aoe 4 E aefey oaSsnaSete BSReena ay it 4 aes ra" ge Nike r 3p]ee yt.ab ay Seas > ee Doth Heuer 6s gee . a feed - " ye BN Es Piel 4 , -- we A atte tL ok af S #4 ; en. ee 5 Seo MEY hd: i Oye A MeL SUCRE SANT ~ ; \ , } | i 9 : 3 Cus oo raB, : iow 5 3 et a : a , y 3 ) , J a 11 i : 13 . i ' 17 . $ x = 3 3 x 2 , 3: y vo xs x Py} . a . . 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE | in Britain Evidence in support of the mesothelial The amount of metachromatic substance in these === origin of these tumours can be found in the tissue tumours has varied considerably This we think is === culture experiments of Stout and Murray 1942 and partly due to the fact that until recently we had not === Sano Weiss and Gault 1950 appreciated the solubility of hyaluronic acid in The variegated histological pattern of tumours aqueous media and the majority of these tumours < arising from the mesothelium of the pleura was remarked on by Klemperer and Rabin 1931 Such J a variation is appreciated when the multipotentiality of the cells lining coelomic cavities are considered | Maximow first demonstrated this feature in 1927 Novak 1931 stated that the mucosa of all parts of [ the M^...llerian canal and the germinal epithelium = were derived from these cells Keasbey 1947 { showed that in the embryo the mesonephros lesions metanephros Wolffian body genital ridge and all were fixed in 10 formol Further Lison 1953 states that the metachromasia of hyaluronic * acid is optimal at a concentration of 1,10,00 1,10,000 and gradually decreases at higher levels When the high concentrations that Meyer and Chaffee 1939 1940 found in their tumours are considered this variation in metachromatic properties seems to have been partially explained In addition with the great differences in the histology of the various it would be logical to expect certain tumours with a ul > " : ' a : os . { dependent urogenital structures are derived from marked adenoid appearance to secrete more than te the mesothelium those with an essentially glandular structure . Campbell 1950 considered the presence of both Three of the five autopsies performed showed epithelial In and mesenchymal elements a major evidence of peritoneal metastases the other two * | diagnostic feature In describing the histology of thoracic spread was observed in one case to the these 1958 { 11 of tumours demonstr demaont streatd ed other lung and chest wall and in the second to the t that either the epithelial or the mesenchymal element mediastinal lymph glands and pericardium Biopsy might predominate He classified his cases into the evidence of metastases has been obtained in two ' { following four groups Tumours of epithelial cases one from the omentum and the other from * character tumours of mesenchymal type tumours subcutaneous tissue of the chest wall while a third ' : of mixed type and tumours of anaplastic type patient developed an implantation nodule in the Using McCaughey's classification on our series thoracotomy seat which showsie mild ar a of tumours the majority are as in Campbell's series to that of the previous biopsy specimen appearance 1 | of the mixed type Of the remainder a few showed The first recorded case of carcinoma of the lung the papillary tubular structure of the tumours of associated with asbestos was described by Lynch 2 { epithelial character and there were several of the and Smith 1935 By 1955 according to Doll a a anaplastic type One case had the appearances of total of 61 cases had been reported Included in tumour of mesenchymal type but even in this case these cases was one mesothelioma Cartier 1952 primitive tubular structures were seen mentioned two cases of difrizz mesothelioma from a | Apart from the original case all the histological Canadian chrysotile min ' A further three cases diagnoses were made on biopsy material Three of were described by van der School 1958 Un- 5 \ these biopsy findings were confirmed at necropsy fortunately no indication is given in the literature In the remainder we have had to rely on clinical regarding the type type of asbestos to which the majority and radiological examination to exclude other of recorded cases of carcinoma | primary sites of malignancy