Document YGjY4NGKJ3OXGE0wBM5X938Jy

Jrh.J. indusir. Med., I960, 17, 260. n<*H DIFFUSE PLEURAL MESOTHELIOMA AND ASBESTOS EXPOSURE IN THE NORTH WESTERN CAPE PROVINCE BY J. C. WAGNER. C. A. SLEGGS. and PAUL MARCHAND From the Pathology Division, Pneumoconiosis Research Unit of the Council for Scientific and Industrial Research. Johannesburg. West End Hospital, A'intherley, and the Department of Thoracic Surgery. University of the M 'itu atersrand and Johannesburg Genera! Hospital * (KICtlVED fOR PUBLICATION APRIL 24, 1960) Primary malignant tumours of the pleura ate uncommon. Thirty-three cases (22 males. 11 females, ages 31 to 6T>) of diffuse pleural mesothelioma are described; at! but one base a probable exposure to crocidolite asbestos (Cape blue). In a majority this exposure was in the Asbestos Hills which lie to the west of Kimberley in the north west of Cape Province. The tumour is rarely seen elsewhere in South Africa. Mesothelioma of the pleura is regarded as an the lungs of the first ease (Case I). and secondly, -. uncommon tumour. In the last four years we have 10 of the cases came from a hospital to which seen 33 histologically proven cases; 28 of these had suspected cases of tuberculosis were referred from a some association with the Cape asbestos field and large asbestos mining area. This hypothesis could four cases had been exposed to asbestos in industry. not be supported at once from the original histories :< The tumour is rarely encountered elsewhere in obtained from the patients, for the)- included house* South Africa. During the past five years, with the wives, domestic sen-ants, cattie herders, farmers, a exception of the present series, no neoplasm of this water bailiff, an insurance agent, and an accountant, nature has been diagnosed amongst 10,000 lungs none of whom were working on the asbestos mines " examined at the Pneumoconiosis Bureau In at the time. We therefore undertook a detailed ' Johannesburg, or in the Pathology Department of investigation of their past occupation and place of - the South African Institute for Medical Research. residence, and the association with asbgstos ex* . Higginson and Oettle (1957) did not observe a single posure was discovered. The cases are summarized case in their survey of malignant tumours occurring in Table 3. Previous biopsy specimens were re* in the Bantu and Cape Coloured population of examined, and newt cases diagnosed, including Johannesburg and the North Eastern Transvaal. asbestos' miners. In only one case do the relatives Our first necropsy specimen of pleural meso deny that the patient either visited the asbestos thelioma with asbestosis was examined at the mines or was exposed to asbestos. Pneumoconiosis Research Unit in February, 1956 This is a preliminary publication and the problem (Case 1). During the early months of that year, is being intensively investigated. one of us (C.A.S.) in the Northern Cape, treated six patients with gross pleural thickening. Pleura) biopsies from two of them showed the features of The Asbestos Area of the North-West Cape mesothelioma. In the ensuing tw-o years, eight According to Hall (1930} asbestos was discovered further cases were found from this region and five by Liehenstein near Prieska during his travels be* from elsewhere in the Union. During this period tw-eeq^JL803 and 180$. Since then it has been GA.S. had become perturbed at the number of established that the asbestos deposits extend from these unusual tumours occurring amongst his 20 miles south of Prieska, northwards through the >; patients, and stimulated an investigation. At this western pan of the magisterial district of Hay, to H stage there were two reasons to suggest that asbestos the eastern portion of the magisterial district of -.1 might be implicated. First, asbestos was found in Postmasburg and finally, to the western area of the ** 260 i 0537.0 DIFFUSE PLEURAL MESOTHELIOMA 261 V district of Kuruman (Fig. 1). These deposits occur in the slopes of a range of hills covering an area of approximately 3,000 square miles. Known as the **Asbestos Mountains'*, these bills extend more or less longitudinally between 22-30 and 23 E. The whole area is semi-arid, sparsely populated, and, apart from mining, cattle ranching it the only important occupation. In the Kuruman area several large tracts ofland in or abutting on these mountains have been reserved for the aboriginal inhabitants and here whites may only reside in the immediate vicinity of the mines. The type of asbestos mined throughout this area is crocidolite, better known as Cape Blue Asbestos. The chemical analysis of the fibre is given in Table 1. Crocidolite is the fibrous form of riebeckite and all stage's of transformation from a massive riebeckite rod; through lamellar riebeckite to asbestifonn crocidolite occur in this region. Magnetite is frequently associated with the crocidolite (Vermaas, 1952). Mining of asbestos first began in the Prieska district in 1893 aod gradually spread northwards. In 1908 production bad begun in the Kuruman dis trict. Between 1916 and 1918 a large number of claims were taken up. This northward trend has continued and in about 1950 mining started at Pomfret near the Bechuanaland border (Table 2). Initially the ore was quarried in numerous small open cast workings. This was followed gradually Tabu 1 CHEMICAL ANALYSES OF CROCIDOLITE AND AMOSITE (ftoa Vcrnm, ISS2). wSAJiO>0, | GKMN*OffOi0 HA' H+ ' F Tout CtociSoIitc 3144 11t030*0911--4134033349147179 10073 r Arnotiu 4t , 1 ! . 