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NOV-05-2002 TUE 05:14 PH SHEPARD HOFFMAN ESQ FAX NO. 2145220420 ..... South African .. /, Medical Journal *. l At (Mktl Ai'iMbifaf ol WS Min k ^. '. . vir Geneeskunde . * '/ ' :/:4l Wf# Of IMwm VtHf|b9 fM hU'Ahttf i ',***,' ' . ' ' . ' . . . '. .'I'v. ** ; - "Ml! ln*<ff>fU*i| |h* tank Miim Mftfirol Ibipirf otf A* MiM h*l of Jovtk Abie* Wfnby Inpiljl b Ab look Aliiioo Mtrf.'iol InnJ ff Of Mttffref Jwimf of Sootk A/rii# , "'?I . '--A| . 3.ass:l . .f 1 * -r o ' * * ; 1961* . . * . . Idit* i Jtvcfotfrvr - f * t A. 1'. Blignault ' . M*. CM., MX, M.W.' Aniilanl. ffJilin r Aitiffftflf'tafotow R. L. Klcinmnn alb., cm., o.tc.0.0. . '/ : :$! . .V- ;V 7* " 1 <vJ1 .. OC.. m( * . . Wt3:\ .r:'4r% ; mV. Vo&jU *. > J jji " \<N Jr HN '***&- >( .c^ij 1?Cf VOLUME 35 Ml DHL 35 M , C~\V*1 fr(. ,r$.[ T**6*MAr .botWi * p|2; Q> at x*--w. ' " *-^P" siiVjwv vqtin ,ox fc^rr^.pX' O^V fV'r^p . V*4 "lk -s. ^V . MVfr:\rfSa Mm' ' '' SC-ALL-10382 4-. .'4'M J. . <TF' / >. "** SCF-FA-5000 (MiiWtf I7 IS Mtrhii.1 limiiliw. ul Jw.O Mif, Mfiwl Mwk, U Wotf SI., Cfpf Ini lifp.fi* f.*i I* M,f... Vvim-girp w W H'ib, Mfvbw N*I|, Vifflllifft }), SfPftlfJ -Mi " Ly%*..- ..-`MV'rir f. ir-m 28 3.A. Medical Journal 14 January 1961 14 Ja geneem word dat die middels wat die pyn verlig die sirkulasie in die kroonstegare verbeter. Oil moet ook aangeneem word dat, aangesien die nilriete gladde spiera laat ontspan (insluitende spiere van die slagaarstelsel), hulle (die nitriete) hartkrerop verlig deur spasme van die kroonslagare op te hef. Al hierdie oorwegiogs is waarskynlik korrek, maar nie een van die aannames is bewys nie, aangesien geen'direkte waarnemlng gemaak, is van die kroonslagare gedurende 'n aanva), met spesiale verwyslng tot die uitwerking van nitriete nie. By miokardiale Infarksie ontwikkel pyn In sy ergste vorm as gevolg van hipoksie van die miokardium. Die pyn is weerstandig vir verwyders van die kroonslagare en Die nitriete het 'n kragtige uitwerking om die akute aanval van hartkramp te verlig. Oliserieltrinitraat (in tabletvorm) 1b gewoonlik die beste. AmielniUriet is nie meer amptelik (BJP.) nie, maar word tog nog aanbeveel wanneer 'n baie vinnige uitwerking verlang word. Gliserieltrinitraat wat ingesluk word (nilro-gliserien) is waardeloos, aangesien die middei in die lewer vernielig word. Die uitwerking word van krag as die middei onder die tong opgelos word; dit neem 'n rukkie langer om opgemerk te kan word, maar dit duur ook weer langer as wat die geval is met nitriete wat ingeasem word. Die middei het 'n vaste dosisvorm eu word dus deur die geneesheer en nie deur die pasiBnt nie, bepaal. Dit is ook tClemf report vuriou Bellini nosis pnlhol iho U and V Dif: rare t 345,01 tal. 1 the li' is moeilik om te. verlig, seifs deur die gebruik van sulke veiliger om te gebruik as die geneesheer nie teenwoordig cases pynstillende middels 'soos morfien. is nie. Daar is verskillende middels in hierdie jiltraat' Die middels wat gebruik word vir verwyding van die groep wat 'n langdurige uitwerking het, maar hulle word largei years, kroonslagare is betreklik non-speslflek, Die nitriete laat nie baie algemeen gebruik nie. in wl alle gladde spiere onlspan, maar die arteriole is meer 'n Groot groep middels wat teenhouers is van histol vatbaar vir hierdie uitwerking. Dit mag wel wees dat hulle monoamien oksldase (iproniasled, isokarboksasled, fenel- numt slegs *n betreklike spesifleke uitwerking het in gevalle van sien, niatemied) het nou verskyn. Hulle het ,'n uitwer only abnormale vatbaarheid, soos byvoorbeeld by spasme van king op die luim van die pasiBnte--.die sogenoemde, mark die kroonslagare, waar klein dosisse verligting bring psigiese energieverwekkera. Sommige hiervan mag wel van sonder dat daar *n algemene gestelsultwerking is. Dit ver- waarde wees by die behBndeling van hartkramp, maar die onderstel dat die middels weinig waarde mag hB vir die hele aangeleentheid behoort versigtlg benader te word. This verbetering van kroonslagaar-Birkulasie as daar geen spasme Aminofillien en teobromien word 'n geruime tyd lank al its e is nie. 'n Middei wat 'n vinnige uitwerking het, is aan- gebruik vir hartkramp, maar, soos dit ook die geval is mine gewese; en as die pyn eers verdwyn, skyn geen verdere met so bale ander middels, het 'n vergelyking met die medisyne nodig te wees nie. Dit mag due gebeur dat, gebruik van plasebo's geen spesiale voordeel aangedui been 1. by die gebruik van vatverwyders wat 'n verlengde uit nie. (3031 V werking het, die pyn reeds al deur rus verlig word voordat die farmakologlese uitwerking van die middei kan Alhoewel daar dus 'n hele aantal middels is wat wel 'a in it was intree; ook kan die uitwerking van die middei dan nog uitwerking het op hartkramp, is die nitriete die enlgste the | lank voortduur nodat daar nie meer behoefte daarvoor middels waarop ons kan reken dat hulle die kroonslagare in 9 is nie. Vir die verligting van 'n aanval van hartkramppyn verw.yd en pyn verlig. Dit is nie bewys dat