Document gaJ76Qa50DnLLDy5R74BgGo6Q

FILE NAME Household Contact HC DATE 1961 DOC HC012 DOCUMENT DESCRIPTION Medical Journal Article - Diffuse Pleural Mesotheliomas in South Africa MEDICAL JOURNAL MEDICAL MEDICAL MEDICAL JOURNAL MEDICAL MEDICAL MEDICAL a ales Sit oe aSS wo EE te, Ke Accidental Poisoning in Children Mean Haematological Values in III Infants and school Children Editorial : Van die Redaksie The Medical Congress Verwyders van die Kroonslagare Diffuse Pleural Mesotheliomas 31961 31961 FO LGU: I'L'A I'L'AI'L'A j handelsmerk handelsmerk merk N MIDDEL VAN VOORTREFLIKE WAARDE VIR j a Die voorkoming en simptomatiese behandeling van suiwere migraine 4 M^'ni^rsee sindroom doolhofontsteking en ander vorms van gehoorsduiseling : * Die voorkoming en behandeling van mi likheiden braking Verkrygbaar as tablette oplossings vir inspuiting en steekpille Breedvoerige inligting is op aanvraag verkrygbaar > YOM MAYBAKER S.A. EDMS BPK n Mediese Produk met die kandresmeri YOM GM bite Mths, hip PORT ELIZABETH POSBUS 1130 TEL 4-5481 TELEGRAMME BISMUTH TAKKANTOOR JOHANNESBERG POSDUS 26 TEL 885-5425'885-85425'8 TELEGRAMME BISMUTH JOHANNESBURG PORT ELIZABET 28 S.A. MEDICAL JOURNAL 14 Janu geneem word dat die middels wat die pyn verlig die sirkulasie in die kroonslagare verbeter Dit moet ook aangeneem word dat aangesien die nitricte gladde spiere laat ontspan insluitende spiere van die slagaarstelsel hulle die nitriete hartkramp verlig deur spasme van die kroonslagare op te hef Al hierdie oorwegings is waarskynlik korrek maar nie een van die aannames is bewys nie aangesien geen direkte waarneming gemaak is van die kroonslagare gedurende n aanval met spesiale verwysing tot die uitwerking van nitriete nie By miokardiale infarksie ontwikkel pyn in sy ergste vorm as gevolg van hipoksie van die miokardium Die pyn is weerstandig vir verwyders van die kroonslagare en is mocilik om te verlig selfs deur die gebruik van sulke pynstillende middels soos morfien Die middels wat gebruik word vir verwyding van die kroonslagare is betreklik spesifiek Die nitriete laat alle gladde spiere ontspan maar die arteriole is meer vatbaar vir hierdie uitwerking Dit mag wel wees dat hulle slegs n betreklike spesifieke uitwerking het in gevalle van abnormale vatbaarheid soos byvoorbeeld by spasme van die kroonslagare waar klein dosisse verligting bring sonder dat daar n algemene gestelsuitwerking is Dit veronderstel dat die middels weinig waarde mag h^' vir die verbetering van kroonslagaar as daar geen spasme is nie n Middel wat n vinnige uitwerking het is aangewese en as die pyn eers verdwyn skyn geen verdere medisyne nodig te wees nie Dit mag dus gebeur dat by die gebruik van vatverwyders wat n verlengde uitwerking het die pyn reeds al deur rus verlig word voordat die farmakologiese uitwerking van die middel kan intree ook kan die uitwerking van die middel dan nog lank voortduur nadat daar nie meer behoefte daarvoor is nie Vir die verligting van n aanval van hartkramppyn is die soort middel wat n vinnige uitwerking het aangewese Daar is baie middels wat n stadige uitwerking het wat gebruik word om aanvalle te voorkom of om n langdurige uitwerking teweeg te bring wat slagare wat in spasme is gou laat ontspan en die pyn dus verlig feitlik voordat dit ontwikkel Daar is egter geen afdoende ant- woord op hierdie probleme nie in die literatuur is daar baie teensprekende verklarings oor hierdie saak Verskeie ondersoeke op hierdie gebied is of swak beplan of onvol- doende gekontroleer Die nitriete het n kragtige uitwerking om Ce aanval van hartkramp te verlig Guiser.eltr~-n~-~-r tabletvorm is gewoonlik die beste Amienitric meer amptelik B.P. nie maar word tog nog aar wanneer n baie vinnige uitwerking vering vering Gliserieltrinitraat wat ingesluk word nitro is waardeloos aangesien die middel in ac vernietig word Die uitwerking word van krag . middcl onder die tong opgelos word dit poem n langer om opgemerk te kan word maar dit duur e " langer as wat die geval is met nitriete wat inge tm Die middel het n vaste dosisvorm en word die gencesheer en nie deur die pasient nie heraal Dit veiliger om te gebruik as die geneesheer nie teeny is nie Daar is verskillende