Ch^tfee were exposed However discussion with management and medical 4 Following the work of Meyer and Ch^tfee1939 officers of two of the factories in which the majority 1940 the possibility of demonstrating hyaluronic of the cases reported in Britain acid in these tumours both chemically and histo- suggests that most of these workerswewreereemployed s handling chemically has been considered as a diagnostic aid chrysotile asbestos Wagner 1958 The i possibility Both these investigations are sult in an early stage that some of these people may also have been Harington 1959 e exposed to crucidolite dust cannot be excluded { Preliminary results of the histochemical experi- ments show that there is metachromatic substance Attempts to produce tumours in experimental animals by exposing them to asbestos dust have been in both the stroma and glandular structures of the made Vorwald and Kari 1938 were unsuccessful i 1 tumours This metachromasia can be reversed by Lynch Metver and Cam 1957 succeeded in e incubation with testicular hyaluronidase This pro- ducing tumours in mice but lung neoplasms in his | 1946 material stains strongly with Hale's colloidal control animals were far too numerous for the iron method The periodic acid Schilf technique results to be considered significant On the other { has given variable reactions These results are not hand Schmahl 1958 working in Druckrey's specific for hyaluronic acid but are strongly laboratory has has been able to produce sarcomas in suggestive of its presence rals This has occurred after subcutaneous and arab ieekr y? 4 ote 4 SEAR 43 sf; ag SIN 1 , . ve PER Tins 222004 Oh 34 _ s tet Ema, or, o, yt Ss = = - . Same ait ms ? 4 w iy i. 9 fears h fr intrapeitoneal DIFFUSE PLEURAL MESOTHELIOMAMESOTHELIOMA 269 intraperitoneal inoculation of both asbestos fibres and dust He states that mineral asbestos was Table 3 Eighteen of these 25 cases were born in the vicinity of the mines and two arrived in the nt used but does not name the variety In our series of mesotheliomata histological district as infants Of these 18 people 11 admit detinite childhood exposure to the dust and two evidence of asbestosis has been observed in eight others were exposed industrially in later life In te of the 10 cases in which lung parenchyma was included in the specimen examined No lung tissue addition two patients with childhood exposure later worked in the asbestos mines Three cases arrived was present in the biopsies from the remaining 23 cases It was only in the four cases that came in the region at an older age but were employed either on the mines or in transporting asbestos A further necropsy that large sections of the lung tissue were three of these 25 cases have had industrial exposure 1 available for examination In all of these specimens evidence of asbestosis was found At first it was thought that the presence of numerous asbestos bodies fragments of fibre and and in only one case do the relatives deny any exposure to asbestos dust The four industrial cases are significant Two of the patients were lagging locomotive boilers and dust immediately below the pleural elastic laminae in these specimens might have been significant in the pathogenesis of the tumours However it is ( more probable that this distribution is a result of the marked atelectasis Similar features have been observed in atelectatic lungs of asbestos miners in which no mesotheliomas have been observed one was lagging steam pipes A man who was an upholsterer by trade was employed in making proof clothing from 1939-1945 As far as can be ascertained these people were never in the Griqualand district These finding tend to add supportto asbestos being the common factor in the development of these tumours and to counter the Pleural fibrosis has been a common finding in <n cases of asbestosis and in some cases large pleural plaques measuring up to 0 cm in thickness have seen These plaques which were first described suggestion that there may be some other environmental cause in the region of Griqualand West If asbestos dust is a factor in the occurrence of these tumours similar cases might have been ex- Gloyne 1933 have been observed following pected from