die- meeste clud is die soort middei wat 'n vinnige uitwerking het, aangewese. Daar is bale middels wat 'n stadige uitwerking het, (wat gebruik word om aanvalle te voorkom of om 'n long- ander middels wat hierdie uitwerking sou hB, wel effekiief of betroubaar is nie. Die nitriete het egter nie 'n voorbehoedende uitwerking nie, miskien omrede van die of C neci 2. durlgo uitwerking teweeg to bring), wat slagare wat in ontwikkeling van toleransie. Die groot behoefte op hierdie asbt spasme is gou laat ontspan en die pyn dus verlig feitlik voordat dit ontwikkel. Daar is egter geen afdoende antwoord op hierdie probleme nie -- in die Uteratuur is daar bale teensprekende verklarings oor hierdie saak. Verskeie gebied is elntlik aan 'n middei wat aan 'n ander farmakologlese groep behoort, en waarteen toleransie nie ontwikkel nie. 3. eilb the Asb ondersoeke op hierdie gebied is 6f swak beplan M onvol- I. Model), W. (1960- 1961): Drugs of Choice. St. Louis: F dbende gekontroleer. C. V. Mosby. hyp plei DIFFUSE PLEURAL MESOTHELIOMAS IN SOUTH AFRICA sub Kir C. A. Sleoos, Medical Superintendent, West End Ho/pllal, Kimberley; Paul Marchand, Deportment of Thoracic Surgery, University of the Wltwalersrand and Johannesburg General Hospital; and ' . J. C. Waongr, Senior Medical Officer, Pathology Division, Pneumoconiosis Research Unit, South African Council for Scientific and Industrial Research, Johannesburg am: spu sur ing We mil In another paper1 we reported on 33 CBSes of diffuse and radiological findings in the 34 cases which we our spr pleural mesothelioma, histologically diagnosed at the selves investigated. - tos Pneumoconiosis Research Unit of the South African I'; , Council tor Scientific and Industrial Research, Johannes COMPARATIVE RARITY OP D1AQNOSIS cliid fin burg, Thirty of the cases were investigated clinically by The histological diagnosis of diffuse pleural mesotheliomas cia ourselves. Since then a further 8 coses have been proved, is a contentious subject. Doubt has been thrown on their CXI '4 of which were under our care. Tbis paper supplements existence as an entity by Robertson1 and Willis.' Primary our other communication with a description of the clinical malignant mesotbetial tumours were described by As 14 January 19$i 14 Januarie 1961 S.A. TyDSKRIF vjr Genebbkundb 29 king om die akute lliserieltrinitraat (in Amielnitrict Is nie tog nog aanbevet) ng verlang word, rd (nitro-gliserienj del In die lewq 1 van krag as die dit neem 'n rukkle' r dit duur ook weer wat ingeascm word, word dus deur die , bepaal. Dit is ook eer nie teenwoordi| in hierdie .nilraal' :t. maar hulls word leenhouers is van karboksasied, fenelulle het ,'n uitwer--.die sogenoemde, iervan mag wel van tartkramp, maar die : benader te word, jeruime tyd lank al it ook die geval is /ergelyking met die voordeel aangedui tiddels is wat wel Id nitriete die enigsle die die kroonslagare wya dat die. meeste sou h6. wel effekte het egter nie 'a ien omiede van die behoefte op hlerdle wat aan *n aader irteen toleransie nie >/ Choice. St. Louis: ICA nesburg General 'h African Council ases which we our- iaqnosis - leural mesotheliomas een thrown on their ' and WiUia.* Primary ; ere described by . Klemperer and Rabin* and Stout and Murray.* Recently reports concerning these tumours have appeared Irom various countries; these include those of Tobiassen,* Bellini and Bovo,' Oodwin' and McCaughey.' The diag nosis in our cases has been confirmed by South African nHihologists and well-known authorities from Britain and the USA, including Dible,1' Oough," Steiner,0 Stewart," and Vorwald.'* . Diffuse pleural mesothelioma is generally considered a rare tumour. Daub and Jones'* reported 3 cases among 34$ 000 consecutive admissions to the Henry Ford Hospi tal The largest series that we have been able to find in the literature is that of Cboptal el al." who described 22 cases sees over a period of many years. In contrast, our larger group has been diagnosed mainly during the last 4 years, ft must be stressed that we have only included cases in which the nature of the tumour has been confirmed histologically, either on biopsy- or necropsy material. A number of cases showing radiological and clinical features only have been excluded. Three of these cases had markedly abnormal cells in the pleural fluid. association with asbestos . This frequency of mesotheliomas is possibly significant in its apparent association with areas where asbestos is mined or milled. Evidence in support of this has already been presented1 and includes: 1. Tbe finding of asbestos bodies in the lungs of 12 (30%) of the 41 patients with mesotheliomas, even though in tbe majority of the earlier cases, before the association was suspected, the biopsies usually consisted of tissue from the parietal pleura only. Asbestos bodies have been found ASBMTOg HILLS In 9. of 11 biopsies in which lung parenchyma was in cluded. Evidence of asbestosis has been observed in 6 out Fig. 1. Map showing asbestos deposits in (be Cape