middels in hierd ' groep wat n langdurige uitwerking het maar hulk nie baie algemeen gebruik nie n Groot groep middels wat teenhouers in monoamien oksidase iproniasied isokarboksasiew sten nialamied het nou verskyn Hulle het n king op die luim van aie pasi^n-dtieesogen` psigiese energieverwekkers Sommige hiervan mag w waarde wees by die behandeling van hartk r heb aangeleentheid behoort versigtig benader te > Aminofillien en teobromien word n geruime tyo - gebruik met so gebruik vir hartkramp maar soos dit ook die g baie ander middels het n vergelyking me van plasebo's geen spesiale voordeel a nie Alhoewel daar dus n hele aantal middels is wat uitwerking het op hartkramp is die nitriete die e middels waarop ons kan reken dat hulle die kroons- verwyd en pyn verlig Dit is nie bewys dat die r ander middels wat hierdie uitwerking sou h^"wel tief of betroubaar is nie Die nitriete het egter . voorbehoedende uitworking nie miskien omrede ontwikkeling van toleransie Die groot behoeite op! gebied is eintlik aan n middel wat aan n farmakologiese groep behoort en waarteen tolerans ontwikkel nie 1. Modell W. 1960-1961 Drugs of Choice S 1 C. V. Mosby DIFFUSE PLEURAL MESOTHELIOMAS IN SOUTH AFRICA C. A. SLEGGS Medical Superintendent West End Hospital Kimberley PAUL MARCHAND Department of Thoracic Surgery University of the Witwatersrand and Johannesburg Gene . ow Hospital and J. C. WAGNER Senior Medical Officer Pathology Division Pneumoconiosis Research Unit South African Co. for Scientific and Industrial Research Johannesburg In another paper we reported on 33 cases of diffuse pleural mesothelioma histologically diagnosed at the Pneumoconiosis Research Unit of the South African Council for Scientific and Industrial Research Johannes- burg Thirty of the cases were investigated clinically by ourselves Since then a further 8 cases have been proved 4 of which were under our care This paper supplements our other communication with a description of the clinical and radiological findings in the 34 cases which selves investigated COMPARATIVE RARITY OF DIAGNOSIS The histological diagnosis of diffuse pleural mesoth is a contentious subject Doubt has beer thrown er existence as an entity by Robertson and Willis p malignant mesothelial tumours were describes Wer nuorie1961 S. TYD^ IF VIR GL KUNDE 29 perer and Rabin and Stout and Murray Recently s concerning these tumours have appeared from 44 Countries these include those of Tobiassen and Bova~ Godwin and McCaughey The diagour cases has been confirmed by South African augsts and known authorities from Britain and UNA including Dible Gough Steiner Stewart waki waki des pleural mesothelioma is generally considered a 475 Daub and Jones reported 3 cases among Tl onsecutive admissions to the Henry Ford Hospi- The largest series that we have been able to find in tetture as that of Choptal et al who described 22 seen over a period of many years In contrast our mour has been diagnosed mainly during the last 4 I must be stressed that we have only included cases nri'* nature of the tumour has been confirmed Sigically either on biopsy or necropsy material A her of cases showing radiological and clinical features have been excluded Three of these cases had edly abnormal cells in the pleural fluid KURUMAN ASSOCIATION WITH ASBESTOS frequency of mesotheliomas is possibly significant in imparent association with areas where asbestos is or milled Evidence in support of this has already - presented and includes The finding of asbestos bodies in the lungs of 12 of the 41 patients with mesotheliomas even though " majority of the earlier cases before the association suspected the biopsies usually consisted of tissue from parietal pleura only Asbestos bodies have been found ASBESTOS HILLS q of 11 biopsies in which lung parenchyma was in- Fig 1. Map showing asbestos deposits in the Cape ert nt Evidence of asbestosis has been observed in 6 out Province ty * 7 cases in which the lungs have been examined at Cape the most extensive in the world extends from 20 gta copy miles south of the Orange River north to the Bechuana- patients with ten : The fact that 19 of these patients worked with land border covering approximately 