43.9044000000203----33224044041037231707135231. , i 10044 ' V7?M o2 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Tabu 2 ^FULATION OF THE MAGISTERIAL. DISTRICTS tN WHICH THE ASBESTOS FIELDS ARE SITUATED (ttkcn from Union Ctnim I92t, and 195U Ditiract Pfietkt Kurumtn H*y PtHtmiiburc Population 1921 W'htie* Nen-uhiiet { Toil }.4>0 4.*79 | 9.309 013 4.499 It.WI 2i.ri 1.114 1 .3t3 Included in the Hay Dht'iev tt'Kim J.JM 4.SII 2.7*7 4.SSI Poputairtn I9SI ! (Q.I47 ' 23.77* 1 9.631 | 21.019 Total >4.2te 2S.M7 124U 2J.9JS by a type of shallow mining; inclined shafting be* today the non*white prefers to live as dose as came more commort after 1930. possible, and the children play on the dumps from Acco.ding to Frood (1915), the quarrying was a the mine and mill. family affair undertaken by the local inhabitants. The men quarried the rock, which was sorted and then hand cobbed by the women and children. 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, a Case Histories The following eight ease histories illustrate various, aspects of the disease and the different types ofexposure to asbestos dust. rotary sieve was sometimes used to grade the fibre Case 1.--B.P., a Bantu male, 36 years of age (bom and eliminate the small particles of dust. After 1920), was a mine labourer, and was the first case grading, it was bagged and weighed. The asbestos diagnosed as a mesothelioma with evidence ofasbestosil. was then transported by donkey wagon to the nearest raihhead. Before the establishment of the Tailway in this area between 1923 and 1930. such a journey He was bom in the Kuruman district but it is not known whether he worked in the asbestos mines. He was employed on the WHwatersrand gold-miDeJ underground for two years and in the change rooms for a further could last as long as 10 days. This transport was 11 years. generally undertaken by white youths (farmers* sons) A radiograph taken at a mine hospital on August JS,* under contract. The white inhabitants played very' 1955 showed a massive right-sided pleural effusion, little part in actual recovery of the fibre, being nearly and 3,000 ml. of fluid was withdrawn. He was admitted always employed is the role of managers or over* * to the Wftwatersfand Native labour Association seers, issuing stores and supervising the grading and Hospital on August 24, 1955, and two days later aspira* weighing of the fibres. Fanning activities were and tion yielded 1,000 ml. of thick gelatinous pus "which are still carried out round the mines. Since the 1939*1945 war, the demand for crocido* could be pulled out in threads'*. He was treated with frequent aspirations and instillation of varidase but without improvement, and he died on February 15, Site has enormously increased. The lucrative claims . 1956 (Marttny, 1936). have been bought by registered companies, others At autopsy the right thoracic cavity was occupied by have been abandoned. As deeper and richer a large gelatinous tumour which displaced the oediasti*. deposits have been found, vertical shafu are being num and compressed the left lung. The tumour had sunk. However, the mines with large shallow infiltrated the pericardium. The right lung was com deposits are still 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 has diminished. In 1915 the first crushing mill was established at Koegas in the south. This was followed by a large mill at Kuruman pletely compressed by neoplastic tissue (Fig. 2) but the right bronchial tree did not show any evidence of a primary bronchogenic carcinoma. Histological sections of the pleural growth showed a papillary mesothelioma (Fig. 3). There was evidence of asbestosis In both lungs (Fig. 4). (operated between 1925 and 1931) where it was <B Case 4.--K.H., a white female, 56 years of age (bom situated within 300 yards of the main street, close 1898). was a social worker, who could only have had a. to which cobbing was also dose for a few years short exposure to tsbesto m a child and probably a (1927*1930). This was followed by a mill at Prieska further slight exposure as a young u-oman. She may is 1930, which was completely rebuilt in 1957. Griquatown had a small miUfn 1928. The practice today is for one min to serve several mines in the have paid several short visits to the mines with her husband at a Jater period. She was bom in Griquatown where she lived until she was 5 years of age. Her family then moved to. immediate vicinity. Kimberley where from 1916 to 1922 she worked as a Is the early days the manager and labourers lived clerk in ao asbestos warehouse. Her husband owned as within a few yards of their place of work, and even . asbestos mine from 1933*1940. DIFFUSE PLEURAL MESOTHELIOMA 265 Fie. 9,---Rifhi law of C*M 14. Fe. 10--Hm4c|ie*J 4ctien> of ivaour Cron Cm 14. x 24 Httmatotyiift otia. She was referred to the West End Hospital, Kimberley, mi July 19. 