The cytological diagnosis of bladder tumours amongst dyestuff workers.

Abstract

Tumours of the urinary bladder occurring amongst the general population usually disclose their presence by the onset of symptoms such as haematuria, dysuria, frequency, or pain. In some cases haema turia may develop from a small benign papilloma which offers a good chance of successful treatment, whilst in others the tumour may have reached large proportions and even metastasized before its discovery. In 1920 Oppenheimer in Germany recommended regular microscopical examination of the urine for the presence of red blood cells as a means for the earlier detection of occupational bladder tumours. For similar reasons in 1934, Cresdee, Guest, and Wignall (unpublished) instituted such regular examinations in two British dyestuffs factories and shortly afterwards Hope and Scott (unpublished) applied them in a third factory. They hoped that red blood cells or other abnormal constituents in the urine might give an indication for cystoscopy before the onset of symptoms due to a tumour so that earlier diagnosis might afford a chance of more effective treatment. During the next 15 years Cresdee, Goldblatt, Scott, and Williams (unpublished) in Great Britain extended these examinations of wet unstained smears of urinary sediments to include more men at more frequent intervals. Many cases diagnosed by this means were included amongst those described by Goldblatt (1949) and by Scott (1952) and all of them were included in the figures used by Case, Hosker, McDonald, and Pearson (1954), and Case and Pearson (1954) in their survey of the incidence of the disease in Great Britain. They confirmed statistically that there was a significantly higher incidence of bladder tumours amongst men exposed to aand ?-naphthylamine and benzidine than in the general population and revealed an occupational hazard of bladder tumours amongst men engaged in the manufacture of magenta and auramine. Similar examinations of wet smears of urinary sediment have been used as an indication for cysto scopy in Germany for a number of years (Gross, 1940). In Switzerland, however, the urine was examined for occult blood in 3932 but by 1937, after consultation with American colleagues, routine cystoscopy was chosen as the most efficient method of achieving early diagnosis (M?ller, 1951). Routine annual cystoscopy of exposed workers was first instituted in the United States of America in 1931 and has continued until recently with concurrent examinations of wet smears (Gehrmann, 1934; Gehrmann, Foulger, and Fleming, 1949). They even advocate the cystoscopy of all men before starting work. Similarly this procedure was adopted early in Italy and still continues to be applied (di Maio, 1937 and 1949). Many tumours have been diagnosed in this way, but there is no indication of what proportion of unaffected men have continued to undergo cystoscopy annually for up to 20 years. It is claimed by the above authors that regular annual cystoscopy can be achieved. In France Billiard-Duchesne (1949) published the results of his cystoscopies, but Aboulker, Gaultier, Benguigui, and Smagghe (1949) record the successful use of the wet smear technique which suggests that routine cystoscopy was not acceptable to them. In Great Britain it is admitted that, although a substantial proportion of healthy men who have been at high risk might undergo cystoscopy on first demand, with repetition the numbers would quickly dwindle to levels which would invalidate any of its alleged advantages. Cystoscopy may be accom panied by some discomfort and is an operation which must be performed with great care if all sequelae are to be avoided. In Great Britain it has been the practice to restrict it to the necessary minimum. Furthermore, in practice, routine cysto scopy cannot be extended effectively to those persons with a relatively small exposure to carcinogens but 270