Document JJXBYBnwXE510XwQ0ZjBq8LRZ

AUG-j-2001 WED 02:21 PH FALK HEDICAL LJ3RfiRY FAX NC. 412 648 3020 08/01/01 ^ 18:11 FAX 218 581 8<77 COLLEGE OF PHYSICIAN'S Hr/f. iitdustr. Mod.. I960, 17, 260. DIFFUSE PLEURAL MESOTHELIOMA AND ASBESTOS EXPOSURE IN THE NORTH WESTERN CAPE PROVINCE BY J. C WAGNER, C. A. SLEOGS, and PAUL MARCHAND Prom ike Paikelegy Phhtien, PneumocvitlcsLs Research Unit f the Councilfar Scientific and Industrial Monarch, Johannesburg, Wat End Hospital, Kimberley, end the $ Department gfThoracic Sergcty. Unhmhy oftic Wtewatererererl endJohannesburg Ceram! Hospital (uxziycd roa h)#ucation akul 24, I960) Primary malignant tumours of the pleuift ar# uncommon. Thirty-three cases (22 males, 11 females, ago 31 to 661 of diffuse pleural mesothelioma are described; all but one have a probable exposure to erocidoUte asbestos (Cape blue), in a majority this exposure was la (he Asbestos Hilts which lie to the west of Kimberley in th* north west of Cape Province. The tumour is randy seen olsewhsre in South Africa. Mesothelioma of the pleura is regarded as an uncommon tumour. Is the last four years we have seem 33 histologically proven eases; 26 of these had Home association with the Cape asbestos field and four cases bad been exposed to asbestos m industry. The tumour is raidy encountered elsewhere in South Africa. During the past five yeans, with the exception of th present jorios, no neoplasm of this the lungs of the first case (Cage 1), aod secondly, 10 of the out* came from a hospital to which suspected aunt of tubercutesR were referred from s large asbestos miaini area. Thu hypothesis could not be supported at oooe from the original histories obtained front the patients, for they included house wives, domestic servants, cattle herders, farmers, a water bailin', an insurance agent, and an accountant, nature has been diagnosed amongst 10.000 lungs oxamined at the Pneumoooniosla Bureau k Johannesburg, or in the Pathology Dcpaitmcnt of the South African Institute for Medical Research. Hjgginson and Dottle (1937) did not observe a single esse in their survey of malignam tumours occurring in the Bantu and Cape Coloured population of Johannesburg and the North Eastern Transvaal. Our first necropsy specimen of pleural meso thelioma with asbestos was examined at the Pneumoconiosis Research Unit is February, 1936 (Case 1). During the early months of that year, one of us (C.A.S.) in the Northern Cape, treated she patients with gross pleural thickening. Pleural biopsies from two of them showed the features of mesothelioma. In the ensuing two years, eight further cases were found from this region and five from elsewhere in the Union, During this, period CAS. had become perturbed ai the cumber of theta unusual tumours occurring amongst his patients, end stimulated an investigation At this Stas there was two reasons to suggest that asbestos might be implicated. First, asbestos was found In none of whom were workioe on the asbestos mines at the time. We therefore undertook a detailed investigation of their past occupation and plan of raidrates, and the association with asbestos ex posure was discovered. The cases ore summarised in Table 3. Previous biopsy specimens were re examined, and new arses dlegnoied, including asbestos miners. In oaiy one ease do the relatives deny that the patient either visited the asbestos mine] or was exposed to asbestos. This Is preliminary publication and the problem It being intensively Investigated. Tbs Asbestos Area of the North-West Caps According to Hall (1930) asbestos was discovered by Licbcosteln near Prlexka during his travels be tween 1S03 and 1806. Since then tt has been established that the asbestos deposit* extend from 20 miles south of frisska, northwards through The western port of the magisterial district of Hay, to the eastern portion of the magisterial district of Postmasbuxg and finally, to the western area of (be 260 DEFENDANT'S EXHIBIT HWBUI0006957 AUG 01-2001 WED 02.`21 PH FALK MEDICAL LIBRARY FAX NO, 412 548 9020 08/01/01 WED 18:11 FAI 218 861 5477 COLLEGE OF PHYSICIANS 1004 DIFFUSE PLEURAL MESOTHELIOMA 261 '.i.-i .S district of Kuruman (Fig. 1). These deposit* occur in the slopes of a range of hill* covering m area of approximately 8.000 square miles. Knows as the "Asbestos Mountains", these hills extend more or less longitudinally between 22-10* and 23* E. *Rw whole area is ictni-arld, spswety populated, and, apart toss mining, cattle ranching Is the only important occupation. In the Kuruman area several largo tracts of hud in or abutting on these mountains have bees reserved for the aboriginal inhabitants and here whites stay only reside in the Immediate vtdaity of the mines. The type of asbestos mined tliroughout this ares is croddolitc, better known as C ape Blue Asbestos. The chemical analysis of the fibre is given a Table i. Crocidotttc is the fibrous form of riebocVite and all stages of transformation from a massive nebeckhc rock through lamellar ricbecklw to a&bestiform croddolitc occur in this region. Magnetite is frequently auodalcd with the o oefdoUta {Vermins, 1932). Minins of asbestos first began in the Priests district in 1193 and gradually spread northwards. In 1908 production hod begun in the JCmuman dis trict. Between 1916 and 1918 a large aumber of claims were tabes up. This northward trend has continued and In about 1930 mining started at Potafret near the BechuonaUnd border (Table 2). Initially the ore war quarried is numerous small open east workings. This was followed gradually Ta*I i chcmioi. analyses or oaocnsouTE ano amositc QMtW V0WM8, 1132). 