the neighbourhood of the Transvaal sure to both amosite and crocidolite asbestos f > uusts In these cases of benign pleural thickening asbestos mines in the Pietersburg and Lydenburg districts where crucidolite and amusite asbestos is no evidence of stromal metachromasia has been mined According to Vermaas 1952 crocidulite ; observed In all the histological sections of pleura examined in in the cases of these mesotheliomas and in more and amosite occur in the same sears in the Pietersburg district As can be seen from Table , amosite is similar in composition to erocidolite In the past eHe than 100 cases of asbestosis no asbestos bodies fragments of fibres or dust have been observed 6 beyond the pleural elastic laminae four years the lungs of 24 cases of asbestosis from the Lydenburg district have been examined In this material two cases of carcinoma have 1. Three patients from the Kuruman district with clinical and radiological features consistent with been observed The one was in a white miner with 19 years service who had an carcinoma 1. those of diffuse pleural mesothelioma had markedly abnormal cells in the pleural fluid These cells showed no specific features to distinguish them from arising from a bronchus The other case was a Bantu miner who had a peripheral tumour No service record was obtainable in this case Only gens cells originating in secondary malignant pleural deposits nor from the grossly atypical cells some- one case of asbestosis has been received from the Pietersburg area All of these men were actually come times seen in malignant pleural effusions As no biopsy or autopsy examinations were obtained in employed on the mines at the time of death the majority having had a relatively short service Our = these cases they have been excluded from the series findings suggest that mesothelioma occurs 20 to 40 The pathological evidence for associating these years or more after exposure to dust Until com tumours with asbestos exposure is not conclusive paratively recently the mining the Transvaal As previously stated only in eight of the 33 cases has evidence of asbestos been demonstrated Of these six had a definite mining history and one had been has been on a small scale and there were no settlements in the vicinity of the mines The lungs of 20 asbestos miners from the Cape exposed to asbestos while lagging steam pipes Th Asbestos Field have been examined in whom no other case was born in the Kuruman district and mesothelioma was observed One autopsy specimen nothing else is known of him until his arrival at Witwatersrand mine at the age of 23. In the remaining 25 cases we can only present circum- Intial evidence of exposure to asbestos dust consisting of three fragments of lung showed asbestosis and an carcinoina Radiological features of n bs t lhaave been observed in many miners from this region without any suggestion of -s, as emer rvwage? 7) aa e t ie as roa eean can Ome fA ty oe cage > Tete x 2 . . ' ee oP T eles oS@ S rwreTteeV eh * arerewv Mie ee aernphdSVao ams 3 Wee baer oN nar metd g % wou, wi Hoty . thse bey ube ro 7. Feta i os ne Ne AG RE 1. 1. 3232 A 1 3 $ 4 $ ry 9 r 6 ec { t W 3 a r 4$ ie 4? oa Ae a wat x 3 ~ . ( ; <f 7 Bote MENSISAUXA MENSISAUXA MENSISAUXA MENSISAUXA MENSISAUXA * A MENSISAUXAMENSISAUXA MENSISAUXA ~ MENSISAUXA MENSISAUXA ** - ** 4 * 34 : 34 1 . 270 BRITISH JOURNAL OF INDUSTRIAL MEDICINE TABLE 3 PPrreetto o DIFFUSE PLEURAL MESOTHELIOMA Association WITH ASBESTOS We 1 Case No. t . > 3 4 $ rs ? & QQ . 10 a : " 12 3 14 S 16 25 25 23 23 2 2 2 2 * % 13 12 29 11 31 . 32 33 2 Year US Birth 1920 03913 3 . 4 8 Age at Diagnosis ' Race : 36 : Bb Sex ane ZZ 242 MXD M 6 Born an Asbestos Freids + 1902 53 * F . 896 38 3 4 : 1925 1903 1920 1694 31 93 36 63 . *** 2424 *** 2424 *** 2424 MXD 2424 r . + 1905 1909 : MXD $2 ZZ . 49 W M . 1898 1910 1909 1918 1916 1896 1911 1920 1922 1906 1912 1859 1895 1922 1899 1895 1904 1899 1913 1909 1913 1908 1890 84 MXD NXX 84 8 NXX . % W NXX ' % M * > F fi 89 > FZ : 89 MXD FZ . 38 B M 327865 MND 7 . 327865 w 7 . 327865 W M . 