Province. .. of the 7 cases In which the lungs have been examined at Cape, the most extensive in tbe world, extends from 20 necropsy. . miles south of the Orange River north to tbe Bechuana- 2. Tbe fact that 19 of these patients worked with land border, covering approximately 8,000 square miles. asbestos, either as miners, millers or industrial workers. Tbe deposits are mainly in the slopes of tbe Asbestos 3. Tbe fact that all except 2 of the other 22 cases were Mountains, a range extending more or less longitudinally either bom, or spent a significant period'of their lives, in . between 22-30* and 23'B (Fig. 1). the asbestos area of tbe north-western Cape Province. Mining and Milling Asbestos Bodies in the Sputum Further, one of ua (C.A.S.), working on the clioical hypothesis that exposure to asbestos causes on increased pleural reaction in patients suffering from tuberculosis, submitted numerous sputa from the West End Hospital, Kimberley, to tbe Pneumoconiosis Research Unit for ex amination. Asbestos bodies and fibres were found in the sputa of 115 patients who bad no definite mining expo sure. Included in these were specimens from people work ing in a dry-cleaning works and abattoirs in the North West Capo in places 100 miles away from the nearest mines. Tbe presence of asbestos bodies and fibres in tbe sputum is naturally only indicative of exposure to asbes tos dust and is not evidence of asbestosis unless there is clinical and radiological support However, from these findings it would appear that people possibly not asso ciated with asbestos production or utilization, have been exposed to the hazard. The type of asbestos mined throughout this area is crocidolite,. better known as Cape blue asbestos. Croci dolite is the fibrous form of riebeckite. All stages of transformation, from massivo riebeckite rock through lamellar riebeckite to asbestifonn crocidolite, occur in this region. Magnetite iB frequently associated with tbe crod- dolite (Vennaas"). Mining of asbestos first began in the Prieska district in 1893 aftd gradually spread northward. In 1908, production had begun m the Kururaan district This northward trend has continued and, in about 1950, mining started at Pom-Pom, near the Becbuanaland border. (Fig. 2 showB, graphically, the asbestos production from 1910 - 1958.) Initially the ore was quarried In numerous small open-cast workings. This was followed gradually by a type of shallow mining;'inclined shafting became more common after 1930. . Since the 1939 1945 war, tbe demand for crocidolite has increased enormously. Since, doeper and-richer deposits have been found, vertical shafts are being sunk.. However, Asbestos In the North West Cape the mines with large shallow deposits continue In use the The area of the asbestos deposit in the North West inclined shaft and tunnel, and quarrying is stiil used by t 30 S.A. Medical Journal 14 January 1661 14 Januai 1955, according to Doll," a total of 61 cases bad been reported. Merewetber" analysed tbe cases that bad occurred in Britain between 1924 and 1954. He found that in a total number of 344 cases, carcinoma of the lung pleural eff Ihe patient Tuberculot pleural dis was present in 55 (16%), the figure for males being 41 of obvious (20% of males) and for females 14 (10% of females). Six cases of mesothelioma of the pleura associated with asbestosis have been described. One was mentioned by Doll," 2 by Cartier," and 3 by Van der Scboot." A further 33 cases with possible asbestos exposure were described by Wagner el at.' . In our series of cases the latent period, between first Age, Sex, . Our 34 C 1). Si* me the Bsbest> time of d Table i. apparent exposure to asbestos dust and the Initial symp toms of the disease, was between 20 and 60 years. In some cases the patients bad left the North West Cape Race and, in others, the exposure bad been of such a transitory nature that it was rapidly forgotten. Evidence of expo sure was only obtained after long and detailed questioning. While Coloured According to Day" and Stewart," a long latent period between initial exposure and tbe development of evidence Bantu of malignancy is one of the features of occupational Total ; tumours. The reason for the tumours having been found in the vicinity of tbe Cape asbestos fields and hot in the were alt region of the Transvaal asbestos mines may be due to this 31. On t Fig. 3. Production of crocidolite by asbeitos mines in lime factor; assuming that the association is significant, men and Ihe Norih West Cape in ions per year (1910-1959). since the industry was established earlier in tbe Cape than these pa' r V; i:.'1 "J 1 . :'j ' o" ' . :C" the few remaining smaller producers. With tbc building of more mills, band cobbing* bas diminished. In 1915 the first crushing mill was established at Koegas In the south. This was followed by a large mill at Kuruman (operated between 1926 and 1931) where it was situated within 300 yards of the main street, close to which hand cobbing was also done for