Document 93jDXOyE62KJapg8bmOMdGZae

.,, a*"*** 3t B r it J m dustr M e d , 1960, 17,260. D IL I U S E P L E U R A L M E S O T H E L IO M A DIFFUSE PLEURA bo rro w in g NOARSTBHESWTEOSST MAW ffl fp iiE s r J C W A CiN H R C A 8 /2), /7 , DHEW PHS c j . A REQUEST >t Oiu m o ii Pm wm Sf*0 SHEETS >! Ht u m ,h Johann *r C to ifWivn tmuty VO (KK 1IVI II K fNCLDSf SHippue usti _ ^ o c l c v i |/a , FOB USE ----------- W HO l ,, f K irs c h s tp - i M o ry (o n * o n tus Prim ary malign tnt 1tumours of the fe to -- I I females ages 31 It: XI of diffuse probable exposure !o . de filile asbc` Asbestos Hills \vhivli Ik. ' ihc west o f I H I M ' is rarely seen clscwhs in South A .. M csulh cliom i o f the pleura is regard' ' VOla7' *>B r i t - J . I n d i i s t r . y e i hriC n c r , J C 260-71 ediijon iUSe PieUral ^ uncommon lu m our In the I is! four vear seen 33 histologically prosen cases 2S of Prence) some issoci.uion with the Cape asbestos four c pcs had been exposed to asbestos ir The tumour is rarely encountered els South Africa During the past live year exception o f the present scries no ncopl. W N CIRCUI flT|NG, PtPAS SUPPLY C l Mic ro film n bard copy IF COST DOES. or EXCEEO $ 'Fil m . _ MARO copy_ _ Jo h n .sburg diagnosed amongst 10 the Pr the Pathology Hep OATf RCCE^TO____ ___ DTE REFUR/vfo__ " ---- ------ nstnute foi Medic a 1ligginwon and Oel lief 1957) did not obsr their su rvey of maligna nt tun m the Bantu a n j C.i pe Colon red Joham usbtirg .,md the North Fa stei 68s 1 naNsoOsMuTmEife-TsiitQiciEeir<eqpe!(,p,RriivP',Rrb,9rielilctiyebirpaftrjyf Our first neeropsy specimen of pie mal1 meso1lie III 111la with asbestosis was ex.mimed at the Pile till] ocomosis R ese itsh Unit in 1chinai v, 1956 ( ( ase 1) Dm mg the early mo nth's of th. it vear. one of us (C A S ) in the Norths rn C ape, tre ated Six deny that tnc (Men. mines or was expose 1his is a orelimm i is being intensively patient s with gloss Idenial 111 icke ning Pleural biopsies fiom t wo o f 1hem show ed the feulures of Ih c \sl)cslus \rc. o f the North-West Cape mesothelioma In the ensuing two yc.us eight fuither eases xveie found from this region and fixe from elsewhere in the Union During this period C A S had become pet im bed at the number of these unusual tumours occm ring amongst Ins patients, and stimulated an investigation A t tins Aeeoidm g to Hall H930) asbestos was discovered by l lehenslcin ne ir Pricska during his travels be tween I SOI and IS06 Stnce then n has been established that the asbestos deposits extend from 20 miles south of Pneska, northwards through the western part o f the magisterial district o f H ay, to stjgc there were two reasons to suggest th it asbestos might be im plicated First, asbestos was found in Ihc eastern portion of the magisterial district of Posim .isburg and finally, to ihc western area o f the BT n i l s . . , RaI f n ---------- bbstace ivruisro s -- ,, ~ ; r ----- -- EBBED FOBS____ .REDDEST ADD ,,r r ~ ~ - ~ woursrfooN BENfl'.FO TO__ and here whites may . .DR period of bedevvalj" vicinity of the mines The type o f asbestos mined throughout this area is crocidohte belter known as Cape Blue \sbestos I lie chemical analysis of the fibre is given in I able 1 C rocidohtc is ihc hbrous form of riebcekilc and all stages of transform ition Horn a massive ricbeckitc rock thiough lamellar ncbeekitc to asbcsliform crocidohte occur in this region Magnetite is frequently associated with the crocidohte (Vcrm aas, 1952) Mining of asbestos first began in the Prieska district in 1893 and gradually spread northwards egun m the Kurum an dis1918 a large immlier of This lim tliw ird trend has l 1950 mining started at in.il md border (1 ible 2). nam ed m numerous small us w is followed gradually 15 A S N g T f P H O T O C O P Y M A D E B Y . T H E J S A T J P N A L - U A S y W W 1V , Nh k T u P U H 8 ' V s r s O F 5 T t i r ) Y O R R F S F C R C H IN M F l i O F L E N D I N G T H F O P B n t J irulustr A W , I9 60, 17, 260. DIFNFUOASRESTBHPELSWETUEORSSTAEELRXNMPOECSSAUOPRTEEHPEIRNLOIOTVMHINEACEAND BY J C W A G N I R , C A S L I C C . S , id p a u l M a r c h a n d on, Iht I . Diu m ii/i, Pm a huttv ill Ht >(luh, John "m t of Vu w` *< > '< >' 1 o f '!'< Conn, d fat S<u nu/tc and 11II'H D , s/ r illI Ho \pt,al, hioihi il, 1 a,III ,hc " u K , ... (KKM U I1 I OR CllHIKAIION Al'KII 24. 1900> Prim ar m aliyivim tumours o f tbs pleura are uncommon rh .M vlh rcc c rscs P ' males i l fenul. -. ages H lo 6XJ o f d i l l W pleural mesothelioma are descnbcd all hut one h probable AvK.