327865 * M 327865 * 17 327865 W M % > F : 908 * M 908 * M 908 11 M ** ** ZZ ** ** M * * 7 | v * * M * * F 7 Asbestos Exposure 8 . Diagnosed Diagnosed . on Biopsy ' a oe . . ee Wit Other history unknown until came to the Wit asbestos watersrand at the age of 23 Mined from 1930-35 left area at the | of age 27 Lived whole life in a location near an asbestus milt Lived on asbestus fields until the age of of 5 i . worked in asbestos warchouse 1916-20 Spent all his working isfe in the vicinity of mines Lived all her life in the vicinity of mines j Lived all his life in the vicinitoyf munes worked | as miner From the age of 24 lived in a village serving local , milies olten visited wipes watched calibing + autside houses , digging Whole life spent near misses digging wells Lived at the mine froin age 7-17 years played | on jumps and in mine as a boy returned to assist from age 21-25 . Whole hit spent near mines miner 1931.4 1 Lived near mines until the age of 17 miner 1927 Lived near mine until the age of 21. played with : fibre as a child Whole lile spent neat mus nauer 193641 played on dumps as a child Daughter of Case 22 lived at mine until age of 20. went to school near cobbing sheds Went to school neat inines transported asbestos - 1914-16 a ' ' - . . : . . an 9 Neuropsy ee , . , ~- . ") r i - ~ 10 uq Sart, Histological fam, Sy~- Evidence of lack Asbestosis | Sy~- | Aled dete eee ' | H ' - - 7 - : 3 - an ' oe . | 3 ' 0 , I 2 | # + 7 tb | 3{ t i o3f : ' ' u . | i" sad * ! . . H t - 4 Sal he 0 : ;k publi - Bellin Camis Carla Carla Doll + Frunni Glo Gaon Hak .. Hall - .. H.m Hir Hur . Ko Kh .. : Lived un major wagon route till age ut 15 : - ; several subsequent visits Whole lite in the vicinity of the mines miner 1945-58 Family lived at mine miner 1938-1959 Spent whole hie in village on wagon tuute lu . . . | Sa : - Kimberley Kimberley of Lived in the vicinity of meines until the age of 16 otter on dumps as a child . Whole life in the swemnity of the nines miner . 1913-32 and 1945-52 in Lived el 19 the vicinity of the mines until until the age a Lived in the vicinity of muli from the age of 1-7 played on the d^"ingsas a child of Lived in a mining area from the age t 1 8 years after 1918 spent whole life in same lana us Care 24 Mined and transported asbestos tron 1929-33 as Userstof . Born in North West Cape transported asbestos Train 1920-24 Liveu whole lite un tartu in mining atea ~ r ni the age of 12 transported asbesti 1916-21 Maintaining locomotive burlers 1931-4 1931-4 Maintaining strani pipes in explosive factories 1930-40 Work s htter In railwa ~r-ailwa ~- maintaining locomotive boilers dates unknowu asbestos Making1939.45 blankets for the Air Na history of exposure to asherwis Force - - . - De - 1s l - G i A . ' Mi 4 Sua | | 9 vu . - i Sue Av - ; are : SD A. A. ' . ee . . ; , - . t ! t KEYS Column 4Race W MXD B - White Mixed Colouredl Barto Column 6 Culam~-n9 -- . Colima 10 = Born on sbestos held . Necrops dane + & Positive histol^gical evang : Not born on asbestus Necropsy Put gone of asbestosis . subminati nelds U Lnknown Lnknown Only sinail tragments tragments at parietal pleura subomitted at Julof y for histologwal . 2 Nu lung tissue subminati O 3. Small tragments of @ ey 146 but -- Ka Evidence 9 * Nabbra Nabbra UR asbestosis to ~~ tumour formation However pleural involvement involvement of individual individual suscepubility must also be con- has been a common finding in these cases Hurwitz sidered possible 959 It is that there has not been a We wish to record the great assistance that we have 9 sufficient lapse of time after exposure for tumour rsseverssseves in this investigation from the medical prae- Griqualand am development in these cases Further the factor Littonces of the Griqualand West District and the Pie Q PPTL ca wae FO | Oa ES % af WY Sac saci Og FESS cb wee SPY LLSS yA nT"hS y SUD KS . SOM PaaS 43 ; i Cine Ls diOge ?FE4 LT nC ewes er Se ireae n % v BSars, % p . a, bn} cr ay : : al Parte see om SOE SRE rhe teeth tae ay went | wi ~~ . i eee 101 mf j Sen: logical free of once MOSIS SIPRA Jn ans i . . J ' 3! i - WN] = - Ji : . to . . oe Fas : ~ H- H- 1 H- ! 