8,000 square miles aA sos either as miners millers or industrial workers The deposits are mainly in the slopes of the Asbestos a The fact that all except 2 of the other 22 cases were Mountains a range extending more or less longitudinally EAD <7born or spent a significant period of their lives in asbestos area of the western Cape Province between 22-30 and 23 Fig ) Mining and Milling Fae ** gov Rodies in the Sputum Irther Irther one of us C.A.S. working on the clinical The type of asbestos mined throughout this area is crocidolite better known as Cape blue asbestos Croci- thesis that exposure to asbestos causes an increased dolite is the fibrous form of riebeckite All stages of al reaction in patients suffering from tuberculosis transformation from massive riebeckite rock through outted numerous sputa from the West End Hospital lamellar riebeckite to asbestiform crocidolite occur mu this L wherley to the Pneumoconiosis Research Unit for ex- - nation Asbestos bodies and fibres were found in the region Magnetite is frequently associated with the crocidolite Vermaas Mining of asbestos first began in the 2. of 115 patients who had no definite mining expo- Prieska district in 1893 and gradually spread northward : Included in these were specimens from people work- In 1908 production had begun in the Kuruman district in cleaning works and abattoirs in the North This northward trend has continued and in about 1950 C4ape in places 100 miles away from the nearest mining started at Pom near the Bechuanaland 735 The presence of asbestos bodies and fibres in the Tumis Tumis naturally only indicative of exposure to asbes- border Fig 2 shows graphically the asbestos production from 1910 - 1958. Initially the ore was quarried in numerous small open workings This was followed - dust and is not evidence of asbestosis unless there is al and radiological support However from these gradually by a type of shallow mining inclined shafting became more common after 1930 nas it would appear that people possibly not asso- Since the 1939 - 1945 war the demand for crocidolite 4with asbestos production or utilization have been sed to the hazard has increased enormously Since deeper and richer deposits~ have been found vertical shafts are being sunk However to in the North West Cape The area of the asbestos deposit in the North West the mines with large shallow deposits continue to use the inclined shaft and tunnel and quarrying is still used by 30 S.A. MEDICAL JOURNAL 14 Jemuer . _ TONS 4 TONS 5 a0 : ' ae : 4 ' cp H H : 20 000 10.0 010.000 4 i cA a 2 Rete GG a 1 nn % lt Litlilitiwttiswitstuts irr mh) who aD YEARS rir mS reise += ae -oe ee bre Tha! Fig 2. Production of crocidolite by asbestos asbestos mines in the North West Cape in tons per year 1910-1958 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 operated between 1926 and 1931 where it was situated within 300 yards of the main street close to which hand cobbing was also done for a few years 1927 - 1930 This was followed by a mill at Prieska in 1930 which was completely rebuilt in 1957. Griquatown had a small mill in 1928. The practice today is for one mill to serve several mines in the immediate vicinity In the early days the manager and labourers lived within a few yards of their place of work and even today the White personnel prefer to live as close as possible to the mills and the children play on the dumps from the mines and mills The industrial use of asbestos has increased during the last 30 years In 1930 Hall stated that there were 4 firms in the Union manufacturing asbestos products in Cape Town Durban Johannesburg and Meyerton which used a total of 900 tons of fibre annually In 1952 17,000 tons of fibre were used in local industry CarrollPorczynshi lists 7 firms dealing with asbestos in Cape Town and 44 in Johannesburg Asbestos cement and an asbestos clay compound are used extensively for insulating boilers in power stations industries and railway locomotives Three of our patients were employed in this way Another patient was employed manufacturing proof clothing Cases of asbestosis have been observed in a variety of industries on the Witwatersrand Asbestos and