-st.is <- raiely sposure to crou jlolitc asbestos ,( ape blue, In a m .jo in y r)m exposure u the lills whieli lie to llie West of Kim berley m the north west o f Cape Prosir 'eeti elsewhere in South A ln c a ~The tumour Mesothelioma of the pleura is regarded as an uncommon tumour In the last four \c us we h n c seen 77 hislologiealK ptosen eases 2,s of these h id some .issoualion m il) the (a p e usK-dos /eld and four eases had K e n exposed to isbestos m industry The tumour is rarely encountered elsewhere in South Africa During the past live veais with the exception o f I he present series no neoplasm o f this natmc h is been dngnosed amongst 10 000 lungs examined at the Pneumoconiosis Bureau in lohaniiesburg. or in the P ithologv Depaitm ont of the South A fuean Institute for Medieal Research I hggmson ind Oelllc (1957) did not observe a single ease m their survey of malign mt tumours occurring m the Bantu and ( a p e Colourcil population of Johannesburg and the North I astern frm svn al O u r first neeiopsy specimen o f pleural meso thelioma with asKsiosis was examined at the Pneumoconiosis Research U n it m F e h iu ir y , 1956 <(ase I ) During the early months e>f that vcai, o ik o f us ( C A S ) in the Northern Cape, treated six patients with gross pleural thickening Pleural biopsies fiom two o f them showed the features o f mesothelioma In the ensuing two sears eight further e iscs were found from this region and live from civcohere m the Union D uring his period ( A S had K-come perturbed at the number o f these unusual tumours occurring amongst his patients, and stimulated an investigation A t this stage there were two reasons to suggest that asbestos might be implicated First, asbestos was found in the lungs o f the fust case (Case I) and secondly 10 o f the eases came bom a hospital to which suspected eases o f tuhcieulosis were referred from a I irgc ixK xM s mining area Tins hypothesis could not K- supported it once from the original histones obt m ud from the patients, for they included house wives, domestic servants cattle herders, farmers, a water badi/r. an insurance agenl and an accountant name o f whom were working on the asbestos nunc' at the lime W e therefore undertook a detailed investigation o f their past occupation and place ol residence and the association with asbestos ex posure was discovered The eases arc summarued in Table 3 Previous biopsy specimens were rc examined and new cases diagnosed, including isbestos miners In only one case do the relatives denv t h u the patient cither visited the asbestos mines nr was exposed to asbestos This is a preliminary publication and the problem is K in g intensively investigated fh c Asbestos \rca o f the North-West (a p e According to H ill (1970) asbestos was discovered by Liehenslem near Pricska during his travels be tween l.x'0 ? and IS06 Since then it has been established that the axKxtos deposits extend from 20 miles south o f Pricska, northwards through the western part o f the magisterial district o f H ay , to the eastern portion of the magisterial district of Poxtmasburg and finally, to the western area o f the ***w* D IF F U S E P L E U R A L M ESO T U k L JO M A district of Ku n im .m (I ig I) These deposits occur in the slopes of a lange of hills covering an area o f approxim tiely X 000 squire miles K n ow n as ihc " Asbestos M o u n ta in s '. these hills extend more or less longitudinally K-tween 22 70 and 27 L The whole irea is semi-und sparsely populated and. apart from mining cattle rm chm u is the only important occupation In the' Kurum an area several large tracts o f land m or abutting on these mountains have been reserved for the aboriginal m bib il.m ls and here whites may only reside in the immediate vicinity of the mines The type o f asbestos mined throughout this area is crocidohlc, better known as Cape Blue Asbcsios I ho chemical analysis o f the fibre is given m T abic 1 ( rocidolite is the tthrous form o f ricbcskiie and all stages of transformation fiom a massive richecKitc rock through I mwllar richeckilc to asbestiform crocidohlc occur in tins region Magnetite is frequently associated with the crocidohlc (Vermaas, 1952). M ining o f asbestos first began m the Pricska district m 1893 and gradually spread northwards In 1908 production had begun m the Kurum an dis trict Between 1916 and 1918 a large number of sl.iims were taken up This northward irern) has continued and in about 1950 mining started at Pomfrct near the Bechuanaland border (Table 2). Initially the ore was qu ail led in numerous small open east workings This was followed gradually Tabli 1 CHi VIK W ACAIYsIX f l l ( ROCIDOl U h A \ l ) AMOSITE I ,, IS A S I N r S r " P H O T O C O P Y ' m A D L R Y ' t H F N A T I O N A L L I B H A R Y O K lYICUie-lNe M U H W s r s OF R T Iin Y o r r f s f a r c h in i ifu o f L ENPINO t h f orw- Kucuitiiri B R IT IS H JO U R N A L O f IN D U S T R IA L M E D IC IN E Ta k ie 2 Bfc SITIM TLD Wl'ilts 1410 Pr.paljuon [951 10JM7 :8 Vi? 2510b by a ispc o f shallow mining inclined shafting, lx- today the m w -itbnc prefers fo five as close as c mte more . ommon after 1910 possible md the children play on the dumps from Aecc'rdmg to ) rood (1915) th<- quarrying .is a (lie mine md null fu m k dYur u m kit.iVi.il bv the lue.il mlmbitants Tfie men quarried the took w hich was sorted and (lien Iu k id cobbed by the om en j d children I I md eobhnig consists of epar.iting the tibre from ills k m d cU irons tone bv sinking the rock enh w nh a small Itunttwcr As the market .is selective a Cave Histones The following eight ease hi'lones dlusirnc vinous