7 yf 1 9 4 ie | 5 * ot 4 tog | ; 9 ' 4 DIFFUSE PLEURAL MESOTHELIOMA 271 . thoracic surgeons and pathologists Pretoria and Durban , We thank the Secretary of Health publish this publish this paper in Johannesburg permis ion for permission to REFERENCES CCaarmtpibeerll 1989 Belloni 19501. Purh putar Li and Boca 1957 tera W. N. Amer J. Arch mulustr Hyg med 5, 262. putar 17 367 Contribution to the Jiscuon G. 1955 1915 Meniorundum Meniorundum 12.the Asbestos Industri in the Frood Union Proviner Report of 76the Government 82 14 Glosne 1933 Tubercle Tubercle Lond 14 493 Godwin M. C. 1957 298 298 Hale C. W. 1946 NaturePhilud 802 . W. 1946 ) Linion South 1930 Asbestos Survey South Hall randum 12. Geolgical the of Mining Engineer Menios Africa Hanngton S. 1959 Personal communication Higginson J. and Oettle A. G. 1957 Actu Un int Cuner 13 944 Hurwitz M. 1959 Proceedings of International Conference ar Experts On Pretonier Johannesburg Johannesburg Feh 1954 Marti1n 95y6 Pron McCaugheyO. 1927 Arch exp Zelltursch 76 $ McCaughey McCaughey Meyer 797 , W. McCaughey W. . Chalice Trust Aim and L Arch , Puth E. 1939 Back Proc So So ti 54 ) 17 exp Bad N.FI N.FI - Novak 1940 2. biol Chem 133 Novak 1931 Amer J Obster apnet 22 826 Robertson It E. 1924 1 Canver Res 8. 317 M. 783 Sanu Schnabl Weiss E. and Gault E 5 1950 D. Z. J Thorac Surg 19581 26L Schnabl D. Krebsforsch Krebsforsch Stout A. and Murray R 19421 I. Tub 51.319 Arch Path t hicagol hicagol 34.951 1955 Auka puth m^t editel Sound Supypt 115 Jubidaesrsen van School H. M. 1958 Neid 7. Geneesk 102 1824 Vermaus H. 1952 Truns geol Sin tir 55 199 S. Vorwald 4. and Karr W. 1938 Amer J. Puth 14. 49 Wagner Submitted Vmoramtion 1.R. C. Europe Vmoramtion Vmoramtion Submitted to the C.S Pr^>tnickoniosaPr^>tnickoniosa Research in 1.R. famous But erworth Willis A. 1948 1st ed and 1953 Butterworth London Pathology is . famous an Addendum Keasbey London in the press Churchill KeasbeyKeasbey L. E. 19471. Amer J. Push Klemperer P. and Rabin C. Push , 1931 . Arch Pash Chicugni Chicugni 119531 LisonLison 119531 Histochimie Gauthier Histochimie Histochimie et Cytochime Cytochimie Cytochimie AnimalesAnimalAnimeales Asnimales pp . 332332--337337 . Lynch K. M. FA Smith Cain A. 1935Amer J. Camber 24. Sn Mith 15 20 " of the 1960 total ByBy end end of JuneJune 1960 a a mesothelioma had been identified cases of 47 47 cases of In 45 of these a a with possible possible with association association association exposure crocidolite crocidolite crocidolite to has been established In one case a mesothelioma of the peritoneum was present 3 Suuad . eo o'oe - ~ : . THE JULY 1960 ISSUE The July 1960 issue contains the following papers Decompression Sickness during Construction of the Dartford Tunnel By F. Campbell Li ldingP. Griffiths H. V. Hempleman W. D. M. Paton and D. N. Walder A Comparison of the " " altitude and " " pressure Syndromes of Decompression Sickness By M. de G. Gribble i Phosgene Poisoning Caused by the Use of Chemical Paint Removers Containing Methylene hloride in Satay - ventilated Rooms Heated by Kerosene Stoves By W. B. Gerritsen and C. H. Buschninn - bf A Study on the Acute Toxicity of the aryl Phosphates Used as Plasticizers By H. F. Bondy E. J. Field 0 : x S Still 7 Still oY fe 7~ , A. N. Worden and J. P. W. Hughes Aerosol Inhalation of CaNa E.D.T.MAosatil by Workers Constantly Exposed to Lead Poisoning By LJ Petrovi~ M. Stankovi~ M. Savi~ evi~and D. Poleti A Biochemical Study of the Urinary Protein of Men Exposed to Metallic Mercury By C. Smith and Agnes R. Wells = : ; i A Simplified Method for the Estimation of Nickel in Urine By J. Gwynne Morgan =Clinical Bronchographic Radiological and Physiological Observations in Teh Cases of Asbestosis By vistological eva~ ca tissue submitted of ragments a G. L. Leathart . The Measurement of Occupational Mortality F. D. K. Liddell Observations on the Occupational Life History of the Coal Face Worker at Two Collieries and D. S. Kerr By O. P. Edmonds : con- 1 The Assessment of Electroencephalographic Changes and Memory Disturbances in Leute Intoxications with Industrial Poisons By B. Chalupa J. Synkov^and M. ev~ ^>k ; Book Reviews ve have il pracnd the . A number of copies are still available and may be obtained from the Publishing Manager British Medical Medical Association Association TaTavviisstotckock Square Square 1. WC 1. pprriiccee 1,71,7 6d. \ TG ee t. x Py 4 { 3 i. ee mere oe Per , ; Xe