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History Lessons: Sentinel Occupational and Environmental Events UCSF OEM CME March 5, 2020 Paul D. Blanc, MD MSPH University of California San Francisco, USA No Conflicts of Interest to Declare Presentation Goals  Examine the initial recognition of selected “sentinel” events in OEM  Interrogate this history to better understand what really happened  Show how the past  insights to the present

Being an Occupational History Detective What has work-related traumatic injury contributed to general medical knowledge? How often is the occupational etiology forgotten or ignored or, conversely, misattributed? Erik Henningsen: A Wounded Worker, 1892 Case Example 1: Phineas Gage “The American Crowbar Case" Nearly everyone who studies human neurology or psychology learns about this case. But how many know the root cause of the accident?

Phineas Gage “This case is one of the clearest demonstrations in history of how the study of occupational injuries and illness can lead to advances in science and medicine in other fields” T. Guidotti Archives of Environmental & Occupational Health, Vol. 67, No. 4, 2012 Case Example 2: Color Blindness Lagerlunda Sweden rail accident November 15, 1875; Alarik Frithiof Holmgren advocates for mandatory color vision testing using a system had developed. The appreciation of color blindness afterward is frequently attributed to industrial medicine Color Blindness

Case Example 3: Brown-Sequard Syndrome as Occupational Trauma Brown-Séquard syndrome Brown-Séquard syndrome … is caused by damage to one half of the spinal cord, resulting in paralysis and loss of proprioception on the same (or ipsilateral) side as the injury or lesion, and loss of pain and temperature sensation on the opposite (or contralateral) side as the lesion. It is named after physiologist Charles-Édouard Brown-Séquard, who first described the condition in 1850. [ref 1] History Charles-Édouard Brown-Séquard studied the anatomy and physiology of the spinal cord. He described this injury after observing spinal cord trauma which happened to farmers while cutting sugar cane in Mauritius Reference Cited: C.-É. Brown-Séquard. De la transmission croisée des impressions sensitives par la moelle épinière. Comptes rendus de la Société de biologie , (1850) 1851, 2: 33–44. Actual Contents: Experimental animal research on lesion

Being an Occupational History Detective What has work-related toxic injury contributed to general medical knowledge? How often is the occupational etiology forgotten or ignored or, conversely, misattributed or misunderstood? Case Example 1: Bari Disaster Pharmacology of Cancer Chemotherapy “White blood cell counts of 100 cells per cubic mm or below were recorded…All cases did not demonstrate the fall in white blood cell counts but all cases with an extremely low count died” Pharmacology of Cancer Chemotherapy American Cancer Society website: “During World War II, naval personnel who were exposed to mustard gas during military action were found to have toxic changes in the bone marrow cells that develop into blood cells. During that same period, the US Army was studying a number of chemicals related to mustard gas to develop more effective agents for war and also develop protective measures. In the course of that work, a compound called nitrogen mustard was studied and found to work against a cancer of the lymph nodes called lymphoma.” Actually, the effect was first described WWI (see also: Miller, J. Blood changes in gas poisoning. Lancet, 1917, i, 793.

Case Example 2: The “First” Occupational Cancer Occupational Cancer • First recognition of any occupational cancer is typically attributed to Percival Pott • In 1775 he reported chimney sweep’s cancer of the scrotum Chirurgical observations Relative to the Cataract, the Polypus of the Nose, the Cancer of the Scrotum …there is a disease as peculiar to a certain set of people, which has not, at least to my knowledge, been publickly noticed; I mean the chimney-sweepers' cancer. It is a disease which always makes its first attack on, and its first appearance in, the inferior part of the scrotum…. The trade call it the soot-wart….