1954, because of dyspnoea and right chest discomfort of acute onset. The chest radiograph showed a locuiated pleura! effusion at the right base. Straw-coloured fluid was aspirated, which on examina tion was found to be negative for M. tuberculosis but contained mesothelia! ceils arranged in acini. At thoracoscopy in Johannesburg on August 11, 19S4 tumour nodules were seen on the parietal pleura. Histo logical examination of the biopsy specimen showed a mesothelioma. Deep therapy and radio-active gold instillation in September, 1955 caused initial regression of both the pleural fluid and nodules but did not arrest the progress of the disease. She received a further course of x-ray therapy without improvement and died in January, 1957. The liver was enlarged and nodular before death but no necropsy was done. (Figs. 5, 6. 7, and 8 show the radiological development of the tumour in this case.) Cue 14.--S.S., a Bantu male, 40 yean of age (bora 1918), was an asbestos miner. He was bom in the Kuruman district end as a child often played on the asbestos dump near an asbestos mine. He subsequently worked with asbestos for several years, being employed at an asbestos mine .w-eighing fibre from 1938-41. In 1942 he worked on a Witwstersrind gold mine but returned to the Kuruman district in 1943 where he worked as a farm labourer until his final Qlness. Hc-was admitted to the West End Hospital on March 3, 1959. He had been well until July, 1958 when he became aware of pains in the right side of his chest. In addition he bad a slightly productive cough and short ness of breath on exertion. Chest radiograph on March 9, 1959 showed obliteration of the right lung field. Asbestos bodies were found in the sputum. Needle biopsy showed histological features consistent with a mesothelioma. AUTorsy.--The right chest was occupied by a huge whitish tumour which infiltrated tbe mediastinum, extending through the diaphragm ooto the superior surface of the liver. A straw-coloured effusion was present in the left pleura) sae but the left lung was not affected. The mediastinal, cervical, and para-aonic abdominal lymph glands to the level of the renal arteries ware infiltrated with tumour. In the right Jung it was found that the tumour mass had infiltrated along the interlobar fissures. The lobes of the lung were compressed into three small segments (Fig. 9). On histological section a papillary type of pleura) mesothelioma was seen (Fig. JO) which had infiltrated into the lung parenchyma In some areas. There was marked lymphatic spread throughout the 266" BRITISH JOURNAL OF INDUSTRIAL MEDICINE lung substance. Numerous asbestos bodies were present haemoptysis. He was referred Jo- the Johannesburg in the air spaees and occasional bodies and fibres were General Hospital for investigation, -five chest radi^ seen in the interstitial tissue. The lung itself was graph showed rots pleural thickening with a markedly atelectatic. Evidence of asbestosis was pleural effusion on the left side. He .was admitted to* observed in the left lung. hospital and on June 10. !95?.a thoracoscopic pleura) biopsy was taken. This* showed the features of a mevo. Case IS.--S.S.V., a w-hite female, 42 years of age thelioma. On June 24. 1957 an attempt at decortication (bom 1916), is a housewife, w-ho lived on a mine near was made. The left upper lobe was stripped easily but Johannesburg and was treated for tuberculous pleurisy the grossly thickened pleura was so adherent to the for six months. It was only after the histological lower lobe that the attempt was abandoned. Sections of diagnosis of a mesothelioma had been made that her the pleura confirmed the diagnosis of mesothelioma previous history was obtained. In addition, it was' He died on December 13, 1957. subsequently learnt that her father (Case 22) hid been borr. on the asbestos field and had a long mining history. Case J6.--A.N.V., a white male, 50 years of age (bom The patient was bom in the Criquatown district and 1906). was a farmer, who was bom at Criquatown and want to school at Kuruman. She spent most of her went to a village school near an asbestos mine. Front youth in the asbestos belt. She has lived near Johannes* 1914-16 he transported asbestos in donkey waggons from burg for 20 years. Hay to Pricska. During these journeys he often slept on In March. J958 this patient developed right chest pain asbestos bags. In 1914 he worked in an asbestos mine and rapidly increasing shortness of breath. She was for a month. admitted to hospital and 2.500 ml. of slightly blood* The patient became ill in December, 1955 with vague stained Arid was removed from the right chest. A aubstemal pain and dyspnoea. A left-sided pleural thoracoscopic examination was carried out on July 27, effusion was diagnosed and he was referred to Mr. J. K. when a small biopsy was taken but this consisted of Bremmer in Pretoria. There was no evidence of malig fibrous tissue. Bronchoscopy was normal and no nancy in bronchial and scalene biopsies. Some apical neoplastic cells were observed in the bronchial washings. pleural thickening and a dense homogeneous opacity at. M. tuberculosis mas not cultured from numerous sped* the base of the left lung was seen in the radiograph oo mens of sputa, pleural fluid nor from the bronchial August 3, 1956. Thoracotomy (Mr. Bremmer) in washings. She was admitted to a Johannesburg nursing February, 1957 revealed a thickened nodular pleura home on October 16. 