1 0~>4aU> | WJieUis SiQ. $II01W2404* 1i a-tt stil a Mw,0- E F ' I'M 1D8& 11 III --1 ^37 Ufe00I0r>-*4*0&3171i r loou I ,irf. H HWBUI0006958 AUG-01-2001 WED 02:22 PH FALK NED I CAL LIBRARY FAX NO. 412 64B 9C20 08/01/01 WED 18:12 FAX 218 881 6477 T COLLEGE OF PHYSICIANS ______ P, 04 0008 262 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Txwr 2 POpUf.A'HQK or THE. zu&tSTtilUAL OlSiiuCTS !K WHIGH TWR ASBESTOS FIlLDS {iJMft ffwtv Uiuoo ClAMI !*!. a) 1*31} SITIUTBD Dauia )*Piesfe&, HP*c3wiutbGi'j VflTUlAtlOfi 4931 WbAot i Ncft-vfiItm 2*141 3 AJO 4.721 4,499 4,B?9 6,109 H.m ! 11,4)1 ` 1.614 i 0.30 (na*dt4 In th uuy r&T^et WJlisAS SJSI on 3.7S5 4.687 16$ i Nen'-wbnw { IUJM1 2i.r 9.431 21.011 i TotaJ 14.201 u.srt H.ree by a type of shallow mining; Inclined shafting be today the non-white prefers to live as dose as came is! common after 19.10, possible, and the children play on the dumps from According to Freed (1915), the quarrying was a the mine and milt. family affair undertaken by the local inhabitantx. The men quarried the rock, which was sorted and Shea hand cobbed by the women and children. Hand cobbing consists of separating the fibre from the banded ironstone by striking the rock cob with a small hammer. As the market was selective, & On* Histories The following eight case histories illustrate various expect* of the disease and the dlfferoat types of exposure to asbeitui duaU rotary sieve was sometimes used to grade the fibre Case l.-JS.P., a Bantu male. 36 years of age (bora and eliminate the small particles of dust. After Hading, it war bagged and weighed. The asbestos was then transported, by fiookry wagon to Use Be&nst rail-head. Before the establishment of the railway in this area between 1923 and 1930, such s journey could last as long us 10 days. This iraneport was generally undertaken by whits youths (rumors' sons! under contract. Tl*e white inhabitants played very Hule part in actual recovery of the fibre, being nearly 1920), was a sties labourer, and was the Hut ease diagnosed as a mesothelioma with evldeac* of agtwciotls. He was bom in the Kurunwn iluukt bul ill* not knows whether he worked in the asbestos muses. He was employed on the Wirwaeerarand cold-mines underground for two yean and in the change cosms for a further II yours. A radiograph taken at & raise hospital os August is, 1955 showed a massive right-sided pleural mown, and 3,000 mi of Quid was withdrawn. He was admitted always employed In the role of manugocs or over seen, issuing stores and supervising the grading and weighing of the fibres- Farming activities wars and are slid carried out round Use mines. Since the 1939-1945 war, the demand for crocidolite has enormously increased. The lucrative claims have been bought by registered companies, others have been abandoned. As deeper and richer to the Witwatenrend Native labour Atsoristioii Hospital on August 24, 1935, and two days law oipfta- tbs. yielded 1,000 mi of thick gakteinous put "whidj oould be pulled out ia thread!"'. He was treated wfts frequent aspirations and instillation of varidan but without improvement, end ho died on February 15, 1956 (Marttoy. 1956). At autopsy the right thoracic cavity was occupied by a krpa gahtUnous turaour which displaced the mediasti deposits have bean found, vortical shafts mo being num and comprawed the left time The tumour had Sunk. However, the mines with large shallow infiltrated the pericardium. The right lung wax earn- deposits are itUl using the inclined shaft and tunnel, and quarrying is Still used by the few remaining smaller producers. With the building of more mills, hand cobbing bas diminished- in 1915 the fine crushing mill <m established at Koega* in the south. This was followed by a large mill at Kummin {defcbr eamprexsad by neoplastic tissue fPig. 2} but the right broaehlsl tree did not show ary evidence of a primary broachogmle ssrelaema, mimlogiea.1 saette of the pleural growth showed a papillary mejoOHUoma (Fig. I). There was evidence -of asimuoab is both lungs (Fig. 4). (operated between 1926 and 1931) where it wus Case 4.