Carcinoma The association of asbestos with carcinoma of the lung was first described by Lynch and Smith in 1935. By * Freeing the fibre from the ore by striking the lumps of rock with a hammer 195 according to Doli a total of 61 cases a reported Merewether nalysed the CASON (FO occurred in Britain betwe 1924 and 1954. Fic four in a total number of 344 cases carcinoma of Ww was present in 55 16 the figure for males 20 of males and for females 14 10 of femak cases of mesothelioms of the pleura associated bestosis have been described One was menuiors Doll 2 by Cartier and 3 by Van der School Ai 33 cases with possible asbestos exposure were de by Wagner et al In our series of cases the latent period betwee apparent exposure to asbestos dust and the initial a toms of the disease was between 20 and 60 In some cases the patients had left the North Was and in others the exposure had been of such a trar nature that it was rapidly forgotten Evidence of sure was only obtained after long and detailed quest According to Day and Stewart a long latent ' between initial exposure and the development of e of malignancy is one of the features of occur tumours The reason for the tumours having been in the vicinity of the Cape asbestos fields and not region of the Transvaal asbestos mines may be due time factor assuming that the association is signa since the industry was established earlier in the Cari in the Transvaal where large mining began cofl tively recently The type of asbestos mined is a possible factor which would apply to the chrysotilt of the Eastern Transvaal However the amostre found in the Lydenburg district is similar to the crocidolite and the crocidolite mined around the P burg district is identical CLINICAL PICTURE OF MESOTHELIOMA Clinical Presentation The majority of patients are over the age of 4 usually present with symptoms suggestive of a pr tuberculous effusion Pain varies from a feer heaviess heaviess to acute pleuritic pain From the beginn after a variable time there may be increasing dys on exertion Cough is not a predominant symptom r group A few patients present as cases of acute respir infection with a productive cough 17. * accom by a pleural effusion In some c is there is an between the respiratory infection and the finding a pleural effusion The course of the disease whit mately similar usually takes one of two forrequim ring ens . pleural effusion continues to increase requiring fre paracentesis or it undergoes a temporary quiescent p while the pleural space becomes obliterated by t Towards the end the patient is seriously disabled the pleuritic pain and dyspnoea develop due either to peritoneal failure Terminally metastases ascite or to Clinically the disease may be described as hat stages Initially the presentation is one of pleuris bronchitis and the usual diagnosis is a virus or p^ pneumonitis At this stage antibiotics are usually su ful in alleviating the symptoms The second stage is a # 1 os r 5 Monae wm Jane 1961 S.A. TYDSKRIF VIR GENEES : ae clusion with pleu thickening af is then that En is usually admitted to hospital for investigation J les malignancy asbestosis and other cases of discase may be considered The final stage is one pes thoracic malignancy 1. Race Habitat and Occupation 34 Canes consisted of 24 males and 10 females Table se se men who had lived all their lives in the vicinity of bestos mines were the only patients under 40 at the + diagnosis Four of them had been numers They | flAND RACT DISTRIBUTION OF THE 34 CASES OF MESOTHELIOMA DESCRIBE Age Total Sex 30 - 39 40 50 Over 60 remale 6 0 wp Male 2 Female 3 0 J Male 5 2 Female 1 0 6 1 3 2 0 2 1 2 0 } 13 8 = 1} 8 os 1 6 7 34 _ lin their thirties the youngest being a miner aged On the other hand 7 patients were over 60 5 being and 2 women The oldest was a man of 68. Six of patients had . and of the * contact with lived for many years in the asbestos 5 men had worked for long periods in asbestos One woman died at the age As far as we have been able to ascertain she had - been in contact with asbestos in her occupation as a ng sister and had never lived in the North West +She is the only patient of the 34 who apparently had 7s ntact whatever with asbestos : The remaining 21 patients 8 women and 13 men were s+ between 40 and 60. The 8 women had either been _ ; *** the asbestos district or had moved there in early hood At the time of diagnosis 3 of these women on the Transvaal and had never or only occasionally d the North West Cape after leaving school Three - en had been engaged in the cobbing of asbestos in ~ - homes The European women mostly lived close : nes in houses where cobbing operations produced .