1951. with a large mast on the left diaphragm. A mesothelioma Radiographs then showed massive thickening of the was seen on histological section. right pleura tth fluid in the right chest. At thoracotomy In April, 1959 he was examined by Mr. J. D. Vis*i in (Mr. Dermis Fuller) the parietal pleura was 2 cm. thick, Kimberley who found small nodules in the subcutaneous "hard as rock" and stripped with great difficulty from the tissue over the neck and chest. A large firm mass was chest wall. The visceral peel stripped fairly easily from found in the thoracotomy wound and a mass was present the upper lobe but separation became more difficult over In the left hypochondrium. There was generafired the lower lobe where the peel was thicker. During the fymphadenopathy and numerous nodules ware present decortication a necrotic mass was found in the paren* on the tongue. Chest radiographs showed the left pleural chyma of the left lower lobe. At the base, confluent with cavity to be obliterated. He wasonevf the few cases to the diaphragm and perhaps the mediastinum, was a hard develop widespread metasuses. craggy mass which could not be removed. Histological A biopsy of one of the subcutaneous chess nodules sections of the specimen revealed to adenoid form of showed a similar appearance to those seen in the original tubular mesothelioma. Subsequently three specimens specimen from the pleura. The patient died on May 22, of sputum were examined for asbestos bodies but none 1959. No necropsy wa^performed. were found. The patient is still alive (April, I960), but her condition i Case 24.--D.G.. a w-hite male. 32 years of age (bom Is deteriorating. 1922), by profession an accountant, was bom in England but came to South Africa as an infant. He spent his Case 22.--D.A.B., a white male, 68 years of age, and a early childhood in Kuruman and left at the age of 7. He farmer, was the father of the previous patient. Although later qualified as a chartered accountant in Kimberley. a diagnosis of pleural mesothelioma was made in In 1944, at the age of 22, he had been discharged medically January, 1957 it was not until July, 1959 that details of unfit from the army because of a left pleural effusion. his exposure to asbestos was obtained. Neither then nor on many sxfeequent occasions ware He was bom in Criquatown and went to school there. acid-fast bacilli found, either in Sputum or pleura! fluid. He w-orked in Kuruman, Postmisburg and Criquatown His only subsequent contact with asbestos was the until the age of 62. Between 19)8 and 1932 he worked auditing of the books of an amosite mine in the as an asbestos miner underground and was mostly In Transvaal. charge of Masting. Between 1932 and 1944 he farmed in In September, 1933 he complained of left-sided cbest the district but returned to asbestos mining from 1945 pains and shortness of breath. A radiograph of the chest to J952. showed flattening of the diaphragm on the left side with . In January. 1937 the patient consulted his doctor be* obliteration of the costophrenie angle and thickening of cause of kft-tided chest pain with cough and slight the oblique fissure. He was seen on numerous occasions DIFFUSE PLEURAL MESOTHELIOMA 267 V . *> +Z. t* P * I Fta. II--Oa Scpwmbar II, 1934. FM. ja--0 Auput 33. iJ7. ' FjCi. || Mid l3.'-RadiofT*plu tb^anf r*lepa>rtt of nunowf m Cam 34. from 1933 to 1957. A radiograph taken early in 1956 showed the development of a left superior mediastinal shadow which enlarged progressively (Fig. 11) and later the de-eiopment of diffuse nodular pleural thickening on the left. During 1957 similar but less marked changes developed on the right side (Fig. 12k He consented to biopsy in June, 1957, and, at operation, a diffuse pleural malignancy was present. Sections of the parietal pleura only were removed and the histological appearances were those of a meso thelioma. He died on October 6,1957. A necropsy was not performed^ Case 30.--G.F., a white male, 50 years of age (bom 1909), is a storekeeper, with a history* of industrial exposure. He has never been near the Cape Asbestos Fields. He was bom in South West Africa and lived there until the age of 21. From the age of 21 to 26 he worked in a factory in the Cape as a boiler-maker and fitter. He volunteered the information that he bad worked con tinuously w ith asbestos, lagging pipes and boiferi. He remarked that the removal of asbestos lagging from old pipes created a very dusty atmosphere and that he would cough a lot at such work. Between 26 and 32 years of age he worked in a factory in Johannesburg in a similar capacity but was not exposed to such heavy dust con centrations. For the past 20 years be had not been in contact with asbestos. Enquiries were made from the factory in the Cape as to the nature of the asbestos used I and these have revealed that during the relevant periods Cape crocidolite wet exclusively in use. He was first seen on March 14, 1959 complaining of cough, pais in the right chest and recent onset of breath lessness. .