aspects of the doe ise md the differenl types e>f exposure ishesl , dust rot tiy 'liv e .is sometimes used to g ride the itbre and sliniiiJ.ile the 'm ail particle' o f dust After gi uling it ss IS Is ij'i'sd and we ighed 1he asbe .tos vsas tilen tr.nispoileO Iss donVcv M tgon to Ihe ne.uest <ase 1 It P , .1 ttintu m ile th ye irs of age' (born VJ20) w is a mule lihouret, nut w in the (list else di lei'" ' d as a nic'i'Uieliom i with o n liiiu of ishesiOsis I k was honi 111 the kuruin m clMi let hut it is not known rul-lie id Ilc.toie tbs estuhhshnji nt o) h i r,lu,iy m this ilea lss.lssse 11 l')2 t auel l 1) 11' Mich a jotuney cmid last is long is Ml d iss in is t r ins p>rt was yetie'l.iiu m ilk 1 1ikvll by while >l mills I f.irnieis sons) under csulll i<I lb s white inh ibit lilts p li\d vets elllplnvsd mi IlK \s itu lursr Hid fold lllllle' Ulldel ground tor (n o eos irnf in die elinife looms fi'r a furlher 11 yv.iis A i .k Iioi r iph l iken at a mine hospital on August 1, JhSS eti.m^d I ni issue i a iit-sidvJ phur.il effusion, lllllc p lit >1! netu tl H u n e lj o / (he- (due I'vlOg Os uly md t POO ml ot thud w is withdr iw n I le was ailniitted .11vs,i\ s empliised 111 tile' in k ol iiiaiiayvrs oi oveiseers is' ui np stores and super s oi in' the pi id int. and sseiphim; d the hbies 1 nming tern dies Wt/e arid are still earned out resmv.l the mines Since die I v l v IV-15 ss.it the demand for eioeido- hle has eiiiu m i'iisk nieieavc'd I I'e Ills r dive' chums base beui bought bv ice islcitd eonipm ics others h ow been abandoned As ekcpi r md richer deposits hiss been found s e ilie i! shifts He W'un; sunk Ih'vvevcr. the mine's with laree sh ill.m deposits ire still iis iih ' the mclmsd shaft am i tunnel .md qu,HI i iti(2 is stdi used by the less remaining sot die r p io c W s rs W ith the hinkhiip of ih d k mills hand eohbmu h is diminished In I'M*) i Ik lust e i usliiiii; null ss.ls es| ibhshe J at kr'c g is in I he south Ib is was followed by a lope duff it k u iiiiiu n !i lite V. aw Hei sr.uHl Native 1 ihi'ur Associilion I lospu d on Aug usi 24, I ht v_ ind two day s I.ik r .ispira tion welded t into ml ol thick feiitm oiis pus 'which e<>uld he pulled "Ml |W tine ids' He Was IlcOlcd WJlh (reiimnl ispu ilioils md msl di ilion of v.uidasC but wntiiHil impiovemeiit. old lie died on J 'ebfiMry IS, !OMs tw m m v , msf,) \l ,t(li''j.ey (lie ngbl lroi lele CIV({y W is "eelipied by l ! 111 e get Unions tum-Hir wInch slispl ued the Hied] Istli mo uul t <>oi/irt s~iI (Jk (ell lung The tumour had m llllrilcd the pede odium The light king was eODli'/eteh eompu ssi it hv neophslle tissue (I Ig 2) but (he i JO(ll hr.nielinl lice did riot show my ivideMic of I Pillow y hmwehi'i one C Iiellli'ii'a Histologic ll Seetliuls ol lile pli Ur 11growth showed J ptpdliry mese'dlehoma ( I l f 4) I hete w is evuknee of isheslOMs III both lungs (J Ig A) (operated between l l>lfi anil I ' A l ) where it vs.is (js e - i K i t iw h ilefem d e 5h years of iye (born , Mill Hell vnliin UK) y irels of the twain s|Tvci close lto>M w is i soet i) w.iihei, who eoidd .udy h ive had a . to wine) eobbmg w v also done for a few sears sloil esposare to ashestos is a child and piohibly a ( f i ns w s folloHLil he a n iiif n (' isk 1 'm illet shrill esposiue is a \>nng wont in Slit nt.iy in In k ) which w is eumplelely rebuilt in 017 ( h iqviale sen h id i sn ill null m k>2b ) he pi edee hive p Mil seselil short \1\||S m tile illuK'S svnh IlcT I.usts m,l ai i l,Per period She w is bum ni (rriiiiulow n where she lived until 1 toil ly is or one null to selVe sevelal m iiKs 1 l the slit was 5 wars of igo (h r family then mourd to nnniedi.i e` vtemity k m ilx ik y when fiom P li |0 t'>22 she worked as a In ihe early days the man igef tnd labourers liv e J cieik in an isfvslos walehouse Her husband owned an wvtlnn a few yards of their place of w ork, and even isbestos mine from IV43-1940 IS.A_SlKGf F" p H m o c O P V M A ' J t BV T H E N D IIF U S h r ii.U / U L S fl.S O T H h U O U A t ~ A ' v w , ~ .J % W .J i` ) Ve S? fi / V, \ , A^ * * f- v '> . *5 ys > ". V * - ~ o y- * ' 'n r e, ' / f'i ' '*' ` >1-, 3 ` - ` ,*V` , # ' w <*,>'' ;, " i . 4 * * V f/ % ; ' If t' _V . * 4 * Vd' V- * . l ' * , lJ u i' J .,* .* _- V,>, * A ' ' ** `` 2. v - - HW1 r* \ v ' ' ,.., `-T` ' ' -. -' : r ^ a e "' X^ A `. J f 'W x ' *\ ' n r ^ TM r>v O R R F S F A R C M IN I L t N O I N C ^ J H F DR*'- *AL 264 e I B R IT IS H JO U R N A L O F IN D U S T R IA L M E D IC IN E * '" / On lith } IV'S 'k _J ~ - *j- 1 1 On M<rih , l'* I ii. 8 On July J, iV'b 8 K uJi.'unph '.howmg de'cl|<muH uf tuiiw'tir in C*w SlU' w is icfci a d lo tils \\ cs| I tld ! 1oil'll it Is linburies , on Jul> iy ly?4 txc uise of ihspni'ci in<l light sliest disuomfort of .Kills onsul I|)i s Ik s rnliii('U |ili showed ,i losulikil pleural ullusion u the right b ini. t>(r.uv-solo(iail (luiil w is is'n itsd uhish on .'..muni tion \vi\ found to hc iiieitise for \l luht u i i Ium' but sont until niusoihcliil e jls m in ia d m ,u.mi \t llun icos^.ipy in Job isMvxlnng on AnguM I ) . 