---X.H., a white female, 56 years of age (born situated withm 360 yards of the main street, dose to which cobbing was also done fur ft few yo&rS (1927-1930). This was followed by n mill at Prleskn in 1930, which wus completely rebuilt in 1957. Griquatown bad a small mill tn 1928. The practice today it for one mil! to serve several mines in the immediate nattily. Is the early days the manager snd labourers lived 1898), was a social worker, who could only have had a then exposure to asbestos as a child and probably a rarcw slight exposure u a young wnman. She may have paid several short visits to the mines With her husband at a later period. fine was burn in Griquatown whore she lived until she ms 3 years of age. Her fitrrdiy then moved to Kimberley where from 1916 to 1922 the worked as e clerk in on asbestos warehouse. Her husband owned aa within a few yards of their place of work, and even asbestos mine from 1935-1940. i i 4 i t i HWBUI0006959 -- ftUGjj.i:jlQ1 WED 02:22 PM FALK MEDICAL LIBRARY FAX NO. 412 548 9020 08/01/01 WED 15:12 FAX 216 661 6477 ____ COLLEGE OF PHYSICIANS d n- HWBUI0006960 SUM1-^01J(ED 02:23 Pfl FALK tlEDICfil LIBRARY FAR NO. 412 648 9020 08/01/01 ^ 18:14 215 561 647? COLLEGE OF PHYSICIANS T1f '.If 264 BRITISH JOURNAL OF industrial medicine P. 05 0007 HWBUI0006961 ftUG-01-2001 MED 02:23 Pfl FALK MEDICAL LIBRARY FAK NO, 412 648 9020 08/01/01 WES IB:16 FAl 218 561 647? r COLLEGE OF PHYSICIANS, DIFFUSE PLEURAL UESOTJlEUOMA 2W fyth. ittAS ufCMe U, mu. sc--luneleaim rniftM ef iwr * caw IS. x a HaemsowyUs sae xo&ta. She wt referred 10 the West End Hospital. JCimbaflcy, on July is, 193d, because or dyspnoea and right cheat dacomfort 0/ scuta onset. lie cheat radiograph showed e loculaiod pleural effusion at the right bate. Straw-coloured fluid was aspirated, whluh an examina tion was found to be negative feu M. mberadotl* but oenuimd raesoEheU&i cells am aged in acini. Ai thoraensoopy in Joflsnneabwj <>n August 11, 1)34 hUhom- nodules we teen oa the parietal pleura. Hlstolosiuil cxaminatiw) of the biopsy specimen showed ruesuthslioma, Deep therapy and radio-salve gold iatti'.istioa Is September, 1)53 caused Initial regression of bath the pleural fluid and noduicr but did not irnsl the progreu of the disease. She reooived a further count of f-ray therapy without improvunmat sod died is January, 1957. The liver was enlarged asd aodtdar before hath but no necropo was dona. (Figs. 3. 4, 7, aM t show the radiological development of the tumour in thi ease.) Case 14.--$.s,. a itemu male, 40 years of age {bom 1911), was as asbestos miner. lie was bom Jo the Kununan district and aa a child oftth played on the asbestos dump cejy sn gebeaiss mine. He subsequently worted wife asbestos for several years, brass employed * *a asbaetos mine walIbing bn from 1938-41. In 1)42 he worked on a Wlrwatersrssd gold mine bui returned to the Kuruman dkrria in 1943 where he worked as u farm labourer until hit *1 illfloss. Hewas admitted to tba West End KocpiUl op March 3. 1939. He had been well until July, 1)38 when he became aware of pains in the right Side uf his cheat. In addition be hid a slightly productive sough and xhortnesa of breath on exertion Chest radiograph on March 9, 1)39 showed obliteration of the right luOg field- Axbactm bodim wen found in the sputum. Needle biopsy showed histological features consistent with a meeoChetiuma. AtrtOMY --The right ohost was occupied by a hugs whitiih rumour which infiltrated the medicstmum. extending through the diaphragm onto the superior surface of use liver. A straw-coloured rffudiots ai present in the left pleural sxo but the left lung was tun affected. The mediastinal, carvtcat, sad paat-aorde abdominal lymph glands to the level of the renal wearies were infiltrated with tumour. In the right lung It wu found that the tumour mau had infiltrated along the interlobar juisru. The lobes trf the lung were compraraed Into throe small segments (Tig. 9). On histological (action a papillary type of pleural mesothelioma was seen (Fit ID) which had Infiltrated into the long parenchyma la arms areas. There was marked lymphatic spread throughout the AUG-01-2001 WED 02:24 PH FALK MEDICAL LIBRARY FAX NO, 412 646 8G20 08/01/Dl WED 18:16 FA1 218 861 8477 COLLEGE OF PHYSICIANS r. ur 2)008 266 BRITISH JOURNAL OF INDUSTRIAL MEDICINE lung MbfCtec. Numerous asbeoat bedlsj were present haemoptysis. He was referred to the fohaaroaburg in the air spues and occasional Studies and fibres ware General Hospital for investigation. The chest radio ms in the interstitial tissue. The lung itself was graph showed great pleural Ihliteniag with a bs.ui markedly atelectatic. Evidence of esbojtojri was pleurai effusion on the left side. Ha was admitted to observed in to left lung. hospital and oa June 10, 1957 s thoracoscopic pleura) biopsy was taken. This showed the features of a tncto. Case lS^-S.S.v, * white female, 42 years of age tbelioma. On June 24, 195? an attempt at doeereieatton (bom 191S), is a housewife, who lived os a mine Boar was made. Tho toff upper lube was stripped eaafiy am JohaoBcshurg and was tressed for futmvulesis ptemlsy the grossly thkkenod pleura was so adhered! to the (at Ut months. If was only after the hhtolopcal lower lobe dm (he attempt was abandoned. Section} of dispsasla Of a moMstteliom* had been made that her tho pleura eefsSrmd the itogflosb of tnciothcUoma. previous history wtu obtained. In addition, it was He died oa December 13, 1937. subsequently team ihsl her father (Cats 22) had ten bom os (ho tubules grid and had along mining hmery. Cos* 16.