`Three pints of fluid had been aspirated from the pleura and cytological examination showed the presence of malignant cells. The radiograph showed marked pleural thickening and hydro-pneumothorax. On March 17. 1959, a thoracoscopy was done. The pleura felt thickened and the lung was collapsed and immobile. Several biopsies were taken. These showed the presence of a mesothelioma. The underlying lung showed the presence of asbestosis. He was treated with nitrogen mustard intra-pleurally and his condition temporarily improved. When last examined he com plained of increased breathlessness. Discussion In 1924 Robertson dented the existence of primary malignant tumours of the pleura and con sidered them to be secondary in origin. Since then, on the one hand, Willis (1943, 1953) and Smart and Hinson (1957) have supported Robertson's views, while on the other hand, primary neoplasms of this nature have been described by many authors in recent years. These include Tobiassen (1955) in Sweden, Belloni and Bovo (1957) in Italy, Godwin (1957) in the United States, and McCaughey (1958) 4* i* * ' - 4 < 4. 1 4-..* > f .1 5 ......^'c'c-w 26R BRITISH JOURNAL OF INDUSTRIAL MEDICINE in Britain. L'viidetve in support of the mevoihclutl _thc amount o( metachromatie subviance in th^ origin of these tumours can he found in the tissue tumour* ha< varied roneidcrxMv. Thi*-*.* f cv*jo*t rvrv-"v- erS\**'i **.* Sam*. Weiss, and d.itili (1950). * / v -A' t.1 . appieciaied the solubility of- hyaluronic acid i? The variegated histological pattern of tumours, aqueous media and the majority of these turnout' arising from the mesothelium of the pleura, was were fixed in 10 / formol-saline. Further, User remarked on by Klemperer and Rabin (1931). Such (1953) states that the metachromasia of hyaluroni;, a variation Is appreciated when the multipoientiality acid is optimal at a concentration of 1/10,000 and of the cells lining coelomic cavities are considered. gradually decreases at higher levels. When the big.1, Maximow first demonstrated this feature in 1927. concentrations that Meyer and Chaffee 0939,1940* Novak (1931) stated that the mucosa of all parts of found in their tumours are considered, this variation the Mullerian canal and the. germinal epithelium in metachromatie properties seems to have were derived from these cells. Keasbey (1947) partially explained. In addition, with the great showed that in the embryo, the mesonephros, differences in the histology of the various lesions, it metanephros. Wolffian body, genital ridge, and all would be logical to expect certain tumours with dependent Orogenital structures are derived from marked adenoid appearanoe to secrete more tfcj- the mesothelium. those with an essentially non-gtandular structure. Campbell (1950) considered the presence of both Three of the five autopsies performed shouec epithelial and mesenchymal elements a major evidence of peritoneal metastases. In the other t* c. diagnostic feature. In describing the histology of intra*thoraeic spread was observed, in one case to the ) 1 ofthese tumours McCaughey (1958) demonstrated other lung and ehest wail, and in the second to the that either the epithelial or the mesenchymal element mediastinal lymph glands and pericardium. Biopsy might predominate. He classified his cases into the evidence of metastases has been obtained in two following four groups: Tumours of epithelial cases, one from the omentum and the other from the character: tumours of mesenchymal type; tumours subcutaneous tissue of the ehest wall; while a third of mixed type; and tumours of anaplastie type. patient developed an implantation nodule in the Using McCaughey*s classification on our series thoracotomy* sear which showed a similar appearance of tumours, the majority are, as in Campbell's series, to that of the previous biopsy specimen. of the mixed type. Of the remainder, a few showed The first recorded ease of carcinoma of the !i:.> the papillary .tubular structure of the `Tumours of associated with asbestos was described by Lyrcf epithelial character", and then: were several of the and Smith (1935). By I9SS, according to DoD, L anaplastic type. One case had the appearances of a total of 61 cases had been reported. Included it "tumour ofmesenchymal type** but even in this case these eases was one mesothelioma. Canter (!952j primitive tubular structures were seen. mentioned two cases of diffuse mesothelioma from e Apart from the original case alt the histological Canadian chrysotile mine. * A further three caste diagnoses were made on biopsy material. Three of were described by van der Schoot (195?). Un these biopsy findings were confirmed at necropsy. fortunately no indication is given ia the literature In the 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 cases of carcinoma were exposed. primary sites of malignancy. However, discussion with management and medical Following the w ork of Meyer and Chaffee (1939, officers of two of the factories, in w hich the majority 1940), the possibility of demonstrating hyaluronic of the cases reported in Britain were employed, acid in these tumours both chemically and histo* suggests that most of these workers were handling chemically has been considered as a diagnostic aid. chrysotile asbestos (Wagner, 1958). The possibility Both these investigations are still in an early stage that some of these people may also have been (Harinpon. 