Book Review

Textbook of Clinical Occupational and Environmental Medicine

N Engl J Med 1995; 332:340-341February 2, 1995

Article

Textbook of Clinical Occupational and Environmental Medicine
Edited by Linda Rosenstock and Mark R. Cullen. 909 pp. Philadelphia, W.B. Saunders, 1994. $125. ISBN: 0-7216-3482-6

Ten years ago a friend and colleague observed that the field of occupational medicine was then at the same stage of sophistication as internal medicine in the 1920s. The problems we were encountering in occupational medicine had very little precedent. The literature relating to the field was terribly thin. In particular, there was no definitive, readable textbook of occupational medicine analogous to Harrison's Principles of Internal Medicine (New York: McGraw-Hill, 1994) or the Cecil–Loeb Textbook of Medicine (Philadelphia: W.B. Saunders, 1971) for internal medicine. That, at least, is no longer the case.

Rosenstock and Cullen have compiled just such a textbook. This is the book that residents and fellows in occupational medicine will want to read from cover to cover in preparation for their board examinations. This is a textbook that belongs on the shelf of any practitioner. Other similarly noteworthy recent contributions to the field have been Occupational Health: Recognizing and Preventing Work-Related Disease, edited by Barry S. Levy and David H. Wegman (Boston: Little, Brown, 1988); A Practical Approach to Occupational and Environmental Medicine, edited by Robert J. McCunney (Boston: Little, Brown, 1994); and the second edition of Environmental and Occupational Medicine, edited by William Rom (Boston: Little, Brown, 1992).

Of all the subspecialties of medicine, there is none more political in its day-to-day practice than occupational medicine. On the far right, there are those who are skeptical about any effects of work on health and would, I sometimes imagine, seriously consider minimal daily requirements for industrial chemicals. On the left, there are those for whom every injured or ill worker is confirmation of Marxist theories of exploitation. Rosenstock and Cullen have managed to chart a course that lies mostly in the political center.

The first of the four sections of the textbook, appropriately entitled “Principles and Practice,” explores to a large extent the context in which occupational medicine is practiced. This should be required reading for students in the field. In order to function in this arena, one must understand the sometimes adversarial nature of interactions with patients and appreciate that in occupational medicine, unlike other medical disciplines, referrals are often made by nonphysicians and third parties with their own interests to consider. Maintaining one's ethical bearings is frequently a challenge.

The second section is given over to three core disciplines of occupational health: toxicology, epidemiology, and industrial hygiene. The practice of occupational medicine is nothing if not sound medical practice enriched by competence in these three areas. The chapters in this section are concise summaries of these necessary disciplines, but they will not in themselves preclude the need for readers to consult individual textbooks at least occasionally.

Section 3 is entitled “Evaluation and Treatment.” Each of its chapters focuses on an organ system or symptom complex. The discussions begin with the familiar diagnostic framework of the history taking, physical examination, and laboratory evaluation. They then progress to workplace exposures as well as non–work-related diseases that may explain the findings. This format keeps the maladies related to work firmly rooted in broader medical experience. The final section analyzes specific hazards in the workplace. Individual hazards or dangerous environments are explored, and there are cross-references to the chapters on evaluation and treatment.

Despite the more than 100 contributing authors, with a few exceptions the writing is remarkably even, clear, and readable. Some chapters stand out. The one on asthma by Dr. Moira Chan-Yeung could have been called “Occupational Asthma Demystified.” The chapter entitled “Disorders of Reproduction and Development” by Drs. Donald Mattison and Mark Cullen, also outstanding, very clearly underscores the hard realities, the hard choices, and the emotional nature of decisions having to do with reproduction or potential injury to the unborn. I particularly appreciated an acknowledgment of the risk aversion among our counterparts in obstetrics. Casual advice to “avoid all chemicals” is neither practical nor always in the best interest of working women and their families. The sections on pregnant women who have been exposed to a hazard and the prevention of reproductive and developmental risk in the occupational setting could be manifestos for enlightened reproductive policy and provide sound guidance to anyone confronting these difficult issues.

Early in the textbook the use of environmental medicine is clearly distinguished from “environmental illness,” as the term is used by questionable practitioners of “clinical ecology.” That distinction having been made, the discussion of multiple chemical sensitivities by Dr. Cullen is an inspiring and sensitive commentary. In a word, he points out that even though we are frequently unable to explain in any scientifically satisfying terms the predicament of people with multiple chemical sensitivities, they are patients who for whatever reason are suffering and, like any other suffering patients, deserve our compassion and support.

There are so many other excellent chapters that it is difficult to highlight them all. Not all, however, are praiseworthy. The chapter on ophthalmologic disorders is written in the arcane dialect of ophthalmology and could have benefited from clearer language for those of us without formal training in this discipline. The chapter on cumulative trauma disorders and mechanical stressors in the workplace failed to convince me that otherwise nontraumatic routine movements can in some way destroy tissue. Similarly, the absence of a scientific and pathophysiologic explanation of fibromyalgia makes me wonder whether this diagnosis is not simply one of convenience. A point of view counter to the prevailing “cumulative trauma disorder” movement à la Norton Hadler would have enlivened the controversy surrounding these social–medical–political entities.

The chapter on dermatologic diseases remarkably did not include a single color photograph. I was disappointed in the risk-aversive (no threshold) point of view that seemed to pervade the chapter on cancer and its prevention. In this discussion there was scant reference to a burgeoning literature on the mechanisms of carcinogenesis that begins to explain the discordance that even the lay public intuitively recognizes between a “carcinogen” as defined by grotesque feeding studies in rats and the exposure of humans to small amounts of the same compound (witness the debate about saccharine).

In future editions, I would like to see contributions from authors in industry; all the current contributors are from government or academia. In addition, those of us in practice, or contemplating practice, would probably value some discussion of the nuts and bolts of practicing or of managing an occupational health unit in the real world. Unlike many other disciplines of medicine, occupational medicine is practiced in a variety of settings, and future practitioners will probably be establishing occupational medicine units from scratch either in hospitals or in industry.

Overall, this is a long awaited contribution to the field of occupational medicine. It is intended to be read and to be used by both practitioners and students. My frame of reference is my trusted Harrison's from medical training. Like those of that venerable textbook, the binding and covers of Rosenstock and Cullen's will be well worn by those who purchase this book — at least by the time the inevitable next edition rolls around.

Jerry H. Berke, M.D., M.P.H.
W.R. Grace & Co., Lexington, MA 02173