--A.N.V., a white male, 50 161$ of age (ben Tbs patient was bora io the Qrtqwstown district and 1906), was a fernur, who was bom tit Griquatown tB<j want to tcbool at KuWnwn. She spent most of her west to a viBags icltnnl near as asbestos mite. From youth in the asbestos bolt, She h* lived near Johannes 1924-36 he transported asbestos la aopkey waggons from burg for 20 years. Hay to Phases. During there journeys ns oh*o slept on Is March, 19SS this patient developed tight text pais asbestos bags, fn 1314 ho worked la aa asbestos mire and rapidly increasing shortness of breath. She was for month. odsdtted to hospital had 2400 ml. of slightly blood- The pattest became SI (a December, 1955 with vagu stated f.ltiS was removed from she righe efcesi. A substeraol pain and dyspnoea. a kftended piaural chomcoaeopie osamioaiioa was carried sue os My 21, effusion was dlagnowd and he was referred to Mr. J. K. when a small biopsy was taken but this cofistmd of firemmer in Pretoria. There was no evidence of mafig. fibrous usnie. Hronehoteopy w normal and no aapey in brooshi&J and scalene btnnsit*. Some apical neoplastic calls were observed in the bronchial washings. pleural tMeknolng sad a dense hoaioeorteosia opacity at M. tuberodotlt was not cultured from numerous upeci* the base of the left lung was earn is the radiograph oa mens of struts. pleural Sold nur from the bronchial August 3, 1956. Thoracotomy (Mr. Bremmer) in washing*. She wu odmtoed to a Johannesburg nursing February, 1957 revealed a thickened nodular pleura home OB October Id, 19J8. with a large trass on the left di&phrarm. A mesothelioma Radiographs then showed massive (hlclamlBg of the was seen os hkrotegieid section. right pleura with fluid in the right chest. At thoracotomy in April, 1939 he van gtamined by Mr. J. D. Vim in (Mr. Dennis Fuller) the piuteuil pleura was 2 an. thick, Kimberley who found small nodules in the subcutaneous 'hard as rock" and stripped with greet difficulty from the tissue over the Deck and chest. A large firm mass was cheat wulL Hie visceral pool atrippod fairly easily from found In the thorsoormity wound and a mass was pretest the upper lobe but separtoJO became more dllficult over In the left hypochondrium. There ww generalised the tower lobe where the peel was thicker. During tho (ymphadenspmhy and numerous nodules were present decorttatlioo e necrotic mass was found in the perwt- os the tongue. Chest radiographs showed the left pleural ChyiDh of the left low lobe- At ib base. confluent with cavity to be obliterated. He was one of the few easts to the diaphragm end perhaps the mraiiastiaum, was a. hard develop widtipread matasusea. craggy mass which could not be removed, HUtoiogkul A biopsy of ode of the subcutaneous cheat nodules vadloas of the specimen revealed on adenoid form of thowod a similar appearance to those seen in the original tubular masoihelkimu. Subsequently three specimens specimen from the pleura. TVe pattern died on May 22, of sputum were mmined for asbestos bodies but none 1959. No necropsy was performed. were found. Thcpatieni is still alive (April. 1960), but her conditiotk Gua 24--D.G.. a white male, 32 years of vgu (bora is deteriorating. 1922), by profession an accountant was bore 1ft England but came to South Africa as an infant. He spent his Case 22---D.A.B.. a white male, <8 yean of age, and a early childhood In Kurumao and left at the age of 7. He former, was the father of the previous patient. Although lfttor qualified at a chartered accountant io Kimberley, a diagnosis of pleural reseorhcHoma was made in hi 1944. nt the age of22, ho had boon discharged medically January, 1957 it was not until July. 1949 that details of unfit from the army because of a la!t pleural effusion. his eapouire to asbestos was obtained. (Voter ten nor os many subeequEtil oocnstena wore Ho was born In Oriauatuwn. and went to school there. aeid-faat bicUU found, otter ifi sputum or pleural fluid. Ho worked in Rumman. Postmasburg and Oriquaiowe His only subsequent contact with asbestos van the until the etas of'SZ Between 1918 and 1912 ho worked auditing of the books of an amoslte mate in the at as asbestos miner underground and wnt mostly in Transvaal. charge of blasting. Between 1932 and 1944 he fanned in In September, 1953 be complained of WHuted test the district but returned tu asbestos mining from 1945 twm and shortest! of bvsaOt. A radiograph of the ten TO 1952. showed flattening of the diaphragm on the left tide with In January, 1957 the patient consulted his doctor be obliteration of (he coitophreolc angle end thickening of cause of left-sided durst pain with cough and slight te oblique fissure. He was tcrai on aumannw oocaslon; HWBUI0006963 AUG-01-2001 WED 02=24 Pfl FALK MEDICAL LIBRARY FAX NO. 412 648 9020 08/01/01 WED 18:17 FAX 218 861 8477 COLf.ECT of pgYSICIANS ftc,. U*- \ September /I, ifjfc, II I2.`b&sdie&Apfa aliening *iu. IX-O&Aawt 33. *>7. f tu&ou? in G&ac 3A tern 1953 to 1957. A radiograph taken early in I8J4 Showed die development of a Ut auperfer mediastinal ibadow which enlarged pto(rwuvt.|y (Pig. ! 