1954 lutnour in>dulus in a m n on tla p u iut il pluiii.i 1hslofogiu il uiim uiition of thu biopsy spLuiiikn showed a inusoltiulinm i l)su|' Uk i tps ind r.ulio-lull's' gold instill ilion in September, 19sS u m , ,t mill il rsyicssion of both the j'kiii.it Jliml u jj nod'iks but <h<| not ,<rasl the progress of thu disease Shu a us ivsd a further sinirss of t-i ; iJs tip y without ir ip'osumuni mil .(nd in Jum .nv, I9S7 11k lour " i s vnl irged and nodulu bufoit vis nh bul no iits ropsy w is duns (f igs 1, h 7, .md 8 show tbs i uliolopKal dc'ck'pmctH <if thu tumour m ihis ease ) C isc 14 S S ,t H.iiitu m ilu, 40 yu irs of igc (born 1911), is m jsbuslos oiniur Hu si.is botn in ills kiiriin iin distriut ansi as a ulnld often j'l iyud on thu asbuslos lUitnp ns ir in asbustos nnnu He subsequently worked wiili .isHl sins for scvur.il u irs. Kin g employed al an ishuSios mint weighing libru from 103X41 In 1942 he worked on d Witwatursr.uid gold mine bul inatnrnu-d to thv Kim nm n drsirici |yJ7 where he worksd .is i f inn Uboua r until Ins lin il illness Hu .is -dimttuvi to thu Wusl I nd [lospn i f ,>11 M iruh 7 W y He had bcuti null until Julv, |`)5R sshun lie bu. mu iw us of '.iins in thu right sidu of his uhesi In addiiinu hu had a slightly productive cough and sliori- nuss of hruatli on esutiion (beet r.tihogriph on M.iruh 9 I9 'V showed oblitutution o f ihu right lung Itsk! Asbustos bodius wuru found in the sputum N iid k biopsy showsd lustologiu.il features consistent with a musolhubowj Ai ini'sy I In. rigln thus! n is ,'cei/picd by a huge whitish turiii'ur whiuh mhltriiud thu mudiasiiiuun. u Hi uding tlmniph the >fi ipln.igiu onto thu supsrior 'iiifiuu ol the h'e r A sir iw-uolotirud ilfusion was ptusunt m thu kit p k u ril s ic but thu k fl king was not ilkutsd Ihu mednsim.il c c n is d and pua-JortK ihdoii'in 11lj rnph gl mds to thu lesul of the ruii.tl arteries ire tuhlrr itud with tumour to the tight hmg it w is found that the tumour mass l u J mi'lli ilud alum: tin mturlolni hssuris lilt lobes of the lung wire o w i'r m u l mb' thruu sin dl segments d ig 9) On lnsiologiu.il suction j p.ipilliry type of p k u ril riicsoifiutiomj was seen (I ig 10) winch had inhlir.itud into the lung ptruiehyiiu in some areas Then, was marked lymphatic spread throughout the i v/ l5_A_Sironi F P H O T O C O P Y MAD E B Y T H E N A T I O N A L L I B H A R Y OK Me d i c i nv v n V p u N H 'V f s o r"s ;T i ih v V ip PFgr'~ A n rH ~n f i r LH yT irl BTn g ' frm o r k " 266 B R I T I S H J O U R N A L O F I N D U S T R I A L M L D I C I N E lung substanec Numerimi asbesto*. bodies s u ri priscul in ihc jir spacci and occasionai ba diti and libre- wcre '-sin in ibe inierstitul laute The lung Uscii was m.irkodly j l d a i me rudente of .isbi'slosis was obsirved iti (he lefi lung ( asc 15 S S V , a bile fonale 42 ymrs of ape (borri /VliS/, is a housessik, alio hvtd on a mine near loh ninc-hurg and ss o. U itesi for tuberculous pkwnsy for sii monilis II v, is onl> after Ibe histologn il iii.ii.wiwe (.f 4 mesoihshom.i h ul hesn mule ih.it hsr piesums historv a Is obl.inied In .iddlljon il us Mibssiiuuulv k ai ni tin i hsr fithsr (Case 22) h.id been burn on );i asix woe filK) .uni h ut ,i long n.uiing hislory Ihs' n 'tieni isis borri in th Criguituwn disim i md " `-tu te> selux.l u Ki.riuwin She spvnt most of her sonili in (he- .l'I't dos bdl Sin h is loeii ne ir foli minsbiirg for 20 je.ns In M irti! |94<, ibis |' un ili desi lupid ngl.t tlissi p un in.l ripu lii in n i ismg silurine ss o f b a u li She ss.is dnuUeel lo hospu il md 2 `'00 ini of shghlls blood- si.imed fiutsl ss.is reoimsel fiom th tight ehsst A III '1 eso'es l'is sv.Mimi.ition ss,ss carim i uni un Ju b 27 1 id i bn'l'sv ss.ts t.ifeil bui line umsisisd lihrmis 1/swie don lieop'nsl le ei If. Well ohve lied in 1he bronchi d seadnng. V mini i n lf'i ' K |V not etilt ill e11 fiom nun it i mis sjxeimens , f' spin.a pk ni i) fluid rloi from ihe btonelii il sushiru >, Mu. w is idnnitid to a lolt.unti shun' nal emit It mu ori fleto b- r Ui 194V R ulio ,plv% then slioiiL.) ) i).'o n e due ke inrig ol tile Ml-lx pitilla "Ith lluul III the I It lit elicvi At Ihotaeotoms i Mr ! K mus j idle 11(he p li icI il pie m i w is 2 tin thick hud Is lock Old stI ijspi d s\Uh ini (I .Min uhi Irorn Ilie >he st v. ill 11k siste i il peel stripped t tills e twls troni Ihe lippe r lobe bill sep ir ilion K s mie moie dulie uh user the lower lobe sshece 'he peel w,.s thiekel Hill nsg tile dieorhe ilion a necrotic miss ss.is lomul m tile puen- ol II,e . i luN t (lie h l- u ilk e snil 'he di.iphragili md IH i h ips th Diedi islmuiii ss is a h ird el.ll'gs III.ISS SSllle h tonili noi be relDOSeii I fisiologie il sietions of th spum iti) t iu a k d ni nleiioid fumi i>f llll>ut,ii me solile homi Suhsigiiintlv linee 'peeuue Ile of spuntiti sseo. eeaiMii'ed for .islv-io-. K k Ik s bui none siero folind fhe p Hit ut is siili ilise (Apri!, 19b( bui Ile r eondition ts dtle/iOMiing Caso 22 | ) M i aline m ik r-H se irs of ige inda farme i ss,js Die h ith ir n i Ib i px woits p itmu Alihtuii'h i eh giuiws of p.lenr il mesothehomi se is isside in I olii irv 1947 a ee,is not uiitil luK l')4v tlt.it del uls of bis ospo'irre lo ashi 'los 11Is obi unni I le ss is b un in Ciri pi itosi n ind sselil io eeliool th Te Me uorksd in Mirtini in ('osmi isbing md Grigliatosin unii' lite ipc ol t>2 belwein l'Jjb J9t2 he orhcd is ari .t'besios mintr undeiground imi u.is mostly in d e a c' <11 b! lettili; He(lise II 19? 