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BLADDER CANCER AND THE RUBBER INDUSTRY
1106
follow abdominal operations 20 21 and a similar situation although the use of known, or suspected, carcinogenic arises in the obese 22 3; and this phenomenon may pro- substances has continued-probably on a small scalevide part at least of the explanation of postoperative until recently, there is no conclusive evidence that a major has affected men employed only since 1949. pulmonary complications. Indeed they may have their riskThe most likely explanation is that the continuing inbeginnings during anxsthesia itself. Excessive expiratory cidence of bladder cancer is due to: the effect of activity of the abdominal muscles is a feature of light heavy exposure before 1950; and a persisting continued lesser anesthesia, especially when an endotracheal tube is in exposure to known carcinogens-including in this cateuse. It is not hard to visualise, therefore, circumstances gory the suspect compound, aldol a-naphthylamine.32 For exactly analogous to those of NUNN’s experiments, when these reasons, the M.R.C. believe that the collection of the patient is allowed to become light at the end of an reliable data about the incidence of bladder tumours in anaesthetic while he is still breathing a readily absorbable rubber workers is highly desirable ". The collection of gas; and collapse would be expected to follow. COLE and such data could probably be best obtained by a study in PARKHOUSE, 24 who studied the arterial oxygen saturation one or two of the large firms; and with the cooperation of in patients breathing volatile agents vaporised in room a number of firms the facilities of the R.M.E.A.’s health unit could be used to carry out a satisfactory investigation. air, found only small falls in arterial P02, presumably The M.R.C.’s suggestion is that the information colbecause of the absence of a soluble gas in the alveoli: lected should aim at showing the incidence of bladder collapse comparable to that described by NUNN and his tumours over the next few years in: (1) those men who colleagues was not observed. The main objection to the are identified as having been exposed to known carcinogens, idea that collapse results from something which happens such as naphthylamine or benzidine, since 1949; (2) during the operation and not in the postoperative period those who were not exposed to these substances but were is this: the substitution of room air for soluble anxsthetic exposed to the suspect compound aldol x-naphthylamine, to any of these gases towards the end of long general anxsthetic, though (3) those men who were not exposed tried many times, does not seem to have noticeably substances. Such an investigation, however, would proreduced the risk of collapse. And it has been known vide only part of the information required. The Senior Medical Inspector of Factories is establishing an advisory since 1878 that the rate of collapse of alveoli behind a panel on cancer of the renaf tract, and the M.R.C. will bronchial block was greatly increased when they were seek to ensure that the rate at which new cases of cancer filled with a soluble gas.25 of the bladder decreases after cessation of exposure is one "
Annotations BLADDER CANCER AND THE RUBBER INDUSTRY
in our columns last year 26-31 led to a suggestion from the Rubber Manufacturing Employers’ Association that the Medical Research Council should consider looking further into the problem of cancer of the bladder in the rubber industry. The M.R.C. has referred this matter to its Occupational Health Committee and other expert advisers; and the Council’s views have now been made known to the R.M.E.A. It has been considered whether the continuing incidence of bladder tumours among rubber workers was sufficient to justify the assumption that a substantial number of cases had been induced by exposure to bladder carcinogens in the industry since 1949-the date when members of the R.M.E.A. were said to have ceased using materials containing known bladder carcinogens. If so, had the use of known carcinogens been sufficient to account for this ? The available evidence shows that a substantial number of cases of bladder cancer in rubber workers have continued to be detected since 1949. Whether this is due to the use of known carcinogens or to some other substance which is carcinogenic, but so far unrecognised, cannot be determined. On the other hand, the committe observes, A
DISCUSSION
20. Beecher, H. K. J. clin. Invest. 1933, 12, 639. 21. Palmer, K. N. V., Gardmer, A. J. S. Br. med. J. 1964, i, 347. 22. Cullen, J. H., Formel, P. F. Am. J. Med. 1962, 32, 525. 23. Said, S. I. Ann. intern. Med. 1960, 53, 1121. 24. Cole, P. V., Parkhouse, T. Br. J. Anæsth. 1961, 33, 265. 25. Lichtheim, L. Arch. exp. Path. Pharmakol, 1878, 10, 54. 26. Lancet, 1964, ii, 25. 27. Parkes, G. ibid. p. 254. 28. Case, R. A. M. ibid. p. 309. 29. Wallace, D. M. ibid. p. 365. 30. Parkes, G. ibid. p. 414. 31. Boyland, E., Haddow, A. ibid. p. 527.