~ - dust even when they themselves had done no such The European women had been to school near mills 4 ad played on the dumps ke13 men aged between 40 and 60 comprised 7 whose L was connected with the mining milling and trans- of asbestos 2 who were born and bred in the district "+ ad not been engaged in the industry they had often ed cobbing operations in native huts and had played _ umps and in mine shafts on farms and 4 who worked - asbestos in distant industrial towns Of these indus- + ses * were boiler makers who had lagged loco- + .. burlers Another of these men had spent the war manufacturing asbestos protective devices for fight- . rcraft fires and the fourth had worked as a boiler sur sur a Cape factory whose supply of asbestos was al from the Cape asbestos fields It is interesting to . That in 1 family both the father and a daughter died ' istologically proved mesotheliomas In 2 other cases a - =z had radiological evidence of asbestosis Physical Signs In the early stages auscultatory evidence of riurisy riurisy bronchitis or consolidation are usual As the disc 2 progresses respiratory excursions diminish until eventually a frozen chest results with flattening of the infraclavicular region tiling of the ribs ana immobility of the chest wall The chest is then stony to percussion anu air entry is grossly impaired During this late stage of the disease evidence of secondary spread may appear Eight cases in our series showed obvious clinical signs of peritoneal involvement before death The peritoneum is usually infiltrated by direct spread throug the diaphragm The liver may be elarged and no~ uturdue to perihepatic involvement Local- izea masses due to involvement of the omentum or para- aortic lymph nodes may be felt In these cases ascites is common Involvement of the lymph glands of the neck has been clinically obvious in 2 cases Implantation of the tumour in a biopsy scar is not frequent but it complicated 4 thoracotomies and |] thoracoscopy in our series Haematogenous spread is unusual and only 2 cases have eventually developed distant metastases These were predomi- nantly subcutaneous but in 1 instance numerous small deposits appeared in the tongue Pleural effusions have always developed Fluid collections of 5 - 6 pints have occurred but often the pleural space is largely obliterated and only small effusions can collect On tapping these effusions considerable resistance is encountered due to the thickness of the diseased tissue up to 2 cm which has to be traversed Even with the point inside the cavity the needle is often so tightly gripped that manipulations are restricted Usually the fluid is coloured but staining occurs and may be heavy Fig 3. Diffuse pulmonary shown in lower lung zones asbestosis particulary well a? S.A. MEDICAL JOUR .. 14 14 Januar SPECIAL INVESTIGATIONS Radiological Features The ray findings roughly parallel the clinical progress The initial radiographs may show few changes In about a third of the cases radiological signs of asbestosis were present Asbestosis in individuals with a proved and adequate record of exposure is characterized by evidence of diffuse interstitial fibrosis of varying degree In a wellestablished case the appearance will conform to the wellknown classical pattern of pulmonary asbestosis This may be either a generalized homogenous clouding of the lung Fields particularly the lower zones or a fine striate and fibrillary change in the lung structure with progressive Joss of pulmonary radiolucency Fig 3 In the majority of cases of asbestosis standing pleuritic changes are also seen Thus a combination of both pleural and pulmonary parenchymal pathology frequently occurs The pleural changes