1959). exposed to croridofite dust cannot be excluded. Preliminary results of the histochemtea! experi* Attempts to produce tumours in experimental mems show that there is metachromatie substance animals by exposing item to asbestos dust have been in both the stroma and glandular structures of the made. Vorwald and Khrr (1938) were unsuccessful. tumours. This metachromasia can be reversed by Lynch, Mclvcr, and Cain (1957) succeeded in pro* incubation with testicular hyaluronidase. This during tumours in mice, but lung neoplasms in his material stains strongly with Hale's (1946) colloidal control animals were far too numerous for the iron method. The periodic add Schiff technique results to be considered significant. On the other has given variable reactions. These results are not hand Schm&hl (1958) working in Dniekrey's specific for hyaluronic add but are strongly laboratory has been able to produce sarcomas to suggestive of its presence. rats. This has occurred after subcutaneous and DIFFUSE PLEURAL MESOTHELIOMA . intrapcritontal inoculation of both asbestos fibres (Table 3). Eighteen of these 25 cases were bom in / and dust. He states that '`mineral asbestos" was the vicinity of the mines and two arrived in the used but does not name the variety. district as infants. Of-these 18 people-11 admit In our series of mesotheliomats, histological definite Childhood exposure"to the dust and 'two evidence of asbestosis has been observed in eight others were exposed industrially in later life, lii of the )0 cases in which lung parenchyma was in- addition two patients with childhood exposure later eluded in the specimen examined. No lung tissue worked in the asbestos mines. Three ca*ses arrived was present in trie biopsies from the remaining in the region atan older age but were employed either 23 cases. It was only in the four cases that came to on the mines or in transporting asbestos. A further necropsy that large sections of the lung tissue were three of these 25 eases have had industrial exposure, available for examination. In ail of these specimen; and in only one case do the relatives deny any evidence of asbestosis was found. exposure to asbestos dust. At first it was thought that the presence of The four industrial cases are significant. Two numerous asbestos bodies, fragments of fibre, and of the patients were lagging locomotive boilers and dust immediately below the pleura) elastic laminae one was lagging steam pipes. A man, who was an in these specimens, might have been significant in upholsterer by trade, was employed in making the pathogenesis of the tumours. However, it is fire-proof clothing from 1939-1945. Ax far as can more probable that this distribution is a result of the be ascertained these people were never in the marked atelectasis. Similar features have been Griqualand district. These findings tend to add observed in atelectatic lungs of asbestos miners in support to asbestos being the common factor in the which no mesotheliomas have been observed. development of these tumours, and to counter the Pleural fibrosis has been a common finding in suggestion that there may be some other environ cases of asbestosis and in some cases large pleura) mental cause in the region of Griqualand West. piques measuring up to 10 cm. in thickness have If asbestos dust is a factor in the occurrence of been seen. These plaques, which were first described these tumours, similar cases might have been ex by Cloyne (1933), have been observed following pected from, the neighbourhood of the Transvaal exposure to both amosiie and crocidoiile asbestos asbestos mines in the Pietersburg and Lydenburg dusts. In these cases of benign pleura! thickening districts, where crocidolite and amosiie asbestos is~ no evidence of stromal metachromasia has been mined. According to Vermaas (J952), crocidolite observed. and amosite occur in the same seams in the Pieters ' In all the histological sections of pleura examined burg district. As can be sfien from Table I, amosite , in the cases of these mesotheliomas and in more is similar in composition to crocidolite. In the past than 100 cases of asbestosis, no asbestos bodies, four years the lungs of 24 cases of asbestosis from i fragments of fibres, or dust have been observed the Lydenburg district have been examined. In ' beyond the pleuraJ elastic laminae. this material two cases of adeno-caremoma have 1 Three patients from the Kuruman district, with been observed. The one was in a white miner with : clinical and radiological features consistent with 19 years* service, who had an