1) sod later 'k d /clopmest of dirtuse nodute pleural thickening on ths left. Durtol 1957 similar tel less marked chsaget developed on the right tide (Pig. 12). He eonaonted to W>I>y in June. 1957, ami, at operation, a diffueo pleural "ttUgnstney wm present. Sections o( the panel*! pleura only were removed and toe histological appearances wets) those at a nteso> ittdioraa. He died on October {, 1957, A necropsy wat not performed. CSe 20--G.F.. a white male, 50 years 0/ age (bom 1909). is e .storekeeper, with a history of industrial upajUre. He has never bean near t&e Cape Astoestej Helds. H was barn in South 'Wen Afriua and lived thereuntil *c 4se of2t. From the age of 2i to 26 he worked in a factory la the Cape as a bcilor-mdJcar nd Stic. He roiunteered the iafamutioB that he hsd worked eonIlnVauely with asbestos, lugging pipes sot) boilers. He ranarltad that ate removal el asbestos lagging from eld Sipes created a very dusty ataospliere and that he would eowgh i jot at suehi work. Between 26 and 22 years of ** worked in n factory in Johannesburg is a aimilsr capacity bet was not exposed to such heavy dust eepccwrajians. For ths pest 20 years ho had not been to cesiaet with asbestos. Knsjuiries were made from the *C!oty in the Cepe as to the nature of the asbestos wed and those have rcvs&kd that during the relevant periods Osps croddolito was exclusively in u. Ho wsa Stst seen on March 14, 1959 cooiplatrrmg of eoukh. pain in ths right chest and resent onset of braathtasssmi. Three pints of fiuld had been aspireted from the pleura and cytologies I at&ffiigstim showed the preaoooo of malignant edit. The radiograph ihowcd marked plows) thiekcaiag and hysfromneursothorax. On March n, tPSfi, * thoracoscopy was dope. Ths pleura felt thickened and Ok lung was eolhtpacd and immobile. Several biopsies were takas. These showed the prasene* of * mesothelioma. The underlying htsa shewscl (he pressman ofgrbctsoglr. He was msstad whit nitrogen mustard ialfa-pIcuraJly anil ids oondllioa tcmnorerily improved. 'When last examined he com plained of iadvued brsathlesanets. JEHsesaritus In 1924 Robertson denied the existence of primary malignant tumours of the pleura and amildcrcd them to be secondary in origin. Since then, on the one Hand, Willis (1941, 1953) usd Smart wed Hinson (19J7) have supported Robertson's views, while on the otter band, primary neoplasms of this nature have been described by many author* in recent yean. These indiuds Tobiatsen (1955) ia Swedeit. BcllonJ and Bovo (1957) in Italy, Godwin (1957) Ln the United State, and McCaughcy (19S8) AUG-01-2001 MED 02:25 PM FALK MEDICAL LIBRARY FAX NO. 412 648 9020 06/01/01 WED 16:16 FAX 218 5 6477 COLLEGE OF PHYSICIANS 268 BRITISH JOURNAL OF INDUSTRIAL MEDICINE 10 Britain, Evldancc in support of (ho mcsothellal origin of these tumours can be found In the tissue culture experiments of Stout and Murray (1942) and Sene. Weitt, and Gault (1950). The vttrteg&ted Mstolugiai pattens of tumours The amount of metachrom&tlc substance la these lumoura has varied considerably. This we think it partly due to the fact that until recently we had not appreciated the solubility of hyaluronic add in aaueous media and the majority of these tumours arising from the mcaothelium of the pleura was were fixed in 10% foratOl-Milne. Further, Lboa remaikcxi on by Klemperer and Babin (1931). Such (1953) states that the metashromasia of hyaluronic a variation It appreciated whan the multlpotentiaEty add is optimal at a concentration of 1/10,000 and of the cells lininc coelomic cavities arc considered. gradually decreases a c higher levels. When the high Maxitnow first demonstrated this feature in 1927. concentrations that Meyer and Chaffee (1939, 1940) Novak (193!) stated chat the mucosa of all parts of found in their tumours ore considered, this variation the MUllerian canal and the germinal epithelium Ih meiachromatic properties seems to haws bees were derived from these culls. Keasbey (1947) partially explained. In addition, with the greet showed that in the embryo, the mesonephros, differences In the histology of the various lesions, it metanejshros, Wolffian body, cental ridge, wui all would be logical to expect certain tumours with h dependant urogenital structures tic derived from stashed adenoid appearance to secrete more than the ntetoshelium. those with art essentially non-glandular structure. Campbell (1950) considered the presence of both Three of the five autopsies performed mowed epithelial and mesenchymal elements a major evidence of petitenaa! metastxsa. In the other two, diagnostic feature. Is describing the histology of Intra-thoracic spread wits observed, in one taut to the 11 of these tumours McCaughoy (1938) demonstrated other lung and chat wall, and in the second to the that either the epithelial or the mesenchymal dement mediastinal lymph glands and pericardium. Biopsy might predominate. He classified his cases into the gridcase Of metastasis has bam obtained is two following four groups: Tumours of epithelial caws, one from the omentum and the other from the character; tumours of mesenchymal type; turnouts subcutaneous tissue of the chat wall; while a third of mixed type; and tumours of anaplastic type. patient developed an Implantation nodule In the Using McCaughey'c classification on our scries thoracotomy scar which thawed a rimiiar appearance of tumours, the majority are, as In Campbell's series, re that of the previous biopsy spedom of the mixed type. Ofthe remainder, a few showed The first recorded case of carcinoma of the lung J? the papillary tubular structure of the ''tumours of awoditcd with asbestos was described by Lynch epithelial character"', and there were several of the and Smith (1933). By 1935, according to