take the form of bilateral pleural thickening pleural adhesions and rather characteristic dense calcific plaques Frost et al While pleural thickening per se in asbestosis is specific in character sclerotic pleurisy with plaque formation constitutes a readily recognizable and rather typical entity Fig 4 The pattern of calcification patently differs from nT eee mick Smith The plaque may be few They are usually bilateral and di or whet 113 patches chiefly in the middle and low Zones See on they appear as linear plaques in the periphery - the diaphragmatic contours and adjacent to the stinum A lateral view of the the < will also vers show extensive linear plaque formation involving diaphragm and the anterior aspect directly behing Sternum Such pleural calcification was encounter several of our cases of mesothelioma Hurwitz " However in the majority of cases no evidence ceding pleural or pulmonary asbestosis was found cases on investigation invariably showed unilatera r involvement in the form of diffuse thickening on eht The appearance may be massive from the begining usually a localized scalloping or solitary mass i periphery raises the first suspicion of pleural neop As the disease advances more extensive nodule lumpy pleural thickening develops Fig 5 This --. PS ee entation Wy ae Ae YOR on STR A QAR re . > : Rok ee +e nm oe oe, te v coe Fig 4. Extensive bilateral pleural plaque formation Typical involvement of paramediastinal and diaphragmatic pleura is also demonstrated pleural calcification due to other causes recognized frequently during the recent miners and millers Even the chance This pattern was investigations of finding of such typical calcification is now accepted as being highly sig- nificant so that previous exposure to asbestos may be predicted with reasonable confidence The dense plaques however do simulate those described in workers exposed to other silicate dusts such as tremolite talc calcimine and Fig 5. Nodular pleural thickening seen cicarly on t right of unilateral pleural pathology is a highly significantf ing in a patient from the asbestos art " but of cour similar appearance may be produced by secondary F. nant involvement of the pleura Very often a large p^ effusion will obliterate the picture and only after reme of the fluid will it become apparent that the pleur grossly thickened and nodular Both the parietal - visceral pleura are affected and an induced preumoth particularly will clearly demonstrate the rather chara istic pattern of marginal massive nodularity along " parietal chest wall over the surface of the collapsed and at the base Fig 6 - . an genet a ? te , itd e : 33 the 1961 S.A. TYDSKRIF VIK GENEESKUNDI FUR SLIT ERASE EERE NT ET, me A OS CEN TEP a Or ye REET car ee ee F * me . Asan though sufficient material jur microscopic examination was usually of mined we feel that a great deal of informa- a a hen tion was m 3 With early cases where the pleura is thin and the 3 effusion clear it is often possible to visualize the discrete pleural nodules overlying the still elastic lung The nocuies are then usually coloured and either smoothly- rounded or warty in appearance Later the discrete nodules coalesce and the underlying lung is obscured The growth is then usually seen as a grey opaque membrane with localized excrescences of variable size and similar appearance appearance projecting into the pleural space At this stage the outstanding feature is the thickness and density of the pleural growth and the complete immobility of the incar- ot reds R * Induced pneumothorax revealing gross malignant isement of pleura A considerable quantity of fluid 0present in the right pleural cavity cerated jung beneath As far as possible it is now our policy to obtain a specimen of lung by open operation operation With 4 early cases attempts were made to decorticate lungs which were com- pletely encased by thick apparently fibrous coverings In 3 cases the findings were similar The parietal picura was ! " 2 cm thick and very hard The lungs were col- lapsed and bound down by thickened visceral pleura identical in appearance with the parietal pleura The picural spaces were occupied by coloured or bloodstained