adeno-carrinoma j those of diffuse pleural mesothelioma had markedly arising from a bronchus. The other case was a abnormal cells in the pleura) fluid. These cells Bantu miner who had a peripheral tumour. No ! showed no specific features to distinguish them from service record was obtainable in this case. Only cells originating* in secondary malignant pleural one case of asbestosis has been received from the * deposits nor from the grossly atypical cells some Pietersburg area. All of these men were actually times seen in non-malignant pleural effusions. As employed on the mines at the time of death, the no biopsy or autopsy examinations were obtained in majority having had a relatively short service. Our these cases they have been excluded from the series. findings suggest that mesothelioma occurs 20 to. 40{ The pathological evidence for associating these years or more after exposure to dust. Until com-' tumours with asbestos exposure is not conclusive. paratively recently the mining in the Transvaal As previously stated, only in eight ofthe ^3 cases has has been on a small scale, and there were no settle , evidence of asbestos been demonstrated. Of these, ments in the vicinity of the mines. six had a definite mining history and one had been The lungs of 20 asbestos miners from the Cape exposed to asbestos while lagging steam pipes. The Asbestos Field have been examined, in whom no other case was bom in the Kuruman district and mesothelioma was observed. One autopsy specimen nothing else is known of him, until his arrival at a consisting of three fragments of lung showed Witwatererand gold-mine at the age of 23. In the asbestosis and an adeno-carcinoma. Radiological remaining 2S cases we can only present circum features of asbestosis have been observed in many . stantial evidence of exposure to asbestos dust miners from this region, without any suggestion of * 270 BRITISH JOURNAL OF INDUSTRIAL MEDICINE Tabu 3 DIFFUSE PLEURAL MESOTHELIOMA: ASSOCIATION WITH ASBESTOS (I) (i) <)> (4) ili> i (6> 1 (7| | (. . <91 1 <101 Yur Cam No. , of Btnb 1 1 1720 " 2 1 *171) 3 ` 1 1702 4 j 119* 5| 1725 i 190) 1 | 1920 1194 7 10 ji 1705 1709 n i tm 12 1 1910 13 i 1709 >4 ! I7lt ts 1i 171* J* 1ST* 17 1911 I* 1720 17 1922 20 170* 21 i 1912 22 I 1199 2) i 1792 24 i 1922 22 1177 1 2* tm r 27 ? 1704 21 , 1999 27 171) JO 1709 31 171) 33 ! 1901 J) ! 1S9Q i 26 *42 9) 91 31 23 36 63 32 49 60 4t SO 42 60 4S 31 37 3) 44 61 63 33 30 47 52 60 44 SO 44 47 Kid ; tti ; B! *: MXD 1 B, w} M M F F 9M WF wM MXD F MXD M wM MXD B w B W w MXD a MXD w w w w w w M M F M F M F M M F M M F M f w w w w *w w w w M M M M M M M F Bom on Aabniot i Fields 4f 1 1 4 1 4. 4 4 4 + 4 ** 4 4 4 4* + 4 4 4 4* 4 -- -- 0 Atbattot Exposure Other hittery unknown until come to the WitAt tht Alt of 23 Mined Atto.iof from 193033; left area At tht Aft of 27 Lived whole (if* in a location near an atbettot mill Lived on asbestos Btldt until the im of 3: worked in atbetio* warehouse 171^20 Spent all hit sorkina life in the vicinitv of mine* Lived ail her life m the vicinity of minAi Lived all hit life in the vicinity of mrnca; worked l Aihet From the ace of 24 lived in a villtfe atrvint local mine*; often visited mmet: watched cebbmf outside house* Whole life (rent nut mtnet. dietini well! Lived at the mine firm ape 7-17 yean; plavad on dumpt and in mine ai a boy; returned to assist from *|t 21-23 Whole life (pern our mines: miner 17)1-33 Lived near mines until the aft of 17; miner 1727 Liisd mi mine until the at* of 21; played with Itbr* at a child Whole life tpcot mi minac: miner 173*41; played on dumm a a child Dtufhttr of Cue 22: lived at mine until ape of 20: went to tchool nut cobbm* sheds Went to achool our mmet: (rantported asbestos 1914.16 Lived on major weon tome tilt at* of |9; tewmlsubMeotat visit* Whole life in tht vicinity of the mine*; miner 1945-5* Famili lived at mine: miner 1936-1959 Spent whole life in villtr* on melon route to Kimberley Lived in tht vicinity of mine* anti! the apt of 16; often on dumpt at a child Whole lift in the vicinriv of the mines; miner 1913*32. and 1745-52 Lived in tht vicinity of the mum until the trt f JO Lived in the vieimty of a m3] from the a*e of 1.7; played on the dumpt at a child Uitd in a minus* arta from tht aft of 10 to II ytarv. alia 1711 spent whole lift in use town at Cam 24 Minad and transported aibattos from 1929-33 it bvtntv Bom in North Welt Opt; transported (buses from 1920-24 Lived whole lift on farm in minim area from the ate of 12: transported atbettot I9IL2I Mtinuinm* locomotive boilers 1931-4J Mamtalnint steam pipes in caplotKa factories 173040 Worked at Utter on raSweyt, maintainm* locomotive betters. date* unknown Makint atbettot blanket* for the Air Force I9394J No history of exposure to ubetirt tOvapneved' on Necropsy : Biopty |I j i-- 1 Hhioloti Atbaatoth 4*t - i v 4 i; i* t ^ 1m | j :* i+ 1* ^a i ! 4* ' _ i _j 1 _ 4} 4 mo i* ! !* i 4\ 4* !* 1 : :J !4 - A. 1 1* j ; St _i 4i - t- *5 i * j _ i 1 _ 14 u -0 !4 ; !