Doll, a anaplastic type. One ease hU (lie appearances of a total of 61 area had been reported. Included in ?! "tumour of mcscoebymal type" but even in this case these eases was one mesothelioma. Cutler ((952) primitive tubular structures were seen. mentioned two craes of diffuse mesothelioma from a Apart from the original case all the histological Ganadlaa Chrysolite mine. A further three eases diagnoses weft made on biopsy material Three of were described by van der School (1938). Un these biopsy findings wet* confirmed at necropsy. fortunately no indication Is given in the literature In Use remainder, we have had to rely on clinical regarding the type of asbestos to which the majority and radiological examination to exclude other of recorded eases of carcinoma were exposed. primary sites of malignancy. However, discussion with management and media! Following the work of Meyer and Chaffee (1939, officers of two of the factories. Is which the majority 1940), the possibility of demonstrating hyaluronic of the cases reported Is Britain were employed, acid in these tumours both chemically and hteto* suggests that most of these workers were handling obertlealiy has been considered at a diagnostic aid. chrysolite asbestos (Wagner, 1958). The possibility Both these investigations are still in an early stage that some of these people may also have ban IHarington, 1939). exposed to croddoUte dust cannot be excluded. Preliminary results of the hutochoraicaJ expert* Attempts to produce tumours is experimental menu show that there is meiachromatle substance animals by exposing them to asbestos dust have been i both the strata* and glandular structures of the m&de. Yorwcld and Karr (1938) wear unsuocoifuL tumours. This metachromasia can be reversed by Lynch, Mdvcr, and Chin (1957) succeeded in pro incubation with testicular hyalurooidase. This ducing tumours In mice, but lung neoplasms in hii material stains strongly with Hate's (1946) colloidal control animalj were far too numerous for the Iron method. The periodic acid Sdtiff technique results to be considered significant. On the other has given variable reactions. These results are not hand Seiimlhi (1958) working in Drudcrey's specific for hyaluronic add but are strongJy laboratory has been able to produce sarcomas in suggestive of its presence. tats. This has occurred after subcutaneous aad i^'rVUiu HWBUI0006965 !L0i?l.2:26 TM " "EDIMi UBMV TM "O' 412 648 9020 ------------------ Fa* 218 S6X 6477____________________ COL^GEOPraysiClANS P. 3 DIFFUSE PLEURAL MESOTHELIOMA 269 taswpcritoisesJ taoeulatkm of belts asbestos fibres- {Tattler 3). Eighteen of thaw 35 esses were boro in and dust. He states that "nittet&i wbeatoj" was the vicinity of die mines and two arrived in the used but does not noma tbs variety'. district as infants. Of these U people 11 admit Xq our series of nusathchomata, hlatologlsai definite childhood exposure to the dual and two evidence of aabralosla bos been observed in right others were exposed industrially in later life. In of the 10 cases In which lung parenchyma was in- addition two patients with childhood exposure latar eluded In the specimen examined No lung tissue worked in the asbestos mines. Three cases arrived was present hi the biopsies from the ronuMng la the region at ah older age but were employed richer 23 casco, it was esly in the four oases that aunc to on the minas or in transporting asbestos. A further necropsy that large section* of the lung smut were three of these 25 eases have had industrial exposure, available for examination. !n all of these tperimeru and in only one case do the relative* deny any evidence of aabostosia was found. exposure to asbestos dual. At first it was thought that tbs presence of The four industrial cases are sjg&ifieast. Two numerous asbestos bodies, fragments of fibre, and of the patients were lagging locomotive boilers and duet immediately below else pleural elastic laminae une was lagging swam pipes. A man. who was as in these specimens, might have been significant in upholsterer by trade, whs employed in making the pathogenesis of the tumours. However, It is fire-proof clothing from 1939,1945. As fir as can more probable that this distribution U a result of the be ascertained these people were never in the marked atelectasis. Similar features have been Oriqualond district. These findings tend to add observed in atelectatic lungs of asbestos mitten is support to asbestos being the common factor In the which no tneotheUon<as nave been observed. development of these tumours, and to counter the Pleural fibrosb has been a common finding in suggestion that there may be some other environ i of asbestosIs utd In some cases large pleural mental cause in the region of Oriqualand West, ^plaques measuring up to 1-0 cm. in tbidcoass have If asbestos dust is a factor in the occurrence of been seen. These plaques, which ware first described those tumours, similar cases might have been ex by Gloyne (1933), have been observed following pected from the neighbourhood of the Transvaal atponirc to both smositc and rraridolile asbestos asbestos mines in the Pictcrsburg and Lydenburg dw$h. in those cases of beings pleural thickening districts, where