Misconception about Pott: His Cancer was Limited to Sweepers • Pott: “Other people have cancers of the same parts….” but chimney-sweepers were more prone • Dr. Earl (Pott’s son-in-law): reported a gardener who came to St. Bartholomew's Hospital with " a large cancerous sore… occupying almost the whole of the back of the left hand." The patient had been engaged in scattering soot in a garden. The hand was amputated. [ Chirurgical works of Percivall Pott ed. Sir James Earle (1808)] The Gardener’s Hand Specimen Z.268 Photograph courtesy of: Carla Valentine DAPT, Barts Pathology Museum, St Bartholomew’s Hospital www.qmul.ac.uk/bartspathology Another Misconception: Potts Was Not Really the First to Describe Occupational Cancer

Carl [Karl] Lebrecht Scheffler d. 1772 Publishes a seminal work on the health of miners, 1770: Abhandlung von der Gesundheit der Bergleute . Broad in scope - gives particular emphasis to the health of the cobalt miners of Schneeberg and nearby Annaberg where Scheffler practiced medicine Scheffler Described a New Illness • Very early mortality of those exposed • Rapid downhill course once disease was manifest • Does not attribute disease to dust, unlike previous descriptions of slow bergsucht [lung disease in miners (likely silicosis)] Key Epidemiologic Insights by Scheffler • Attributes disease to an inhaled gas or “emanation” • Higher disease prevalence in a specific cobalt mine • That mine: very long and poorly ventilated galleries • Miners had to transverse this to reach the rock face

After Scheffler…. No further medical recognition for > 100 years Schneeberg Miners, Marcus Semmler Mine (Bad Schlema) circa. 1880 Miner’s Fountain 1879: FH Härting and W Hesse “Der Lungenkrebs, die Bergkrankheit in den Schneeberger Gruben“ Vierteljahrsschrift für gerichtliche Medicin und öffentliches Sanitätswesen • 1878: Initial public health officer notice • 1879: Extensive report with a mine medic • Lung cancer = Schneeberger krankheit • 1869-77: 150 ↓ /650 miners (23% rate) Note: in 19 th Century, lung cancer rare!

Uranium, Radon, and Lung Cancer in late 19 th Century • Accumulating data on the extent of the Schneeberger krankheit • Confusion on pathology: initially mistaken as sarcoma, later typical carcinoma confirmed • Arsenic wrongly suspected as the cancer- causing agent Uranium, Radon, and Lung Cancer in the 20 th Century • 1898: Radium discovered* – becomes a new and marketable cobalt mining byproduct • 1905: Radon first measured at the mines • 1921: Radon first proposed as the disease cause • 1925: 1st Berufskrankheiten-Verordnung (German Occupational Diseases Decree) lists Schneeberger krankheit 1 of only 10 conditions for compensation *P. Curie, Mme. P. Curie and G. Bémont, “Sur une nouvelle substance fortement radio-active, contenue dans la pechblende,” Comptes rendus de l'Académie des Sciences, Paris, 1898 (26 December), 127:1215-1217 Key Argument Against Radon First Decades of 20 th Century : Why no similar disease in Joachimsthal in Bohemia? [Near Schneeberg in Germany, mining the same material] Footnote to Curies’ discovery of radon: “May we be permitted to thank here M. Suess, Correspondent of the Institute and Professor at the University of Vienna? Thanks to his benevolent intervention, we have obtained from the Austrian government the free gift of 100 kg of a residue from the treat- ment of the Joachimsthal pitchblende, containing no uranium, but containing polonium and radium. This gift will greatly facilitate our researches.”

Jáchymov (1548) The Answer • It wasn’t lack of disease – it was just that no one reported it under Austrian rule • Post WW I: Czechoslovakia nationalized mines • April/May 1929: Drs. H. Šikl and A. Pirchan; and Dr. Julius Löwy present Jáchymov cases to the Comité d’Hygiène de la Société des Nations • 1931: Pirchan and Šikl publish paper on the epidemic in the American Journal of Cancer Jump Ahead - 1950s Uranium Miners And Millers • Epidemiology convincing….. however • No good animal model – and “modeled” radiation exposure does not seem to explain effect • Wilhelm Hueper (1894 - 1978) 1st director, Environmental Cancer Section of the U.S. National Cancer Institute argues forcefully on occupational cancer in uranium miners But…exposure continues