ei few years (1927 - 1930). This was followed by a mill at Prieska in 1930, which was completely re built in 1957. Griquatown bad a small mill iD 1928. The practice today is for one mill to serve several mines in the immediate vicinity. , In tbe early days tbe manager and labourers lived within a few yards of their place of work, and even today the non-Wbite personnel prefer to live as close as possible to the mills and the children play on the dumps from tbe mines and mills. Tbe industrial use. of asbestos bas increased during the last 30 years. In 1930 Hall stated that there were 4 firms in the Union manufacturing asbestos products (in Cape Town, Durban, Johannesburg and Meyerton) which used a total of 900 tons of fibre annually. In 1952, 17,000 tons of fibre were used in local industry. Carroll- Porexynshi" lists 7 firms dealing with asbestos in Cape Town and 44 in Johannesburg. Asbestos cement Bnd an asbestos clay compound are used extensively for insulating boilers in power stations, industries and railway loco motives. Three of our, patients were employed in this way. Another patient was employed manufacturing fire-proof clothing. Cases of asbestosis have been' observed in a variety of industries on the Wiiwatewand. in the Transvaal, where large-scate mining began compara tively recently. The type of asbestos mined is another possible factor which would apply to the chrysolite mines of the- Eastern Transvaal. However, the amosite fibre found' in the Lydenburg district Is similar to the Cape crocidolite and the crocidolite mined around tbe Peters burg district is identical. CLINICAL PICTURE OP MESOTHELIOMA Clinical Presentation . The majority of patients aire over the age of 40, and usually present with symptoms suggestive of a primary tuberculous effusion. Pain varies from a feeling of heaviness to acute pleuritic pain. From the beginning or After a variable time there may be increasing dyspnoea on exertion. Cough is not a predominant symptom in this group. A few patients present as cases of acute respiratory infection with a productive cough. This is accompanied by a pleural effusion. In some cases there is an interval between the respiratory infecdon and tbe finding of tbe pleural effusion. The course of Ihe jdisease, while ulti mately similar, usually takes one of two forms --either the pleural effusion continues to increase, requiring frequent paracentesis, or it undergoes a temporary quiescent period, while the pteural 'space becomes obliterated by tumour. Towards the end the patient is seriously disabled through pleuritic pain and dyspnoea. Terminally ascites may develop due either to peritoneal metastases or to cardiac failure.. area and close uoi of 60. A never be nursing Cape. SI no contt The t> aged be born in cbildhoc lived in visited t women their be to mint much d work. 1 or had The work v port of but bar watcho on dun with a> trial ct motive years i ting ai Asbestos and Carcinoma . The association of asbestos with carcinoma of the lung Clinically the disease may be described as having 3 stages. Initially Ihe presentation is one of pleurisy and ' maker obtaim was first described by Lynch and Smith In 1935." By bronchitis and the usual diagnosis is a virus or pyogenic note d pneumonitis. At this stage andbiotics are usually success of blsl 6; * Freeing the fibre from Ihe ore by striking the lumps of rock with a hammer. ful in alleviating the symptoms. The second stage is one of sibling 14 January 1981 14 Januar|0 1081 S.A. Tydsxrip via Gsnbbsxunde 31 1 cases had been cases that had 54, He found that oma of the Jung r males boing 41 ( of fomales). Six tsociated with asas mentioned by ichoot.0 A further ,-e were described iod, between first the initial symp- 0 and 60 years. North West Cape such a transitory Evidence of expo tailed questioning, ong latent period yment of evidence 1 of occupational taving been found ds and hot in the nay be due to this ion is significant, - in the Cape than ig began comparemined is another e cbrysotiic mines the amosite fibre ailar to the Cape round the Pieters- BLIOMA te age of 40, and Jvo of a primary >m a feeling of . the beginning or creasing dyspnoea it symptom in this . f acute respiratory is is accompanied : >ere is an interval ' the finding of the iscase, while ultiforms -- either the requiring frequent y quiescent period, srated by tumour; ' 1 disabled through tally ascites may ases or to cardiac , 'ibed as having 3 ' e of pleurisy and ; virus or pyogenic , re usually success- . ond stage is one of i nieural effusion with pleural thickeoing; it is then hat Physical Signs ihc oatient is usually admitted to hospital for investigation. In the early stages auscultatory evidence of pleurisy, Tuberculosis, malignancy, asbestosis and other causes of bronchitis, or consolidation are usual. As the disease pro pleural disease may be considered. The final stage is one gresses, respiratory excursions diminish until eventually 0f obvious thoracic malignancy. , a frozen chest