fluid Attempts to strip the peel off the chest wall could only be made through the extrapleural plane but even then the interu stal spaces were constantly entered and no vestige of normal parietal pleura could be found Calcified plaques within the diseased tissue were frequently encountered particularly over the diaphragm and inter- the later stages a considerable part of the pleural may be obliterated and a comparatively small space remain Here fluid may collect under tension and the may be further compressed in spite of being encased >. s thick tough covering of malignant tissue As the medi** nal pleura thickens and the regional lymph glands be- me infiltrated widening of the mediastinum is seen radio- Net <2 ally Eventually the pericardium is involved by direct pression and the resultant pericardial effusion causes 6 gressive enlargement of the cardiac silhouette and Remar : change in its configuration Extrapleural extension can + oc" cur then radiological evidence of rib involvement mete +. be present Vozt and Murray remark upon the sided pre- arance of the disease In the series of 24 cases re- F. ned by Choptal et al 19 were sided Our cases ttent ttent an identical distribution since 27 of the 34 cases : sided lesions In no case was the mesothelioma. process initially bilateral although the rays of 10 the patients showed bilateral changes due to asbestosis Iconscopy Iconscopy and Thoracotomy The information obtained from thoracoscopy was dis- arpeting The view is always limited in cases of mesonma because the cannula cannot be freely manipu- sed When blood has extravasated into the effusion the ae) _ ths of the cavity are covered with fibrinous deposits and architectural details are visible The chief objection to Pe ra he technique as a diagnostic measure is that the choice area for biopsy is restricted and it is impossible to en a representative specimen Thoracoscopy was the >} diagnostic procedure in the early stages and al- ( 3 i z Fig 7. Macroscopic specimen of mesothelioma of pleura a Ot Lg ue S.A. MEDICAL JOURNAL 14 January 1 lobar fissures It was never possible to define planes between the visceral pleura and the pathological tissue so that separation was possible only by entering lung tissue False planes could be developed through compressed peripheral lung When the deep aspects of the peel were inspected fine blackened fragments of lung were seen adhering to them The tumours dipped into the lung substance along the interlobular septa and for this reason stripping along these false planes was halted every few millimetres Inevitably the procedure has to be abandoned leaving a collapsed tattered and leaking lung AUTOPSY FINDINGS At autopsy the whole thoracic cavity may be occupied by a large gelatinous tumour which displaces the mediastinum and markedly compresses the lung Fig 7 In other cases the tumour may be dense and cartilaginous in these advanced cases no remnant of a pleural space may remain The tumour infiltrates adjacent structures so that the pericardium heart chest wall diaphragm and liver may form one solid mass In 1 case the tumour extended into the posterior peritoneum encasing a kidney The mediastinal cervical and aortic lymph glands may be involved and appear as large discrete tumours The lung is always compressed with marked lymphatic spread in some terminal cases Because the neoplasm extends along the interlobar fissures the lobes appear as 2 or 3 small deeply pigmented areas within a huge pinkish mass PROGNOSIS AND TREATMENT Our first impressions based upon the apparently fibrous nature of the tumour was that it was growing but we found this to be far from true According to Choptal et al the average duration of life from the time of onset of symptoms is 18 months Hochberg's review of 43 cases showed that 37 86 died within the first year Of the 34 patients discussed here 28 have died 17 61 within a year of the development of symptoms Seven 25 died during the second year 2 % during the third year and all 28 were dead within 48 months which is the longest survival time among our patients It has already been shown that operative removal of the growth is impossible and some form of