2 ansi (9 14 he f si illesi ITS Ihe elisir iti hut lelurited to tsKsloe iiiining fn>m 194' lo 1952 In Jjnn.iry, 1957 ibe julcutt eoneuite'ei his d<x.lor bc- eausc of lofl-wded elicsi pam Uh eeiugh and yhghl h ii/noptysis fie ss.is referred to the Johannesburg General Hospital for insesugauon The chest radio graph showed gross pleural thiekenmg with a basal pleural effusion on (he left side He seas admitted to hospital and on June 10, 1957 a thoracoscopic p k u rj) biopsy ssjs t iken This showed the features of d meso thelioma On June 24, J947 in utempt at decortication seas made I lie- left upper lobe seas stripped easily >u! the gtosels thickened pleura vets so adherent to the lower lobs th it Iht .iirmipl was buieJoned Sections til the pleura eonhriiled the dtignosis of toesoUishe'ina He died oil December I I . 1947 ( ase if. A N )<X)/<) u o i firn u lute malt, 40 years of age (bori, s born at Grigu iiosen an Sesiit to I sihigs ssheiol ne an asbs slos nunc Jron ISJ14 lit he U in s p o iliJ ,Isbe os in donkey ss iggons fron ll iv in |>n, sjtj Dm mg (hi : journeys he often slept oi isbestos h igv In 191 he orked in in js K s io s min< for i month 1he p iI h ni December. (9.45 ssjlh vague substern il pu ll and dyspniK'a A kft-sidcd pleura tifn'ioil w 1s di .anossil and lie w is referred to M r J K llreiililler ni PreIon i ) hire w is no <<(donee of malig n me\ m bm in im i md -s delie bieipsies Si'mc lines1 [>k(<( il fiiKkciinie old ,i delist homogeneous opacity a. the 11isi ol the kit King w is son in Ihe radiograph ut Miglisi 1 !9 Vi 1hoi iinlm m (M r llrim n iir) n lel'MMM 194? m e ik d 1 thick,. tieJ nodular pkur. With .lire's in is- on ihc k it di iphr igm A n io n lh ilm n i, ss IS Seen o11 lil'toloi leal seelitui ln A p n ) JUsghe n.is ev unified by M r J () Visset iu h i nbeikv who found wo dl n glides in the siiheul lneou- (issue os eI the licek Old chest A large hfltt mass s\ |- lound in llle ihor k o Ioids u<>im<l iik ) a mass a s present in tile leIt hspoehondi mm Mitre' ss.is gcncrali/eU Iwnph ulepop Ohs and riumeious nodules iseio prtseiil on the toneue C lies! r id on ipln shimul the left pletird e m is to be obliti rats d He ss is one of the fovs eases ti dc'clop mdesprerd riletistises \ blopsS of t'lie of the subeih illcous the si nenJllle' sho.sed a wind ir ippe ir uiee to those seen in the ongin i spev uIK n fnu the pie III 1 ! be p ItieIII died on May 22 I N o ViesTops', ss.is pciformcd <.t'i 24 D O i svhiic oi tie 12 years o f age (born I9 12l by profession ill iceouiltillt ss is born ill 1ng! md but e me (o South \lrie i is an inf ml Me spent hie.u Is childhood m kurnm m imi kfi ,u ihc age o f 7 Ms liter gii ili heii is a eh.irtued leeoimt.tnl in Kunberle; at the Igeof 22 he 1 id been disellai ged iiSedle.dlv nnht from the aiins because of i left pk il! l) i`lflKlo/1 Neither then nor on in my suhseguent occasions were ien|-fisi b.Kilb found either in spulimi or p k iii.il Hind Ills only subseguent contact s'dh ,isbcst<is ss.is tin inditing o| the books of hi .miosite mine in the (n September 1941 he comp nned of left-sided chest p line irid shot (ness of bie uh A radiograph of (lie ehe'I showed flattening of the di iplir igni on the left side with obliteration of ihe cosiophrenic angle and thickening of the obligt/e fissure' He sv.is seen on numerous occasions D IF F U S E P L E U R A L M L S O F H E L IO M A -3 II Aeu-uet 2` 1917 loin 1941 to 947 \ i uliogi .ipii I iken e iris ill 19'h hoisccl the desek'piiient of i kit superior medi istmi! li uhm which ud ireed progressiscly (1 ig I I ) and later 'be de elopnicill o f ddfi s. nodular pkui il thickening i'll the left Dill Ulg I 957 Willil It hut ). ss m liked eh rnges dc sv1iped oil the tight side (1 Hi 12l I k consented to 'i >['M id Jude I9'7 and it Opel ition. a dlfluse plellial 11ilign.mes ss is present HesUons ol the p lriel ll pkni 1only Mele iciisosed met die htsloloe'le d i|'|ic.uarTcCs were (hose of a Ulesothehofii i He died on Oetobei li IVS7 A necropsv seas not jieiformed Case 1(5 Ci I white uilk- 4(1 >,e irs of tge (born l`/00) is a Wo i[H r iwlh i history of industri il <sposine l le I icier been ne ir the ( ape Asbestos I Kids 1k w is bo, n in Sonili U . .1 'fried m j Joed there until lite ige of 21 Troni the age of 25 to 2M ie worked m a Nctorv m (he Cape is i hoik r-m,il er md l'Iter He solunteered the usfofiMHum that he had worked con tinuously with isK'IO s, lagging pipes md h o ik r' He rim irked (bat (he remos d of a bestos lipging from old Pipes ere .iteli a se rs elusiy aniosplle le and th it lie would sough a lot it such woik ihisscsn 2r. and D se us ol ige lie ssoikid ai t f tetory in Joh.innesbmg in i wnui