results, with flattening of the infraclavjcular Agr, Sex, Race, Habitat and Occupation Our 34 cases consisted of 24 males and 10 females (Table ]) Six men who had lived all their lives in tbo vicinity of ihc asbestos mines were the only patients under 40 at the region, 'roof-tiling* of the ribs- and immobility of the chest wall. The chest is then stony-dull to percussion and air entry is grossly impaired. During this late stage of the diseaso, evidence of time of diagnosis. Four of them had been miners, They secondary spread may appear. Eight cases in our series showed obvious clinical signs of peritoneal involvement TABLE I. AOS AND RAM DISTRIBUTION OF TH8 34 CASKS OF before death. The peritoneum is usually infiltrated by . MESOTHELIOMA DBSCRJBBD Age direct spread through the diaphragm. The liver may be en Totalal rged and nodular, due to perihepatic involvement. Local Ract Sex 30 - 39 10-49 }0- 59 Over 60 ized masses due to ihvolvemeht of the omentum or para /Male (14) 2-6 3 20 Whin \ Female(6) 0 I 3 2/ 20 aortic lymph nodes may be felt. In these cases ascites is common. Involvement of the lymph glands of the neck has . , . /Male (J) 2 Coloured |Pemale (3) 0 o Bamu /Male (3) 2 \Pemele (I) 0 Total 6 2 2 2 0 13 0 l.\ . been clinically obvious in 2 cases. Implantation of the 1 0/ * tumour in a biopsy scar is not frequent, but it complicated 0 I\ s. 1 Of 6 4 thoracotomies and 1 thoracoscopy in our series. Haema- 8 7 34 togenous spread is unusual and only 2 cases have even ' tually developed distant metastases. These were predomi were all in their thirties, the youngest being a miner aged nantly subcutaneous but, in 1 instance, numerous small 31. On the other hand, 7 patients were over 60, 5 being deposits appeared in the tongue. men and 2 women. The oldest was a man of 68. Sbt of Pleural effusions have always developed. Fluid collec these patients had lived for many years in the asbestos tions of 5 - 6 pints have occurred, but often the pleural area and 3 of the 5 men had worked for long periods in space is largely obliterated and only small effusions can close contact with asbestos. One woman died at the age collect. On tapping these effusions, considerable resistance of 60. As far as we have been able to ascertain, she had is encountered due to the thickness of the diseased tissue never been in contact with asbestos in her occupation as a (up to 2 cm.) which has to be traversed, Even with the nursing Bister, and had never lived in the North West point inside the cavity, the needle is often so tjghtly Cape. She is the only patient of the 34 who apparently had gripped that manipulations are restricted. Usually the fluid no contact whatever with asbestos. ' is straw-coloured, but blood-staining occurs and may be The remaining 21 patients, 8 women and 13 men, were heavy, . aged between 40 and 60. The 8 women had either been born in the asbestos district, or had moved there in early childhood. At the time of' diagnosis, 3 of these women lived in the Transvaal and had never, or only occasionally, visited the North West Cape after leaving school. Three women had been engaged in the cobbing of asbestos in their homes. The non-European women mostly lived close to mines in bouses where cobbing operations produced much dust, even when they themselves had done no such work. The European women had been to school near mills or had played on the dumps. The 13 men aged between 40 and 60 comprised 7 whose work was connected with the mining, milling and trans port of asbestos, 2 who were bom and bred in the district but had not been engaged in the industry (they had ofton watched cobbing' operations in native huts and had played on dumps and in mine shafts on farms), and 4 who worked with asbestos in distant industrial towns. Of these indus trial cases, 2 were boiler makers who had lagged loco motive boilers. Another of these men bad spent the war years manufacturing asbestos protective devices tor fightting aircraft fires, and the fourth had worked as a boiler maker in a Cape factory, whose supply of asbestos was obtained from the Cape asbestos fields. It is interesting to note that in 1 family both the father and a daughter died of histologically proved mesotheliomas. In 2 other cases a sibling had radiological evidence of asbestosis. Pig. 3, Diffuse pulmonary asbestosis, particular well shown in lower lung zones. ! i `r.r 1 ;> 32 S.A. Medical Journal 14 January 1961 14 Jenuarl SPECIAL INVESTIGATIONS , . Radiological Features The X-ray findings roughly parallel the clinical progress. The initial radiographs may show few changes, In about a third of the cases, radiological 'signs of asbeslosis were present. Asbestosis. In' individuals with a proved and ade quate record of exposure, is characterized by evidence of diffuse interstitial fibrosis of varying degree. In a wellestablished case tbe appearance will conform to the wellknown classical pattern of pulmonary asbestosis. This may be either a generalized homogenous clouding of the lung