chemo- or active therapy would seem to provide the only hope of effective treatment Results have been disappointing Two patients were given repeated intrapleural injections of nitrogen mustard Both men died within 6 months Four patients with seemingly localized areas of disease were given deep therapy All were dead within a year Six patients have had active gold instillations Four died within 13 months of the commencement of their in- jections and 2 are alive but their treatment was recent There seems little to be gained by subjecting patients to the additional discomforts of present forms of therab we still advise active gold intrapleurally 11 comparatively early case where the lung retains elasticity SUMMARY The clinical and radiological findings of 34 patien fering from diffuse pleural mesotheliomas are desent Thirty of these patients gave a history of expe to crocidolite asbestos mined in the North West ( However even when lung tissue was available histolog evidence of asbestosis was not obtained in every Asbestos bodies were found in the lung tissue of 30 the cases The findings of this and our other paper are suffer striking to justify further epidemiological and labor investigations These investigations will attempt to du mine the causative and correlative factors include possible relationship with asbestos or other den especially in the regions from which the cases hav frequently been reported We wish to thank the many medical practitioner it Griqualand West District and the thoracic surgeons phys radiologists and pathologists from elsewhere in the L whose assistance has made this investigation possible We thank the Director of the Pneumoconiosis Hurcat permission to reproduce the ray plates shown in F3 . 4 We thank the Secretary for Health for permissirt publish this paper REFERENCES 1. Wagner ) C. Sleggs C A. and Marchand P. 1960 fra 3 - Med .7 260 2. Robertson HE 1924 J. Cancer Res 82 317 Willis 3. worth R. A 1953 Pathology of Tumours 2nd ed London 1 4. Klemperer P. and Rubin C. R 1931 Arch Path 11 35 5. Stout A. P and Murray M R 1942 Ibid 34 951 6 Tobiassen G. 1955 Acta path microbiol scand suppl 105 ; 7. Bellini G. and Bovo G. 1957 Acta med palav 17 367 8 Godwin M C 1957 Cancer 10 298 9. McCaughey W. T. E. 1958 J Path Bact 76 517 10. Dible J H. 1959 Personal communication 11. Gough J. 1959 Personal communication 12. Steiner P. 1957 Personal communication 13. Stewart H 1959 Personal communication 14 Vorwald A 1959 Personal communication 15 Daub and Jones H 1947 Radiology 39 27 Choptal 16. 12 J. Campo A. Jean R and Camps 341 <1956 B. 17. Vermaas F. H. 1952 Trans Geol Soc S Atr 55 9 18. Purczynishi C. S. 1955 Manchester The Textile Institute Asbestos from Rock K 19 Lynch and Smith W. A 1935 Amer 20 Doll R. 1985 Bra Industr Med 12 81 J. Cancer 1 i 24 5 21. Merewether E RA 1954 Annual Report Inspector of fe 27 23 24. 25. 26. 27 p 191. London Her Majesty's Stationery Stationery Oifice Carter P. 1952 Arch induser Hyg 5. 262 Yan der Schoot H M C 1958 N^,d T Geneesh , 102 1127 Day E 1985 Personal communication Frost Smith , Georg J and Muller P F. 1956 Dan Med AR AR 1952 Amer J. Rochtgenol 167 375 Bui Hurwitz M 1959 In Proceedings - Pueumoconos Curie London Churchill 28 Idem 1960 Personal communication 24 Hochberg A. 1951 Amer Rev Tubere 63 150 PASSING EVENTS : IN DIE VERBYGAAN South African Institute for Medical Research Johannesburg Staff Scientific Meeting The next meeting will be held on Monday 23 January at 5.10 p.m. in the Institute Lecture Theatre Dr. L. Webster of the Pneumoconiosis Research Umt will speak on Pneumoconiosis problems * Southern Transvaal Branch M.A.S.A An important general meeting of this Branch will be held at Medical House S Esselen Street Hospital Hill Johannesburg on Tuesd January 1961 at 8.15 p.m. Reports will be presented i President on the recent developments in connection medical insurance companies b medical and societies c the Medical Services Plan The Domidle Clause St. 24 of the Medical Dental and Pharmacy Act will as before the meeting for full discussion Members Branch are urgently requested to attend this important r TyTN et epee awe oa ip pe Oe et ene me MA > POST PROT LACE