croctdolite and amositc asbestos is no evidence of stromal mcuchromasri has been mined According to Verotaas (1952), crocidoUto observed. and amosiie occur in the same seam* in the Pietets- In nil the histoioclcal section* of pleura examined bufg district. Ar can be seen from Tabic 1, amoslte in the cases of these mesotheliomas and in more is similar in composition to crocidolitc. In the past than 100 cases of asbestos Is, no asbestos bodies, four years the lungs of 24 oases of asbcstosl* from fragments of fibres, or dust have been observed the Lydcnbuig district have been examined. In beyond the pleural elastic laminae. this material two ewes of adtao-earsutoma have Three patients from the Kurumnn district, with been observed. The one was In a white miner with clinical and radiological features consistent with 19 years' service, who had art adoiw-Gareiaoma (hast of 4lfhwc pleural mesothelioma hod markedly arising from a bronchus. The other case was * abnormal cells in the pleural fluid. These cells Bantu miner who bad * peripheral tumour. No showed no specific features to distinguish thorn from service record was obtainable in this esse. Only oils originating in secondary malignant pleural one case of asbcstosl ha* been received from the deposit* nor from the grossly atypical cells somo- Picwre&urg area. All of these man were actually bmes seen in nob-malignant pleural effusions. A* employed on the mines at the bate of death, the bo biopsy or autopsy examinations were obtained ia majority having had a relatively short service. Our fbesc case* 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 himours with asbestos e*poture is not conriusive. paratively recently the mining in the Transvaal As previously stated, only in clgln of the 33 esses has has been on a small scale, and there were no scttlo- evidence of asbestos been dem<>nf*tod. Of them, meatx ic the vicinity of the mines. 5" had a definite mining histot y and one had beat The lungs of 20 asbestos misere from the Cape exposed to asbestos while lagging steam pipes. Tht Asbestos Reid have bees examined, in whom no other case waj born in the Kiiruman liiitikx and mesothelioma was observed. One autopsy specimen nothing else Is known of him, until his arrival at s consisting of three fragments of lung aaowed Witwaicruand gold-mine at the age of 23. In the asbestos!] and an adeno-carcinoma. Radiological "wuiato* 25 eases we can only present dream- features of asbestosis have beat observed In many tiamial evidence of exposure to asbestos dust miners from this region, without any suggestion of !<! m I! :#L ili HWBUI0006966 270 BRITISH JOURNAL OF INDUSTRIAL MEDICINE ihorc * Tasix i Pretoria. We thetr pvblUb lb mi OwN. m YOU or ftinH l 0) ! ' A8 | 81 . XUt|M4i( 14; 33 CM Sons e*t lu Asbouft* Fidai & Eiptttwrr I C?) Dtafnewd ft <*) 1, no) | S* w<***,' HteusiestaJ IW, , Nctno7; i; RMfienae ofiSyfflloCwTM*'* | <0** lionH 0..! JBQlXtt, * Mkv, F. <1 I 1 1920 > 34 i b : M a slU ' 41 MXD M 2 I no: 33 S F 4 1881 39 w F 3 1921 91 18 M i 7 1903 1920 33 36 Wt w ti l 1894 63 MXD ? OtMr kln9ff u*feftftw* aatfl oua io (fie wimmmdO #1 im *a ( 21 Mim3jSMiHOtf from 1Q2fcJJ: 1*11 * ( m< liJ5 wfcoic life [ft a iwSMidn *r r &! Umf on iiKim lUfe* limit iH* ** *F S'. wertMft & 8S901S* war*f* ISlfcle iMiu u Mft wortuns life in (he Mctniiy of (nines Uvd all h* ilia in ttc talUy of . I,;vm1 &J)h4a1tr<tX* vlrinUyof min*: worm M a twiar .. , , , Prom (Ha in r24 1N*6 m villa** afwSft# laeal aunn: Ik* tutted mina: wtMIttd oobbiaj S ditau* ood. G. Casv ^ 11 Union ync. S R 28 n 3.' ttwjp. M. tlA C. ill A> t-1 ru8t>' iriflsiOa. ^ Sn3un. / irvltx. M E.rpen CHa` i9 20 1901 1919 92 MXD u i W M OuillQC U0UIO Wlioic lift spun UI mina. JlfaftK U* , IM it (to nu/w turn >|i 1.1T n: PU tM Uiuufr ftiuS m inina o boy: mufuoft W auai&MiUfcJld$ . 11 52 11 1898 1910 29W eo MXD 8 MM 90 W F WtaoU HU *l *!"': 'JfilSpiv MawituM M hlmnof U. taw Uoamrnilliml!I tl\ a"0 wUI' AM<1 1 MHO , , ,,1U., I1S2 StiUcim ? c, TiTii. Liaen . !.. IN QattlH l.jrncK. K. M Melvef tilth, i M 19K 4ft 8 M IS 2918 62 W F 16 ias>< 1 6ft w M Whale lift wear *" mlna' ,95Ml> DMJia*tyoaSJfCOr|tf lfuc*iRal^$3*:1 lIivIt6fld&i mine unljl *8* , atfr^fti 80 whool n* eohbtas WtU(l9MI98lmKflrfna: iSWOMWS MWws 'I Stcfi eim! t 17 ' m\ (8 1920 69 boa> F U aM lillli^or mijfl* MIM Mws lilt M* *f tuhaiqiilAt viaUs , Wfioif hi* >n tti* vkinily Of *6 . B<Mr i 21 SlUJ a** 20 :922 !90< n MXD M 32 w F 21 1922 , 64 wM U 1H87 ff w M 21 ir?3 w F Family lived ti min*; minw ISM-1959 SciU %ie UC in vlUaee oft wa^ft row* ua liSjJ/nhe^wtwiy a r rain* wvilj ihe # *fi&: Wfeaiy i5i lr in* r uo mMi mo^ 1*14-3?. BftO 1943.33 .k Uv0 H* vttiniiy f &* muSOb WftUt ll" af* The 1 9 u Decempre.H. V i; s it Conpsti M. dk 24 !U22 33 w M Uvsfi tfi tt>8 viciTiuvaf awillfroi* 0* 68* f 1*^* Xf&yc6 DP. ke 4uws5 m & chile . 48 PlraSne 22 1899 30 %> F Liv8 tft mlftinroiti fro **?,<* an: tnr IOCS tpani wiiolc lift i some fJliabn lU-vei 24 1893 49 w U n 1904 32 w M a 1809 60 w M 1913 44 w M 30 1909 30 w M it mi 64 w M It (90S 66 w M 13 1890 3W w F KEYS: C*)ufn 6-- ftaea: W - WftU.' MXD - MU*a (Coinuroo^ %* (own 8i Com 3* ' , M^neS flfl traotpon8 satoW lkMu (vavajJ ftJ^1T?ehW.a C; x&MPonM ittUiuo.