fields, particularly the lower zones, or a fine striate and fibrillary change in the lung structure, with progressive loss of pulmonary radiolucency (Fig. 3). In the majority of cases of asbestosis, old-standing pleuritic changes are also seen. Thus a combination of both pleural and pulmonary parenchymal pathology fre quently occurs. The pleural changes take tbe form of bi lateral pleural thickening, pleural adhesions and rather characteristic dense calcific plaques (Frost el al.u). While pleural thickening per se in asbestosis is non-specific in character, sclerotic pleurisy, with plaque formation, con stitutes a readily recognizable and ratber typical entity (Fig. 4). The pattern of calcification patently differs from mica (Smith1*), The plaques may be few or widespread. They are usually bilateral, and disposed in irregular patches, chiefly in the middle and lower zones. Seen endon they appear as linear plaques in. the periphery, along the diaphragmatic contours, and adjacent to the media stinum. A lateral view of the thorax will also very often show extensive linear plaque formation, involving the diaphragm and the anterior aspect directly behind the sternum. Such pleural calcification was encountered in several of our cases of mesothelioma (Hurwitz1'-"). However, In the majority of cases, no evidence of pre. ceding pleural or pulmonary asbestosis was found. These cases, on investigation, invariably showed unilateral pleural involvement in the form of diffuse thickening or effusion. The appearance may be massive from the beginning, but usually a localized scalloping, or solitary mass in the periphery, raises tbe first suspicion of pleural neoplasm. As the disease advances,- more extensive nodular or `lumpy' pleural thickening develops (Fig. J). This pattern Pig. 6. Linvolvem< is still p Fig. S. Nodular pleural thickening, seen clearly on the right. * Fig. 4. Extensive bilateral pleural plaque formation. Typi cal involvement of paramediastinal and diaphragmatic pleura Is also demonstrated. , pleural calcification due to other causes. This patient was recognized frequently during the recent investigations of miners and millers. Even the -chance finding of such typical calcification is now accepted as being highly sig nificant, so that previous' exposure to asbestos may be predicted with reasonable confidence. Tbe dense- plaques, however, do simulate those described in. workers exposed to other silicate dusts such as tremollte talc, calcifnine -and of unilateral pleural pathology is a highly significant find ing in a patient from the asbestos areas, but of course, a similar appearance may be produced by secondary-malig nant involvement of the pleura. Very often a large pleura) effusion will obliterate the picture and, only after removal of the fluid, will it become apparent that the pleura is . grossly thickened and nodular. Both the parietal and - visceral pleura are affected and an induced pneumothorax, particularly, will clearly demonstrate the rather character istic pattern of marginal massive nodularity. along the parietal chest wall, over the surface of the collapsed lung, and at the base (Fig. fi). ' ' In the I cavity may may remai lung may ' by a thick astinal pie come infill logically. 1 extension, progression a change also occui may be pi Stout a ponderanc ported by present at had righttouis proc of the pat Thoracost The ini appointin; thelioma lated. Wb walls of t no arebih the tecbo of area I obtain a usual dia 14 January 1961- 14 januarle 1961 S.A. T v D8KRI F V.R Gbneesxunde 33 ew or widespread, tosed in irregular t zones. Seen end. ie periphery, along enl to the media- 'ill also very often on, involving (be irectly behind the - as encountered in Hurwitz*'-"). . o evidence of prewas found. These d unilateral pleural Itening or effusion, (he beginning, but itary mass in the pleural neoplasm, naive nodular or g. J). This pattern n clearly on the ly significant findi, but of course, a ' ' secondary'maiigten a large pleural only after removal . that the pleura is : the parietal and red pneumothorax, s rather character- ' (ularity along the 1 the collapsed lung, i: In the later stages, a considerable part of the pleural cavity may be obliterated and a comparatively small space may remain. Here fluid may collect under tension and (he lung may be further compressed, in spite of being encased by a thick tough covering of malignant tissue. As the medi astinal pleura thickens, and the regional lymph glands be come infiltrated, widening of the mediastinum is seen radio logically. Eventually the pericardium is involved by direct extension, and the resultant pericardial effusion causes progressive enlargement of the cardiac silhouette- and a change in its configuration. Extrapleural extension can alio occur; then radiological evidence of. rib involvement may be present. .' Stout and Murray* remark upon the right-sided pre ponderance of the disease. In the series of 24. cases re ported by Cboptal et al.,u 19 were right-sided. Our cases