- i !4 I - -- u Si . Column 4-- Rant: W - White MXD Miaad (Coloured) Rama Column* 4 - Bon on atbettot field* -- m Not born on asbestos held* 0 " Unknown Column 7-- 4 -- Nacmrtydone - m Kacreptv not doM * * Only until frapneau of parietal pleura submitted at autopty fot biatelotical eumiaation Column 10 a - FothtvebHtolofiealavtf of ubcaioth -- m No lunp tittue tebtrasr 0 * Small frapman'A of A \jua. but no eddeset f ab*ttow* lumour formation. However, pleural involvement has been t common finding in these cases (Hurwitz, 1959). It is possible that there has not been a sufficient lapse of time after exposure for tumour development in these eases. Further, the factor of individual susceptibility must abo be con* sidered. '- w* *ish to record the great assistance that we have received in this investigation from the medical precshsontrt of the. Griqualand West District and the' *' DIFFUSE PLEURAL MESOTHELIOMA 27 J ; ihor?cic surgeon* and pathologist* in Johannesburg. Pretoria, and Durban. , Wc thank the Secretary of Health for permission to publish (his paper. References Scileni. O.. ana Soio, C. 1157|. Arto m*4. pot**- 17. 3*7. Campbell. W N (1930). Amrr. J rah.. 26. 473. Canwr. f (1*571 Arch, toduitr. H)f.. S. 367. (Ceniribunan io Iht divutMnn.) Ooll.K UV55) B'u. J t+4u\<t. htr4., 17, (I. Fu4,G.t K <l*it>. Mr>"Arn4u*i cm the Atbttim inJi/HH- n ihr (jv ftmurf. fltpon of the Covcrnmcnt Mmmf EiifiMtt, Union of South Africa, pp. 76-S2. Clnyn*. S K (I9.3i. (L<**X 14.4V) Go4.n. M C <1V57| Cantu (PhiluAi. 10. TVS. Hale. C. W (l*40i. (Lund.). 157. SO). HaU. A. L. (IVJOl A\hrnOi in thr (Jnttm c/ South Afrit*. Memo randum no. 13. Gcolotical Survt> of South Africa. Haiinptoa. J. S. (195*). Prnonal communication. Hipm>nri, J . ana Otitic. A. G. (1957). Art* Co. tot Coon* I). 94V. Huruttt. M. <1*5*1. Ptnrrtdirtft of lotrrootumol Coofritoit of ftAoit on Ptttomu. orxinti. Johaiuwthurt, Feb. 1959. Churchill. London. (In lb* prm) hcathrt. L. I I I947 Amrr. J. fur*,. 23. 171. Klemperer. t*.. and Kabm. C. U. (1V3I|. Atrh. Put*. (Chitecu). U. HV Liaun. 1.. (J*55i ll.nttkimtt tt Cyurtktmir Ammoltt, PP- 337-337. Gauthi r-V ilUrt. Prfa. L>nch. K. M . and Smith. W. A. <19351. Ami. J. Cootrr. U, 36. --. Mdvtr. F. A., dnd Cain. J. R. (1937). A.Mj*. Art*, mduttt. Hit*, IS. 207. Maniny. O. (1*561. Pror. Tr*oir. Attor mrd. Ofir,' Alt u ei Maaimow, A. IIV27). Air*. rxfT2rll/nrtr*--A. |. "* MeCawthry. A'. T. (IVJSl. J. Pot*. Sort., 76. ill -- Meyer, K.. and Chaffee, E. 119391. Trot. Sot. rap. BmA. (ti. YI ------ .----- 1 (1940). J M. C*rm.. 1J3. I). Nmai. E. (19311. Amrr. J. Oburt. Gtrtrt.. 22. Roemvon. H. . 0924), J. Court Art..*. )13, Sano. M E . Wem. E.. and Gault. E-S. (1930). J. tAorot. S*'tZ Schmihl.'D. (19311.' 2. KrrbiUmrb.. 62. 361. Smart. J., and Hinton. K. F. W. (1937). B'it. J. Tt+rtt Si Jt Siout. A. F . and Murray.-M. R. (19421. Air*, pot*. (Cituotrti. 24. 951. Tetuiien. G. (1933). Att* p*t*. minobiui. arond^ Suppt. )0S, p 192. tan drr School. H. C. M (1931*. Krd. T.Gntml. 102. 1124 'ermtat.F H S (19521. Treot. troi. Sot. S. Alt..lf. \90 Voroald. A l., and Kan. j. W. (193*1. Amrr. J. pot*.. |4, 49. A'ajiitr. 3. C. (1*56). *irm.trooJnm m PoramtHttoitta Brtrott* m uroftr. Submitted to the C.S.I R. A'illu. R. A. (1941. In ad. and 1953). Potboimfr of Tomoon Buiicretonh. London. Addendum By the end of June 1960. a total of 47 cases of mesothelioma had been identified. In 45 of these a possible association with exposure to crocidoliie has been established. In one case a mesothelioma of the peritoneum was present. .jf f! i t . I> 1 h i t ii a '-??;.).* :f| ! ... >} A '. :'* * a : : <". THE JULY (1960) ISSUE The July (i960) issue contains the following papers:-- Decompression Sickness during Construction of the Dartford Tunnel. By F. Campbell Golding, p. Griffiths. H. V. Hempleman, W. D. M. Paton, and D. N. Wilder. A Comparison of the 44 High-altitude ** and " High-pressure " Sj-ndromes of Decompression Sickness. Bv ' M. de G. Gribble. Phosgene Poisoning Caused by the Use of Chemical Paint Removers Containing Methylene ChJoride in Ill-vcntiiatcd Rooms Htatcd by Kerosene Stoses. By W. B. Gerritsen and C. H. Buschmann. A Study on the Acute Toxicity of the Tri-aryl Phosphates Used as Plasticizers. By H. F. Bondy, E. J. Field, A. N. Worden, and J. P. W. Hughes. Aerosol Inhalation of CaNa2E.D.TrA. (Mosatil) by Workers Constantly Exposed to Lead Poisoning. By L). Petrovid. M. Stankovid, M. SaWderid, and D. Poleti. A Biochemical Study of the Urinary Protein of Men Exposed to Metallic Mercury*- By J. C. Smith and Agnes R. Wells. ______ A Simplified Method for the Estimation of Nickel In Urine. By J. Gwynne Morgan. Clinical, Bronchographic, Radiological, and Physiological Observations in Ten Cases of Asbestosis. By G. L. Ixathart. The Measurement of Occupational Mortality*. F. D. K. Liddell. Observations on the Occupational Life History of the Coal Face Worker at Tho Collieries. By O. P. Edmonds and D. S. Kctt. The Assessment of Electro^ncephalographic Changes and Memory Disturbances In Acute Intoxications with Industrial Poisons. By B. Chalupa, J. Synkovi, and M. Sevdik. Book Rtriens. . A number of copies are still available and may be obtained from the Publishing Manager, British Medical Association, Tavistock Square, W.C.l, price 17s. 6d. il 'C J