ir s.ipieitv but was not evposed to such Ik iss eluvi eon- eeiitt itumv lest the past 20 ye v v he h id new been m contact ssuh asbestos 1ngutrii'i were ntatk fiom the factory in the Cape is to the nature of the asbestos used md these h.i'e rese tied th it during the leks.ml jseriods C ipe sl'ielde-'ile ssus eselusisely Ih list He was lirsi sun on Match 14, 1949 ce'mplammg of eongli pain m tin i iglii chest and recent onset of brealhkssnesv three pints of fluid It id been .tspu.itid from die pienti md eyloloyie'il isummation showed (he presence ol in ilipn ini cells lhe r.idmgriph sliossed m ilked pkur.d thickening and fiydio pneumothorax On M irds 57 1949, a the'racv'svopv ss.ts itone- The pkma leU llnekened and the lung Ss.is eoli ipsi'd .lini mimoblk Se it / d biopsies Were l.lke'n IlCse shensed the presence of i mesothelioma I lie' iniekrbing lung sho \ed the' presence of .isbesWMS Ile ss is ire lie'll ssilh nitrogen nui't ini ij i.i pku rd ly md his eondinun teinpot n ik improsid When list esmiuteij he eOmpf lilted S'f USeiei'.cd ble.tthkssiscss DiscwsMiin In 1924 Robertson diiueii the' oxisle'itec of primary iv.dign.mt tmswwits o f \hc pleura and con- side i cd the ni lo lx sun m l.iry " ) ('Mgm Suite then, e>n the o ik hand W ilh s (194X |957| and N u u rl and Hinson 11957) have' supported Rolierlson's views, wink- on Ilie o ih ii hand, (uim .iiy neoplasms o f this nanne have been desei ibod by many authors in recent ycats 1hese include Tobiasscn (1955) in Sweden, B ilio n i ,md Uovo (1957) m Italy, G odw in (1957) m tlie United Stales, and M cC jujdie y (JV5 8) C y ff ^ mudili ,.^ 'l S 'A S N r r P H O I O C O P Y M A D E H Y T H E N A T I O N A I . i T A Y o r ' i w t U l e - ' ' . 'l . u . O H P o d e W n F S T n w O R R F S F 6 R C H I N k i L i L S - L f F P " - v'AL 268 B R I T I S H J O U R N A L O F I N D U S I R I A L M L D I C I N E in Britain Fvidcnce in suppoa of the mcsothchal origin o f t h e tumour cun he found in the tissue culture experiment of Stout und M u rray (1942) and S.m o, Weiss, und G au lt (1950) The variegated histological pattern o f tumours arising from the mesothchum o f the pleura was remarked on by Klem perer and R abin 1)94)7 Such i v in 11ion is appreciated when the m ulitpolcm iuliiy o f (he tells lining c o jo m ic c iwlies arc considered Muxim ow lost demonstrated this feature- in l `>27 Novak ( I P l I ) st ited that the uuiuisa o f ill pails of the M u llc iu n canal and the gemunal epithelium were derived from these eelfs Ko.ishcy (1947) showed that in the embryo the m tsonephios nii't inephnis W o lthan hods genu il ridge and all The amount o f ntclachrotnattc substance in (lies, tumours has varied considerably T his wc ihm k t, partly due to the fact that until recently we had m .ippreeiaicd (he solu bility o f hyaluronic acid i aqueous media and the m ajority o f these turnout were fixed m I0 gu formol-salinc fu rth e r, Ltso , (1954; states (h it the m eia ch ro n u sij of hyaltirom acid is optimal at a eo/ieenb.ition o f 1 10,000 an giadually decreases at higher levels W hen the big concentrations that Meyer uni rhalTee <1939. I9 U , tound ,n !)ie-,r tumours arc eonsiderevi this variatK m met lehrnm itie propeities seems to have 1m p a itiilly explained In addition with the gre df/Tc'fcrves rrt the histology o f the vanous lesions would be logical to expect eeit.un tumours with the mesothelium t aniphcll (19^0) considered the picsenec o f both epitliehaf and iiiescnelivm il clc-mcnis a major di iciioslie feature In describing the- hisioioev of M o f these HiiiHHirs M d auglicy ( |95S) ele moils)ruled ili it cither the epuhcli d oi ihe mesenehsm d element iniglll p/cdi'ltmt Ke lie classified his eases into the following four groups Im m n irs o f eptthciul sh,u ictet tumours of nieseneiiym il tvpe tumours >'f mixed tvpe and turnouts o f anaplastic type- IN in g M e ( in g Jiiy x el tes/fie tlion on our series o! turnouts the m uoiity ate as m ( umphcll s s u n s o f the mixed type O f the ictn under a few showed Ihe pn pd luv fuhular stiu luie> o f the lumen,rs o f epithelial character and there were several o f the* an ipl.islre type O iu e ise had the jp(X. u uie'cs of J IIIIIK'UI Ilf mesenchymal type' but even in this ease prim itive tubuJ ir s liu t iu a t were sect A p a il fri'm the original ease all the histological diagnoses w eic made on biopsy m iten al Ihiee- ot these biopsy findings cue- eonfumed it vveereipsy In the remamder we have had to rely on J m it u l and radioleigieal examination to exclude other prim ary sues o f malignancy fo llo w in g the w o,k o f Meyer and t lialfee ((919, l'>40) the possibility o f denionsliatiug hvulurome acid in these tumours both chemically and histoehemit ,l)y has hex.n eonsrdeied is a di ignostie aid Hoih these investigations ire still m an early siage (H at ington 1959) Acb m in u ry results o f the lnstochemie.il experi ments show that tlu-ie- is metaehrom,tire subs! nice m both the xtiomu and glandular structures o f the tumours This nictachrom isu c u t Ise icxeiscd by incubation with Jeslie'u/ar