aspect of research which is considered. A further suggestion from the Council is that more information about the occurrence of bladder tumours in rubber workers and others might be obtained from the occupational histories of all patients registered as having bladder cancer in the cancer registries of Birmingham, London, and other centres. Investigations might also be based on the occupational history of rubber workers dying of bladder cancer under the age of 65, to see whether they tended to have been employed at a limited number of factories known to have used carcinogens (or
suspected carcinogens). The R.M.E.A. (who sent us the full text of the M.R.C.’s reply to their suggestion) are taking immediate steps concerning the M.R.C. recommendations and proposals. The industry had already indicated its willingness to give all cooperation in any further inquiries. RICKETS IN IMMIGRANT CHILDREN
APART from the disquiet at the prospect of importing cases of infectious disease, such as tuberculosis, much attention has been drawn to another aspect of immigrant health. Deficiency disease, such as rickets, has now become rare among indigenous children in this country 33indeed, over-enthusiasm in prophylaxis with vitamin D was widely held to have been responsible for what amounted to an epidemic of infantile hypercalcsemia in the early 1950s. Subsequent smaller vitamin-D recommendations 34 may have been effective in reducing the incidence and severity of this disease.35 During the past few years, however, reports have appeared of nutritional rickets amongst immigrant children in some of our large new
32. See ibid. Feb. 6, 1965, p. 306. 33. Stewart, W. K., Mitchell, R. G., Morgan, H. G., Lowe, K. G., Thomson, J. Lancet, 1964, i, 679. 34. Ministry of Health. Reduced Levels of Vitamin D in Welfare Foods and Infant Cereals. H.M. (57) 89. 35. British Pædiatric Association Report. Br. med. J. 1964, i, 1653.
follow abdominal operations 20 21 and a similar situation although the use of known, or suspected, carcinogenic arises in the obese 22 3; and this phenomenon may pro- substances has continued-probably on a small scalevide part at least of the explanation of postoperative until recently, there is no conclusive evidence that a major has affected men employed only since 1949. pulmonary complications. Indeed they may have their riskThe most likely explanation is that the continuing inbeginnings during anxsthesia itself. Excessive expiratory cidence of bladder cancer is due to: the effect of activity of the abdominal muscles is a feature of light heavy exposure before 1950; and a persisting continued lesser anesthesia, especially when an endotracheal tube is in exposure to known carcinogens-including in this cateuse. It is not hard to visualise, therefore, circumstances gory the suspect compound, aldol a-naphthylamine.32 For exactly analogous to those of NUNN’s experiments, when these reasons, the M.R.C. believe that the collection of the patient is allowed to become light at the end of an reliable data about the incidence of bladder tumours in anaesthetic while he is still breathing a readily absorbable rubber workers is highly desirable ". The collection of gas; and collapse would be expected to follow. COLE and such data could probably be best obtained by a study in PARKHOUSE, 24 who studied the arterial oxygen saturation one or two of the large firms; and with the cooperation of in patients breathing volatile agents vaporised in room a number of firms the facilities of the R.M.E.A.’s health unit could be used to carry out a satisfactory investigation. air, found only small falls in arterial P02, presumably The M.R.C.’s suggestion is that the information colbecause of the absence of a soluble gas in the alveoli: lected should aim at showing the incidence of bladder collapse comparable to that described by NUNN and his tumours over the next few years in: (1) those men who colleagues was not observed. The main objection to the are identified as having been exposed to known carcinogens, idea that collapse results from something which happens such as naphthylamine or benzidine, since 1949; (2) during the operation and not in the postoperative period those who were not exposed to these substances but were is this: the substitution of room air for soluble anxsthetic exposed to the suspect compound aldol x-naphthylamine, to any of