QJM Advance Access originally published online on March 31, 2009
QJM 2009 102(11):827-828; doi:10.1093/qjmed/hcp034
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Oh no—it's Donald Hunter!
Once upon a time the MRCP (London) was divided, like Gaul, into three parts: the compulsory essay questions and clinicals; the path viva (not confined to pathology); and the final viva before the President, Censors and senior examiners. Each step weeded out the majority, leaving a very nervous 
10% for the final ordeal. And in the path viva there was the risk of meeting Donald Hunter. I only saw him once, as a student, when he came to give an invited lecture at our medical school; he was a big man and spoke impressively on the history of occupational diseases. His book on the subject became a classic and the British Journal of Industrial Medicine which he founded and edited remains, as Occupational and Environmental Medicine, a leader in its field.
Although there are sporadic records of doctors commenting on work-related illness back to Roman times, diseases of ordinary working people were of little interest to doctors until Bernardino Ramazzini, professor of medicine in Padua, wrote his great work, De Morbis Artificium Diatriba, in 1715. Ramazzini made the first addition to medical history-taking since Hippocrates with his advice not to be too proud to sit down with a working man and ask about his job. The first description of a cause of cancer, scrotal cancer of chimney sweeps’ apprentices in 1775, by the London surgeon, Percivall Pott, curiously quoted Ramazzini's description of lead poisoning in its first paragraph. But the first British description of the generality of work-related disease was by the argumentative Charles Turner Thackrah, one of the founders of the Leeds school of medicine, in 1832. He saw beyond the classical poisonings and dust diseases to more subtle causes of ill-health, including what would nowadays be regarded as stress. Donald Hunter's masterpiece, The Diseases of Occupations, first published in 1945, may be regarded as a worthy successor to these seminal works.
Hunter was a consultant physician at the London Hospital who, like Ramazzini and Thackrah, took an interest in diseases of workers, and his book and journal spoke of these to a wide audience. As an examiner in the London MRCP, he was as likely to present the candidate with a piece of rock or a drill bit as with a radiograph and so, if you were sensible, you read his book before presenting yourself for the exam. If you had not done this and had the misfortune to meet him, you were sunk; hence the cri de coeur of a colleague that I have used as a title. The positive consequence of this was that all physicians of my generation were familiar not only with lead and mercury poisoning, silicosis and phossy jaw, but also with the social and industrial history of Britain and of the legislation to prevent these diseases. He made sure that we all understood the importance of an occupational history and were alert to the possibility of an occupational cause of ill health.
When Donald Hunter retired, few took up his mantle and the subject passed into a long decline. Two important factors seem to me to have contributed to this. First, clinical occupational medicine, a tradition dating back to the hiring of doctors to pronounce whether children were old enough to work in factories by examining their teeth, did not become part of the new National Health Service in 1948, rather being confined to the medical services of the major industries and to a few university departments or delegated to untrained general practitioners. Secondly, the interests of medical research and its funders shifted overwhelmingly from environmental causes to mechanisms of disease, reflecting the increased understanding of biochemistry, immunology and genetics, and the hope, sometimes realized, that such understanding would lead to the development of cures, Erlich's silver bullets. Cure rather than prevention became the sexy thing to study. In consequence, relatively few undergraduates have been taught occupational and environmental medicine. Any review of hospital or general practice records reveals this starkly; the patient's occupation is rarely even noted, still less described. This matters, since exposure to physical, chemical, biological and psychological stressors at work are almost universal and, although the pattern of occupational disease in a post-industrial society has changed, work-related illness is still commonplace. Among 50 consecutive hospital employees with prolonged sickness absence whom I once reviewed, remedial work-related factors, usually ergonomic or psychological, were major contributors in no fewer than 18.
The loss of curiosity of doctors implicit in this means that work-related illness, sometimes serious, is liable to be missed. This may not only affect the chances of treating the individuals successfully but also make it impossible to prevent the same affliction in their fellow workers and in some cases delay the introduction of preventive regulation. Pott's description of scrotal cancer drew attention to the scandal of chimney sweeping but it was to be another 100 years before an Act was passed to protect these vulnerable children. Even in our time, this gap from discovery to effective regulation has been remarkably long; asbestos (70 years) and smoking (50 years). Powerful and wealthy voices are raised to prevent regulation; the voice of the medical profession is needed on the other side, and if we do not recognize these associations we cannot prevent them. A rare example of things going well was the case of angiosarcoma of the liver in vinyl chloride workers, where effective regulation for prevention of the disease was instituted within a few years of its first recognition.
Donald Hunter's book taught me much, and not only about occupational diseases. I learnt the derivation of the word ‘dollar’ (taler, from Joachimstaler, the coin minted from the Bohemian silver mines in Joachimstal where Agricola worked). I thought I had read ‘The Water Babies’. The original edition had an iconic drawing of Tom, the sweep's apprentice, emerging from the top of a chimney, and reproduction of this illustration in Hunter's book led me to look it up. I must have remembered my grandmother reading from a much abbreviated version; I discovered its contemporary support for the new theory of evolution, published by the Rev Charles Kingsley's friend, Charles Darwin. The emotion expressed by the candidate on seeing Donald Hunter across the room, at a table stacked with unfamiliar objects, indicated that to pass MRCP you were well-advised to understand the inter-relations of work and health. Would that were still the case.
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