-nn1o>Ji0j4U "* -f- *in ---- jyns lfi ABC Ol miai IPII'-II Matlnaulieoii<iia i}oceomevvec bvxmnimon I9>HS _ MaMUOAing Meant Jiipo (" aotosM *" ^arkaif0( finer ft railway!. rt*imalft`"l laoamiiii*bOliarOai**MnknowA Mekmf aabwioa hliftkma fe Ih* Air Fere* i*J9.aS No f.lliory f eiBkrtur* lo *** ObLusui 6 . > Bam on alhMOl **!* -> " Not 0rr. en aabOtOI 0 - unknown Calumn -- . - Naorepcy an* - r iMesreeey net 4oft > Only mull f ^Qjloioi plwia wbfwtud m auuce Ua IUAtetOSitai U Sli1d5il.xf siijj aLwi 6i i Cw.lur*o.oP1Cnrohbt. los. , tv.i.8t<a1^l71 Of aaKMtomi* - - No luta tlo* aubmlt-C i 0 - SkuU frtfB\0At( ul l#%r. (bmiv Out * es8^ - A Study oi A. M Aerosol b Lj. P. A Blochen Ajne- A Stapilfi- dnical, > G. L. Th Mms Olrsemtlc and I tumour rornulioa. However, pleural Involvement has Seen a common finding in these casea (llurwitz, 1959). It Is po-olble that there has run been a sufficient lapse t>r time after exposure for tumour devclornnant In these cases. Further, the factor of individual hiHMptlbiltty must also be con sidered. We wish m record the *rt asdstanoe thu m have received in this investigation from the medical pnelilioiters of the Griyualand West District umd the lbs Asset' ltidusi Book Revi A nm Medical t k HWBUI0006967 jG-O!-2001 WED 02:27 PH FALK MEDICAL LIBRARY FAX NO. 412 648 9020 08/01/01 WED IB: 20 FAX 21B 861 6477 ________ C07.T.PGR OF PHYSICIANS ! 014 DIFFUSE FLEUMAL MESOTHELIOMA 271 thoracic mpwns and pafitologhts in Johnnmstnirg, Pretoria, and Durban. We thunk (be Secretary of Health for permission to publish ihi* paper. BgMirtal, O., RsrasNeis .wto C. C1937J. ATM r4. fwr#r. 17, IS?. J. fSik, 34. 473. t*Aofr. 4, SSS. {QkuH1mUa to & Dell.R. (IMS)'.' jMr./. Mnr. A*4m U.ll. Preti. O. S. 5. (191$). MemerwUUtm mm tin J*k*4tmt tn&oity in nm Cgp* fwtaet* $./* ef the Mwsttif EasiAmt, Union ef 3CUO A/flct, m. 1MBClarA*.. - H*J3jT rfcrffr (UaST) 4.493. M. C (1937). CM00f (Mfltf.) 11.191, Halt C. w, (t. Nsv (Jurtd.), H?. 102. Kell. A. L. 0930). iff (Ar V*t* mf X*tuk AJHtu. Mcmo- nagutfino. (2- Goolofienl Sumv er seutp A.Men. Hsrtftgwft. i. 5. <1999% Pcnonnl twmttw&eatieti. Vlgsiraea.J., uui OcuK /U O. (1937). a a* (ft. fat. C*i**~ 13. Mf, W?wifx. M. (19X0, freetmdlmft ttf itii&twikimf mf tx&tn mm fmmmwmmmii, ;Ananft*jnL Feb. 1959. ChureAlii, (Ip tho pn(4 Kdusbcy. L, . (1947). <<M/' J Peril*X\ 871. KWrip^er. and JU&Ja, C 1. flfli). 4^. Pmtk It. *J. Uiaa, ^UU. 8<tii#y})}*.vatManltiudrnumm.if ft CytochimJc Assimaki, pp. 334*337. K. M., &ati Smlii, ?#, a. (1135). 4nff. s, Cemrts 84,58. --. Mtnwr, F. A., mu) CaU. /. &< (I99D. 4.A1.4. 4r**. MUttr. Mftk, k Ml. MMtarxtmimro, *O. .4(.1(913942)7,%vP4/vrct./ulVr(Mpf,f.gfWlffi/t*imo paWk...4O,TjJ.rS Am,, IS, S3. McGuilluy. W. T. (1958). /. Ark #*rf., 78. 511. Merer, A,. aim Oieflee, 1. Of3$). />*r. . *xp. **/. Of./.)* 41, 7S7, --~ U94U). 4. Mel. C4em^ US. 83. Ntfrok, S. 093!), 4*v*. 4. OfeMf. <7**r,, 23,04. $E7$.ffg: iatt^Y'YUk /. *. UM4hi.'u. ntsti- *. fcwwso*.. at. lai, _ Smart. J., amt Hlnmm, K. F.W.*J7S Jni. 1. Ttiknc, SI. JIS. Siva, MA.. Ml.Md Mwny. M. *. (IMU. 4rtk. nut. T^iw^O. <19SSV. 4mm patk. at%mk, Suppl. 191. xtmaat.r,Kl(hIM. c.Zml.. <rin*.,Smrr..Scu.snstTinlw, im. . VwwlZ A. J, and Kan. i. W. OSMX Anr. J.)'at*., to. e. Kiev, i. C. 0910. Hem m rwawwKMlI Rtrca*a ta brw>. susraliM w e C.S.I.K. waia, R. A. (I9W, III M- Ml 1M1I. ratkatatr af TtiaimM. Rultvrmrlh, heaeoR. Addeaduu By (he end of June 1960, u total of 47 eass of mnothelioma had been Identified. In 43 of these a possible association with exposure to c/odooiiui has been atabiisised. in one cose a mesothelioma of (he peritoneum was present THE JULY (I960) ISSUE i The July (I960) issue contains the following papers:-- Docooipmsfoii Sickness daring Cotiwurtlan of (be Dartferd lluma). By F. Campbell Golding, P. Griffiths, H. v. Hercplcman, W, D. si. Patoo, and D. N. Walder. A Compartoon of the " tUglfaMtudc " and '* Kigh-pwascre " Syadrontos of Deconpresdon SSefawsa. By M. de G. Gnibble. PhEe PoisofliRg Ceased hr the U*e of Qhemiazi Pam Renews Containing MeftyltM CUorids la M-rcnfiiated Rooms Heoiad by KaroMM Stem By W- B. Gerritsea and C H. Buschmann. A Study en tea Aatle ToxJdty of (he Tthoryl Phosykata Used as Phstidzers. By H. F.- Bosdy, E. 3. Field, A. N. Worden, and J. P. W. Hughes. Aerosol Inhsktien of CaPiajEJD.TJU (Motet by Workers Cmartantiy deposed to Lead Psasoah, By Li. Petrov!t. M. Sliahovid. M. Savidcvid, and D. Poieti. A Bioteoieal Study of Me Urimry Protein of Man Expwod to Metafile Merevyr. By 3. C Smith nod Agnes It Wells. A Simplified Method for the Ruination of Niekel to Urioa. By J. Gwytmc Morgan. Cliniod, Broodtographie, RAaioloplcal, and Pbydologica] Ohurvatini in Ten Canes of Aibotnil By G. L. Leatbaa The Meuuretaent of Oc<U|uaoit&J Mortality. F. D. K. Liddell. Obsfsmttitms os the Oeaspafissal Life Htotory of the Coal Face Worker at Two Cettertas. By O. P. Edmonds and IX S. Kerr. The Asaasmewt of EteerrMneophalograptile Cbanyes and Memory Disturbances in Acute InbwioatloM wfth IMwtrial PotooM- By fi Chaiupn, J. Synkovd, and M. Ssvdtk. Some Rastowa. A number of copies are still available and may be obtained from the Publishing Manager, British Medical AKoemiun, Tavistock Square. W.C.l. pride ]7r. 6d. 'if M'-feii HWBUI0006968