present an Identical distribution, since 27 of the 34 cases had right-sided lesions. In no case was the mesothelioma- tous process initially bilateral, although the X-rays of 10 of the patients showed bilateral changes due to asbestosis. Thoracoscopy and Thoracotomy The information obtained from thoracoscopy was dis appointing. The view is always limited in cases of meso thelioma because the cannula cannot be freely manipu lated. When btood bas extravasated into the effusion, the walls of the cavity are covered with fibrinous deposits and no architectural details are visible. The chief objection to the technique, as a diagnostic measure, is that the choice f area for biopsy is restricted, and It is impossible to obtain a representative specimen. Thoracoscopy was the usual diagnostic procedure in the early stages and, al though sufficient material for microscopic examination was usually obtained, we feel that a great deal of Informa tion was missed. . . With early cases, where the pleura is thin and the effusion clear, it is often possible to visualize the discrete pleural nodules overlying the still elastic lung. The nodules are then usually cherry-coloured and either smoothlyrounded or warty in appearance. Later the discrete nodules coalesce and the underlying lung Is obscured. The growth is then usually seen as a grey opaque membrane, with localized excrescences of variable aize and similar appear? nee projecting inlo the pleural space. At this stage the outstanding feature is the thickness and density of the pleural growth and the complete immobility of the incar cerated lung beneath. As far as possible, it is now our policy to obtain a specimen of lung by open operation. With 4 early cases, attempts were made to decorticate lungs which were com pletely encased by thick, apparently fibrous, coverings. In 3 cases the findings were similar. The parietal pleura was I 2 cm. thick and very hard. The lungs were col lapsed and bound down by thickened visceral pleura, identical io appearance with the parietal pleura. The pleural spaces were occupied by straw-coloured or blood stained fluid. Attempts to strip the 'peel' off the chest wall could only be made through the extrapleural plane, but even then the intercostal spaces were constantly entered and no vestige of normal parietal pleura could be found. Calcified plaques within the diseased tissue were frequently encountered, particularly over the diaphragm and inter- Pig. 7. Macroscopic specimen of mesothelioma of the pleura. ! :;;i ; ] . ! ': ' - n . :.i- :V 1 : 34 S.A. Medical Journal 14 January 196]' 14 Jnnuai lobar fissures. It Was never possible to defino planes be the additional discomforts of present forms of therapy, tut tween the visceral pleura and the pathological tissue, so we still advise radio-active gold intrapleuraily for tht that separation was possible only by entering lung tissue. False planes could be developed through compressed peri pheral lung. When the deep aspects of the peel were in spected, fine blackened fragments of lung were seen adhering to them. Tbe tumours dipped into the lung sub stance along the Interlobular septa and, for this reason, stripping along these false planes was baited every few millimetres. Inevitably, the procedure has to be abandoned, comparatively early case, where the lung retains sornt elasticity. SUMMARV . The clinical and radiological findings of 34 patients suf. faring from diffuse pleural mesotheliomas are described. Thirty-three of these patients gave a history of exposurt to crocidolito asbestos. mined in tbe North. West Cape. SOUTH A It js with r. that ncgolii Society tiB1 cannot be insured by tp. 1064 o t>t treated leaving a collapsed, tattered and leaking lung However, even when lung tissue was available, histological rendered i awopsv findings' evidence of asbestosis was not obtained in every case. lor the pa; Asbestos bodies wore found in tbe lung tissue of 30% ol Cheques At autopsy the whole thoracic cavity may be occupied the cases. ' Mutual M by a large gelatinous tumour, which displaces the media Tbe findings of this and our other paper1 are sufficiently account rt stinum, and markedly compresses the lung (Fig. T). In striking to justify further epidemiological and laboratory injurmice other cases tbe tumour may be dense and cartilaginous. In investigations. These investigations will attempt' to deter these advanced cases no remnant of a pleural space may remain. Tbe tumour infiltrates adjacent structures, so that tbe pericardium, heart, cbesl wall, diaphragm and live'r may forin one solid mass. In 1 case the tumour extended into tbe posterior peritoneum, encasing a kidney. The mediastinal, cervical and paraaortic lymph glands may be involved and appear as large discrete tumours. The lung is always compressed, with marked lymphatic spread in some terminal cases. Because tbe neoplasm extends aloog theinterlobar fissures, tbe lobes appear as 2 or 3 small deeply pigmented areas within a huge pinkish-white mass. mine