In iluion id ise This n ialenal stains strongly with Hale s ( 194b) in JIojd nl iron method T he periodic ueid SclnlT teehnnjuc has given vjriahle reactions these results arc not speulic for hyaluronic atid but arc strongly suggestive o f its presence. linked uli-rvoiij ip n rtrin e e io secrete more tha those w iih an essentially non-gl uidulur stiucture Three i>f tin- live* autopsies performed shows ev ids nee of pu itniie.il met istases In the other tw, inlra-thorasis spread was ohsei ved in one-case to th o lln r lung k k ! chest w a ff and in the* second to ll niedi i'tin il Ivmph gl unis and p i i icurdum? lltopevidence of nietast ises has been olit uned m tw eases one fipm the om aU u m and the other from il subeut meiins tissue ol ilk* chest w id while a ihn pitiem developed ,ut unpl m illio n nodule in tl ih oiaeotoim se ir which showed a sim ilar appe uaiiv to that o f (he previous biopsy specimen Ih e tnsi iscorded e ise o f tu ic in o in j o f the lun tsso uilcd with asbestos was deseiihcd by l.yne aiul Smith (P.M5) By 1955, tceording to H ull, total of id e.i-es !iad hoot iciH irted Jiicluded i these e ises was one mesothelioma C a itiei <195 mentioned two c ises o f JilTuse- mesothelioma from C .in .iJ, m ehrysoiile- mme A fuither tlirec case were described by v .,,1 der School U95X) U , lorum ately no indie Hum is given m the literatui re*,; tiding the type o f asbestos to which the majorit o f recorded eases o f e.iremom.t .ere cxposco I lowcvei discussion with management amt nie'die oliiecrs evf tsso of the* f leteVncs in winch the m ajoiu of Die* tises fc(>orled in Britain were employee' suggests that most o f these workers wcie* bandbn chnxotilc asbestos ( W igner, !95S) The posstbilu th tt some- o f those people m ay a k o have bee exposed to crueidohtc dust eann<>i be excluded Attempts to produce tumours m experiment anim als by exposing them to asbestos dust have bee id ivie Vorw ild and K a , r (/ 9hS| were unsuecessfu 1 xiieh M elvcr, and ( am (1957) succeeded in pri tluim g lum om s m miee but lung neoplasms ,,i In eontiol animals were* far too numerous for th results to be considered significant On the ot he hand Nehmabl tl9 $R ) w orkin g in D m ek rcy * Ijb oiu U iry has been able to produce sarcomas n rats This has occurred after subcutaneous and , ; I i i 1 | | ^ D H t U S L i'L L U R A L M E S O T H E L IO M A 269 intrapcritoneal inoculation of both asbestos fibres and dust H e slates that "m ineral asbestos' was used but does not name (he variety In our scries o f mcsotlisliomuta histological -videncc o f asbestosis has been observed m eight if the 10 eases ,n which lung parenchyma was m- ludcd m the specimen examined N o lung tissue .v.is present in the biopsies from the remaining 22 c.pc (l a s only m the four eases that came io veeropsy that laigc sections of the hmg tissue were* ivailahle for ex limitation In all o f the'se sp<emiens .videncc o f asbestosis was found At lirst u was though! (hat the presence of lumcrous asbestos bodies fngm ents of hbre md lust inimedi ttely below the plcutal elastic laminae ii these vneemjefis might have been significant m ihe pathogenesis o f the tumours H ow ever it ,v moie probible that tills distribution is a result of the matked atelectasis Sim ilar features have been 'bxerv eel 111 lleleet ll IL Jungs i>f U'bc'stos miners tn which no me'olhehoni.is have been observed Ble urd llbrnsis has been a common Im ding in v ises o f asbestosis and in some eises large piciual id upies me isuring up to I 0 cm m thickness have tieen 'Cell I llesc' plaque's which were In si vlesc rilled ,n ido vile ( I 9? v j It.iVe been observed following exposure lo both nnosik and vroeuloJiie- obesios dusts In these ease's of benign piem al thickening 'io evidence o f s im n u l msl.ieIir<>m,Ki,i lias been observed In all ihe histological sections of j'leuia examined 'n the cases of these niesothehom is and in more than 100 e'lses o f asbestosis, no asbestos bodies frigm eiils o f libres or dust h u e been observed beyond the pleural elastic laminae Three patients from the K om m un j is u iu , with clinical and r idiidngHul features consistent with those of dilfuse pleural mesothelioma had markedly tbnormu! tells m the* pleural fluid These cells showed no vjie-edie features tvi distinguish them from cells originating til second try malign nt pleura) deposits nor from the giossly atypical cells sometimes seen in non malignant pleural elfusionc As no biopsy or autopsy examinations wort obtained m these cases they have been excluded from (he series The pathological evidence* for associating these tumours with asbestos exposure* w not conclusive As pie'vunisly stated, only in eight of the 44 cases has evidence of asbestos been demwnsuafed Ot these s,x had a definite mining history and o ik lu d been exposed tn asbestos while lagging steam pipes ih e other case was born m the Kurum .m district and nothing else is known of him, until Id s am v.d ,t a WuwnlersranU gold-mine* at the age o f 2.? In the remaining 25 cases we can only present circumslu n