these gases towards the end of long general anxsthetic, though (3) those men who were not exposed tried many times, does not seem to have noticeably substances. Such an investigation, however, would proreduced the risk of collapse. And it has been known vide only part of the information required. The Senior Medical Inspector of Factories is establishing an advisory since 1878 that the rate of collapse of alveoli behind a panel on cancer of the renaf tract, and the M.R.C. will bronchial block was greatly increased when they were seek to ensure that the rate at which new cases of cancer filled with a soluble gas.25 of the bladder decreases after cessation of exposure is one "
Annotations BLADDER CANCER AND THE RUBBER INDUSTRY
in our columns last year 26-31 led to a suggestion from the Rubber Manufacturing Employers’ Association that the Medical Research Council should consider looking further into the problem of cancer of the bladder in the rubber industry. The M.R.C. has referred this matter to its Occupational Health Committee and other expert advisers; and the Council’s views have now been made known to the R.M.E.A. It has been considered whether the continuing incidence of bladder tumours among rubber workers was sufficient to justify the assumption that a substantial number of cases had been induced by exposure to bladder carcinogens in the industry since 1949-the date when members of the R.M.E.A. were said to have ceased using materials containing known bladder carcinogens. If so, had the use of known carcinogens been sufficient to account for this ? The available evidence shows that a substantial number of cases of bladder cancer in rubber workers have continued to be detected since 1949. Whether this is due to the use of known carcinogens or to some other substance which is carcinogenic, but so far unrecognised, cannot be determined. On the other hand, the committe observes, A
DISCUSSION
20. Beecher, H. K. J. clin. Invest. 1933, 12, 639. 21. Palmer, K. N. V., Gardmer, A. J. S. Br. med. J. 1964, i, 347. 22. Cullen, J. H., Formel, P. F. Am. J. Med. 1962, 32, 525. 23. Said, S. I. Ann. intern. Med. 1960, 53, 1121. 24. Cole, P. V., Parkhouse, T. Br. J. Anæsth. 1961, 33, 265. 25. Lichtheim, L. Arch. exp. Path. Pharmakol, 1878, 10, 54. 26. Lancet, 1964, ii, 25. 27. Parkes, G. ibid. p. 254. 28. Case, R. A. M. ibid. p. 309. 29. Wallace, D. M. ibid. p. 365. 30. Parkes, G. ibid. p. 414. 31. Boyland, E., Haddow, A. ibid. p. 527.
aspect of research which is considered. A further suggestion from the Council is that more information about the occurrence of bladder tumours in rubber workers and others might be obtained from the occupational histories of all patients registered as having bladder cancer in the cancer registries of Birmingham, London, and other centres. Investigations might also be based on the occupational history of rubber workers dying of bladder cancer under the age of 65, to see whether they tended to have been employed at a limited number of factories known to have used carcinogens (or
suspected carcinogens). The R.M.E.A. (who sent us the full text of the M.R.C.’s reply to their suggestion) are taking immediate steps concerning the M.R.C. recommendations and proposals. The industry had already indicated its willingness to give all cooperation in any further inquiries. RICKETS IN IMMIGRANT CHILDREN
APART from the disquiet at the prospect of importing cases of infectious disease, such as tuberculosis, much attention has been drawn to another aspect of immigrant health. Deficiency disease, such as rickets, has now become rare among indigenous children in this country 33indeed, over-enthusiasm in prophylaxis with vitamin D was widely held to have been responsible for what amounted to an epidemic of infantile hypercalcsemia in the early 1950s. Subsequent smaller vitamin-D recommendations 34 may have been effective in reducing the incidence and severity of this disease.35 During the past few years, however, reports have appeared of nutritional rickets amongst immigrant children in some of our large new
32. See ibid. Feb. 6, 1965, p. 306. 33. Stewart, W. K., Mitchell, R. G., Morgan, H. G., Lowe, K. G., Thomson, J. Lancet, 1964, i, 679. 34. Ministry of Health. Reduced Levels of Vitamin D in Welfare Foods and Infant Cereals. H.M. (57) 89. 35. British Pædiatric Association Report. Br. med. J. 1964, i, 1653.