Document x5dKLN7KdGv2B49yOwb776QaG

THE LANCET, JUNE 29, 1974 1323 metises to produce v.c But unreacted v.c which is present in newly manufactured p.v.c may be released during storage and when the material is heated during manufacture of p.v.c. products. Compounding processes known as dry blending, Banbury/2 roll THE LANCET mill compounding, extrusion compounding, and paste mixing, and fabrication processes such as extrusion, calendering, and paste spreading may be Cv ; associated with release of v.c into the atmosphere. Carefully planned ventilation at appropriate points in P.v.c processing plants is therefore recommended. Vinyl Chloride, P.V.C., and Cancer The reaction of food-packaging experts is still awaited. By the time P.v.c sheeting is used for At the end of 1972 a man of 71 died in the Victoria Hospital, Blackpool, from a rare form of neoplasia, angiosarcoma of the liver. He had worked for 20 years as a process worker making polyvinyl chloride (p.v.c) from vinyl chloride (v.c). The derails of the case are given by Dr Lee and Dr Hamy on p. 1316: according to them, this is the nineteenth case of its kind, though die first in die United wrapping food its v.c content is probably low and very little may find its way into food or into the atmosphere of the food supermarket or domestic kitchen. Nevertheless, information is needed. At the very least the public should be told--if it is true--that the grades of P.v.c used for wrapping food are pretreated to remove as much free v.c monomer as possible. Kingdom. Cases of hepatic angiosarcoma in men To date, all those workers who have developed exposed to v.c. have been previously reported in angiosarcoma of the liver have a history of inter the United States of America,1 Sweden, and mittently heavy exposure to v.c over "periods of Germany. fromT2"to 27 years in P.v.c-manufacturing plants. The reaction of experimentalists to the situation is to ask why nobody heeded die results of work on rats, published in 1971. Violo and his colleagues * reported the occurrence of cancers which were later found to have arisen in the acoustic duct, and cancers of the lungs, bones, and other sites in 17 out of 25 rats exposed to 30,000 p.pjn. v.c for 20 hours a week. The answer may be that, in some eyes, experimentalists have too often cried " cancerwolf" on quite inadequate evidence of real hazard. In any case it could have been argued that 30,000 p.p.m. is very high in comparison with human exposure levels to v.c in most p.v.c-mahufacturing plants in 1971. The reaction of the Department of Employment Factory Inspectorate has been to set a new interim upper limit for exposure to v.c in p.v.c manufacturing plants at 50 p.pjn. with a maximum time-weighted average expoaure of 25 p.p.m. However, these limits will almost certainly be lowered in view of Cesake Maltcwi*s claim to haw pmHnced unginmmnmw rf dig litwr by erpnamg There have been no cases among p.v.c processors. Most examples of heavy exposure date tack to the early days of p.v.c manufacture before certain other, non-cancerous, health hazards associated with exposure to v.c were recognised, Raynaud's phenomenon (acro-osteolitis) in response to v.c was reported as early as 1957 ***; more lately, chronic liver poisoning leading to portal obstruction, from oesophageal veins, end splenic enlargement were identified as v.c effects. Their discovery led to ever-increasing efforts to protect workers from exposure to v.c Nobody knows how many more cases of v.c-mduced angiosarcoma of the liver will come to light. Optimists will argue that the con ditions in industry have so greatly improved that we may already have seen the worst., Pessimists, how ever, will say that we have so far probably seen only those cases with the shortest latent interval resulting from the heaviest expoaure, and that an epidemic of cases with longer latent intervals associated with lesser exposure a yet to come. Moreover, m effect rats to only 50 p.p.m. v.c (reported on May 10 at a of v.c on the incidence of certain less rare forms of meeting organised by the American Cancer Society cancer may so fin: have" passed nnnncicrd Whatever and New York Academy of Sciences). The reaction happens, the v.c. episode will have provided a of the manufacturers, through the Chemical Indus salutary lesson. It vrill not be quite so easy in the tries Association Ltd., has been to pool their experi future, as it has been in die past, for any chemical ence and resources in the production of a guidance manufacturer to assume, until proved otherwise, document for p.v.c processors.* There is no indica that a chemical to which workers are exposed is tion that p.v.c is itself dangerous or that it depoly-1 2 3cardnogenically safe. There must surely be moresys- 1. Crwcfa, 1 <**- Mtd. 1974, 14. ISO. 2. Violo, P. L., Bigoni, A., Caputo, A. Cnur Ktt. 1971, SI, 516. 3. Vinyl Chlorid* Monomer: Advisory Nou for tht Guidance ct PVC Procceton. Published by Chnmral Induecriee Aaodadoa Ltd., Alembic Home, 93 Albert Embankment, London SE17TU, June 12. 1974. 4. Lascar, D.9 Grwnbarg, L. JL, AJim, W. R. Am. md. Hyg. Am. J. 1963, 24, 265. 5. Lange, C. E., JOha, S., Stain, G^VdtmaiwC. Int. Arch. ArUitmnU. 