tbe causative and correlative factors, including a possible relationship with asbestos or other elements, especially in tbe regions from which the cases have most frequently been reported. , We wigh to thank the many medical practitioners in th Qriqualaod West District, and the thoracic surgeons, physicians, radiologists and pathologists from elsewhere in ihe Union whose assistance nas made this. investigation possible. - We thank the Director of the Pneumoconiosis Bureau (or permission to reproduce the X-roy plates shown in Figs. 3 and 4. When the insurance the medic: They fisc considers all done ' they appr assist ihei The Fe in March medical l by incurs PROONQSIS AND TREATMENT . Our first impressions, based upon the apparently fibrous nature of the tumour, was that it was slow-growing, but we found this to be far from true. According to Choptal We thank the Secretary (or Health for permission to publish this paper. REFERENCES Wajncr.^J. Cg Slew. C A. ir>d Merdund, P. (1960): BrU. J. latfusU. down lot of Counc companie providing the medi satisfied et al,u the average duration of life from tbe time of onset of symptoms is 18 months. Hocbberg's review" of 43 cases showed that 37 (86%) died within the first year. Of the 34 patients' discussed here, 28 have died, 17 (61%) within a year of tbe development of symptoms. Seven (23%) died during the second year, 2 (7%) during the third year, and all 28 were dead within 48 months, which is the longest survival time among our patients. It' has already been shown that operative removal of the growth U impossible and some form of cbemo- or radio-active therapy would seem to provide the only hope of effective treatment. Results have been disappointing. tWo patients were given repeated intrapleural Injections of nitrogen mustard. Both men died within 6 months. Four patients, with seemingly localized areas of disease, were given deep-X-ray therapy. All were dead within a year. Six patients have bad radio-active gold instillations. Four died within 13 months of the commencement of their in jections and 2 are alive, but their treatmeul was recent. There seems little to be gained by subjecting patients to Robtrtton. H. B, (1924): I. Cancer Res., 81, 317. those pc; Willis, R. A. (193)): PoiMoty of Tumourt, 2nd ed. London: Buur worth. Klemperer, P. end Rabin, C. B. (19)1): Arch. Pith., lie >83. Stout, A. P. ndMmy, M. R. (1943): Ibid.. 34, 931, fundame: vision ot and the Tobiown, o. (1933): Acts. path. mierobJol. eend. oopol. 103, 198. Bellini. Q. ood Bovo, O. (1937): Acta mod. 17, 367. Oodwtn, M. C. 093717)1): Cancceerr,. |"0, 298. , McCullhor. W, T, E-. ("IM"1S>:):7......P..a.t.h......B...w...t..., VS. JI7. Dibfc, 7. H. (1959): Pcnon.l commoiUcaiiofl. Oowji, (Ifa?): 'PenceoI communication. Stoiner, P. (1937): Pmonal communication. Stewart, H. (1959): Pmonal communication. payment At its agreed, f compani bers of sponsor! Vonrold, A. (1999); Pmonal communication. VDallulVb,. )n1. aSHnUd Jena, nH. \(t1wM'en2g);: MRaWdiiVotloUgWy,i J. 27r. Qtoguil, Cvnpo, A., Jam, R. ond Campo, C. (1996): Poumoft, income panics v all insu: Vermaai. F. K. (1933): Tram. Ood. Soe. S. Afr., 53, IP9. . be rega CarrolKPorcryndu. C. S. (1933): Atbottoc from Rock to Fabric, Manchester The TttUla Institute. ' Lyncb.K. M. and Smith. W. A. (1925): Amer. J. Cancer, 34. 36. insurant rules to Doll, k. (1993): Bril. J. Industr. Mod., 13, 81. Follo Mmweiber, B. R. A. (1934): Annual Report. Inrpeetor of Pretoria, p. 191, London: Her Manty'a Suttoceiy 0(1fee. Canter, P. (1933): Arch, mdatu. Hra*. S, 263. wers he took pi Van der School, H. M. C. (1938): Nod. T. Ornok,, l3. >123. Comm! Day, B. (1938): Penonal coramunfeotlon. Fwi.-J., Oooru. L end MoUer, P. P. (1936): Dob. Mad. Bu9., 3. 2PL Smith, A, R. (1933): Amer. J. Roentmtol., 167, )73. insurer* income HurwMi, M. (1939): In Proceedings -- rneumocordorli Conference I9S9. persons London; Cburchiil. Idem (I960): Personal communication. Hoohbcrs, L. A. (1931): Amer. Rev. Tube*., O, 130. ' receive sallsfae of SAI I membe PASSING EVENTS : IN DIE VERBYGAAN live of unfortr South African Institute for Medical Research, Johannesburg, Staff Scientific Meeting. The next meeting will be held on Monday 23 January' at 5.10 p.m. in the Institute Lecture Theatre. Dr. L. Webster, of tbe Pneumoconiosis Research Unit, will speak on `Pneumoconiosis problems'. Southern Transvaal Branch (M.AS.AX An Important general meeting of this Branch will be held at Medical House, S Bssclen Street, Hospital Hill, Johannesburg, on Tuesday 17 January 1961 at 8.15 p.m. Reports will be presented by the President on the recent developments in connection with (a) medical insurance companies, (b) medical old societies, ood ' (c) the Medical Services Plan. The Domicile Clause in Section . 24 of the Medico), Dental and Pharmacy Act will also bs before the meeting for full discussion. Members of' the Branch are urgently requested to attend this important meeting. . the rut any de The two sc The ne did noInter a the fee