iijl evidence o f exposure to asbestos dust (Table 3) Eighteen o f these 25 cases were born tn the vicinity o f the mines and two arrived in the district as infants. O f these 18 people 11 admit definite childhood exposure to the dust and two others were exposed industrially in later hfe In iddilion iwt> patients with childhood exposure later worked in the* asbestos mines Three cases arrived m ilie region at an older age but were employed (h e r on the* mines or in li.uispornng asbestos A further thre'e' o f these* 25 c ises have h id industrial exposure, and in only one ease do the icdaiives deny any exposure to asbestos dust Hie* four industrial eases are* significant T w o ol ilie. siiieitts uc-rc* lagging locomotive boilers and one was lagging steam pipes A man. who was an upholsterer by trade, was employed in making tire proof clothing from 1949-1945 As far as can be ascertained these people we-rc never in the Gruiuularu! district These linduigs lend to add support to isbestos being the common factor m the development o f these tumours and to counter the suggestion that tlieic m ly be some other cnvtron" enial cause m thv region of ( irujiiul.iivd West Jf ivbesfos dust is a fastor in the neturrenee of these tumours sim ilar eases might h ive Iv e ii e*peeted from the iu i.'hbouthood e>f the Transvaal asbestos mines in the Ib eursburg and l ydenburg ilisti lets where crocidoliie- and uuro-utc asbestos is mined Aeeoielmg to Veim aas (1952), sroeiduhlc and am osiie occur in the same- scums m the Piclersbtirg district As t nr he seen fiom Table 1, amewat x .............. . composition te> crocuJohie. In the* post four ye irs the lungs of 24 eases of asbestosis finil) (lie- ) ydenburg elistnet have been examined Ip this m,iteti.il two eases of adeno-curemoma have been obsetved The one was m a while miner with 19 years suviee, who had an udeno-e.trsinoma ,insing fiom a bronchus The other ease was a Bantu miner who had a pcuphcrat tumour. N o service record was ohi unable m this ease Only one' ease o f asbestosis has been received from the Pictersbnrg are'i A ll of ihesi men were actually employed on the mines at the lime of death, the m ijonty having had a (d a tive ly short service Our linduigs siiggesi that mesothelioma occurs 20 to 40 years or more after c'xposuie lo dust U n til coinp.intivc'ly recently the mining m the Transvaal has been on a small scale, and there were no settle ments m the vicinity o f the mines Hie lungs of 20 asbestos miners from the Cape Asbestos I ieId have been examined in whom no mesothelioma was observed One uulupsy spc*cuncn coiVMstmg o f three ftugmcnls of lung showed asbestosis and an adeno-eareinonu Radiological features o f asbc'stosis have bc*cn observed m many miners from this region, without any suggestion of ^ A ^ S j N O 1 f PHO TO COP Y MADE BY THE NATIONAL LIBRARY OK MLDlC^- Tw SSZSSaBH B * -- OF ^ T i m V OR R F S F A p C H IN 1 i*FfT 0^" N*DI N G T H F O R B R U IS / / JO U R N A L O F IN D U S T R IA L M E D IC IN E " 'T M " ^ L Ta b i 3 W ' o r n i u o ' 1, ASSOCIATION SS,TH AS.ESTOS Other h, .Mmtti j 1 mie lile in j ),sta/Ni/ ire^T an asbc&lns i j'hesi.is fitlili 1,111,1 he ak o f i ."' working life ut lhe M.mny ,,f ininrs lTli\siu*>Ulno,kcicea>|T Platril nu .]sn,i|,.. ill att nf K unni the abc of If h n r . x X ' , 1 U is possible th.it there h.is nul b a n a s u iIm u I lapse o f time after exposure for tumour .............................. .......-- ....... ............ *- w, . , c 7 " " 7 rt't ''ri l K src`lt "`' l' U n '-c ,h-'< c h.iu : , . r s r sTM , D U tU S h P U .V R A L U L S O lF i 10M A thoracic surgeons and (Mlhologisis Preiona, and Durban Johannesburg. w c th.snk lise S .s r .u r y ,,f Health for permission us publish ibis paper Marlin, o Mj'iimts \ i i 9<m p,,,c t,, -ir,* , 271 4<i. '5, 6) t Bu4 | n , R i 11i sc is llsllnni (i msl n,,,,, (, ,|vv> , r,, ,,,, , r,,,,, l7 UT 111 sv ' ", r iz, :s J1 r ""' *' t . 317 ' S (190> K) asno / mi) Hm.,m I V. , < *2 'f I " f 'ImOstcrhiiK,,, ...... g .I r1l//1'l0i1r,//<1J' u I am 10 (|9l(l| ` ' ,, ,i, ',,,,, C , I S tl ' ' J S (I9"i) P.f'isie,] . i V 119) Uld Hnll.ftA.srth 1.'ftjon /'llm/.ru .,( 7, I II9"I^ H,,n,h,, fIs./tS.rI IJi'dA SmJ1uUU| (' iHh IS :i)7 Js'hJ ;>,lts>) Vddeiidum Hs 111. C I,I o f J ,, ,, C lU M . |,,,.,| ,,f ,7 ASmsstiihcliom.i b u ) K o n k-imfiu In o f ihcse ,1 poss,hlo .is s o s c u o i, ssssh ssP ,, s u ,, . ,,s cm .,,I,,!,,.. s u n LV..I s iis iL. j in oncease a mesothelioma >! nit p tn io iK iiin \s.is present T M U J I J I . Y (I9 6 0 ) Is S S U K Ills Ally ( ! % ( , } ISSUS SIII.IIIIS ,hs foil,,,Slug . Dee,in,pr.ssimi S i.k iu s s iir iiiR ( ,, ,, s ir e lim i ,, r ii,,. U n ir , a V I Is,lipis,,,.,,,. 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By O P l'llmoniis ,bc ...... .......... ........... - Itool R o ie n s . ...... ,hc R""^ IS _ A _ S lN f;i F P H O T O C O P Y M A D E B Y T H E N A .O N A L L I B R A R Y O F vTfcbTNi J . ... .............................................. ... _ o r ^ T I I D Y o r R F S F A R C H I I )FU OK L E N D IN G T H L ORi< - AAL