1974, 32, i. 6. JOha, S., Langt, C B. Scam, G., Vclcman, G. Dt. mid. Wtdw. 1974, 9S 2034. \ BFG23153 !V i i I 22923001, T 1324 THE LANCET, JTJNE 29, 1974 rimatic evaluation of industrially used chemicals have had exposure to some specialties, and it enables for carcinogenic risk to workers. In its own area, the specialist surgeons to gain experience in fields other thalidomide disaster was a milestone. Vinyl-chloride than their own and general surgery. One hopes angiosarcoma is a milestone in occupational hygiene. that, in time, there may be a move towards the specialist f.r.CS. for more surgeons, as already applies in Canada and Australia for almost all the accepted specialties but in Britain is available only Specialisation in Surgery for ophthalmology and otorhinolaryngology. This Sir Charles Illingworth 1 once declared, in a somewhat whimsical address, that general surgery had no future. The Joint Committee for Higher should reduce the need for specialists to spend some of their, intellectually speaking, most productive years working in spheres largely irrelevant to their ultimate careers. Surgical Training set up by the Royal Colleges has Earlier specialist work might provide a solution recognised eight specialties; and now general surgery to another problem, which is the limited amount of styles itself the ninth (or first). In fact, almost half the surgeons in Britain are in a recognised specialty other than general surgery. Institutional inertia research carried out in the surgical specialties. When a major funding body lately discussed why this should be so, it was told that the prolonged training has, however, ensured that both colleges and universi periods required for specialists left young men with ties still act on the assumption that surgery really little time for diversions into research; also that the means general surgery. Most undergraduate teaching is still carried out in so-called general surgical limited academic establishment in the specialties was a disincentive to research-minded surgeons in wards, although in trying hospitals many of these training, who mostly opted for general surgery are highly specialised. But when it is suggested that (which offered a number of senior university posts students or preregistration house-officers should to which they could aspire). Although, some chairs spend a major part of their surgical time in specialist in orthopaedic surgery have been established, other units there is talk of these being unsuitable. It is specialties have had to be satisfied with theoccasional difficult to see why, if it is accepted that the\educa- personal chair, which often does no mbre than tional purpose at this stage of training is to expose acknowledge the local pre-eminence iff an established young minds to the principles and practice of and largely clinically oriented surgeon. Stich a surgery in general, rather than to general surgery. personal chair provides no sound basis for a proper This means becoming familiar with preoperatwp department and it provides no substructure \or assessment, dealing with the patient and his familyj. promotional ladder for younger academic surgeons, liaison with the anesthetist and nursing staffi post- \ because there is no assurance that a vacancy will, operative care, and the like. Technical derails of what \ arise in the future. The solution lies in the hands of' happens in the operating-theatre are of little con the professors of (general) surgery. Already several sequence at this stage, so what is the essential younger ones are making specialists welcome in their educational difference between one surgical specialty research laboratories and are anxious to include and another ? Undergraduates would want to spend them in their wider academic teams. A few have some time with abdominal and acddcat/orthopsedic created specialist academic departments headed surgeons, but beyond this electives could be organised by professors, or by senior lecturers with some to complete the surgical component'of the practical independence; but many mote have proceeded to curriculum. mate sebond chairs in general sprgery. Certainly no At the postgraduate levelthe failure to acknowledge medical school would want drain in all eight specialist that general surgery is only one among many brandies (not is the University Grants Committee specialties has a more serious effect. Still imprisoned by the regulations for the M general " vjlcs., all likely to allbw tins kind of pluralism). But it would benefit surgeky in general if each school had two or surgeons must complete a considerable time in three specialise chairs, chosen according to the general surgery and then face an examination largely particular opportunities and facilities already existing organised by general surgeons. One proposed locally. This would provide a reasonable career training scheme for surgeons begins no sooner dun structure far younger academics in the specialties, two years after qualification and permits rotation to would enable seriobs and continuing research pro specialties only after 2 yean* continuous training grammes to be supported, and would strengthen the in general surgery. A more balanced attitude is school of surgery in that particular university. This evident in two other regions which allow for 18 strengthening would be' more likely if the academic months each in general surgery and in the other departments of surgery in a university were grouped specialties, with alternating periods of 6 months in into a division of academic surgery--to borrow a general and in specialty surgery. Such a scheme useful administrative term from the National Health ensures that those who will become general surgeonsI. Service. In such a division the specialist professors I. Illingworth. 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