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7X0 THE MEDICAL JOURNAL OP AUSTRALIA Skptbmiirr 23, I'.,;; \tetliral Survey OCCUPATIONAL ASPECTS OF RAYNAUD'S DISEASE1 A CRITICAL HISTORICAL SURVEY A. J. Christophers, m.h., r.s., b.sc., d.p.h." Depanment of Healih, Victoria \i,,i i Mint.. 11*72, 2: 7;u*-7;i;:. The literature is reviewed beginning with the first descriptions of occupational Raynaud's disease in the second decade of this century. At the beginning of the fourth decade, the importance of vibration in the aetiology of the disease started to gain acceptance, and this Idea solidified during this decade and the next to the extent that the disease is now called "vibration disease", or "vibration-induced white fingers", instead of "Raynaud's disease". The writer maintains that vibration was accepted erroneously as an aetiological factor, and that the perpetuation of this error has confounded Investiga tions into the aetiology of the disease ever since. In the appendix, It is pointed out that certain occupational manifestations of Raynaud's disease have been recently described as a new disease named "occupational acro-osteolysls" and spurious aetiological factors have been postulated for it. In 12*12. Muiinu Raynaud published his thesis describing * he disease to which hts name has been given. Interested primarily in the rare and serious disease then known ns spontaneous bilateral gangrene of the extremities, lie maintained that this was connected by intermediate steps to the common and benign affliction known then as local syncope, and now referred to as "white fingers". He stressed the importance of cold as an exciting cause oi the attacks; but he did not include it in the predisposing causes. He attributed the disease to spasm of the blood vessels arising from vasomotor activity of the spinal cord, and in 1874 he published further observations in support of this hypothesis. Ills theses were accepted by Thomas Harlow, a famous tbiglish physician, who translated them into English,1 and whoso description of the disease in Allbutt's "System of V-'difii.e" (1SHTj i" is classical. - i:t id fit the f.unual meeting of the Australian Society of <X cpath.rml Medicine, Sydney, October 8 to 10, 1971. - f'hirf In.Iit.-tri.i 1 Hygiene Officer. .vMrvs ho i\ prints*. Dr A. J. Christophers, Industrial 11} cicno liivision. Department of Health, Parliament Place, Mc.l.i.iirn,-, Vic, 2002. Unfortunately, llaynaud's work was not so well accepted by Jonathan Hutchison,* another famous English physician, who called the malady "Raynaud's phenomenon'', and not "Raynaud's disease" on the grounds that it included a large group of maladies which differed widely in their setiology. Hutchison's views pn the mtiology of the malady ate quite absurd when viewed in the light of present-day knowledge; yet his authority was sufficient to start a fashion which has persisted to this day. The fashion did not follow him In discarding "disease" for "phenomenon", hul. it heB persistently asserted some fundamental difference between Raynaud's disease and Raynaud's phenomenon. It is a foregone conclusion that any disease due to cold will have its- occupational manifestations. Neither Raynaud nor Barlow saw any relation of the disease to occupation. In fact, Raynaud mentioned the idea only to dismiss It. A certain number of patients had manual occupation such as wasnerwoman, chambermaid, burnisher, sculptor, etc. But an this circumstance was wanting in many other cases It appears to me that we cannot attach any importance to It. Apparently it was first reported as an occupational dlscaso in 1911 by Professor G. Loriga* of Rome, who described its occurrence among operators of pneumatic tools. * *0 In 1914, BramwelP of Scotland reported nine cases ot scleroderma associated with Raynaud's disease, five of -which involved stonemasons working with hammer and chisel, while one invMved a coppersmith also using a hammer, and chisel, and one Involved a coal miner exposed to cold when cycling to and from work. Hg suggested that the relatively frequent occurrence of sclerqderma among stonemasons was due to the holding of a chisel in the hand in cold weather. The first large investigation was 'made by the U.S. Bureau ot Labor Statistics and the UiS. Public rfellth Service' as a result of complaints made by the President of the Journeymen Stone Cutters' Association of North America on December 28, 1916 -- complaints of the injurious occupational effects of dust and of pneumatic tools on their members working in the Indiana limestone belt, resulting in tuberculosis and paralysis. The paralysis was not, in fact, such, but was Raynaud's disease. ASI 000016033 Min u 23. 1972 THE MEDICAL JOL'ILV.VL OF A1 NTICW.IA in' investigation was apparently set in motion by the i,, ji iiy L)r Miller of Chicago, on November 18, 1916, I'.iuil'^ d'MMise in ii hiniieeutter* Dr Miller related tin' npi-ration of ;i pmaimntic tool and conveyed this ii in the Stonecutters' Association. Tie results of the investigation were published in the of the U.St. Burro it of Labor titatistics. Number Jrly, 1918, under the title, "Effect of the Air Hammer Ik Hands of Stonecutters", and Includes reports by following physicians: Alice Hamilton, of the Harvard 'u!ici l School, who was commissioned by the Bureau to ::,,i stigate, and who was assisted by Thor Rotbstein, a , -o es ;or or nervous and mental diseases, who made a j ,U(d clinical investigation of eight men; Major Cary, i'u i vaniinod eight soldiers who were formerly stone: l>r l.eake and Dr Eilsall, of the U.S, Public Health r.ic*1; Dr Cottingham, who had examined seven men i behalf of the employees; and Dr Barnes, Dr Proctor ,ud Dr Herring, on behalf of the employers. liiiiuilton maintained that the trouble was not Raynaud's !h. are, and coined the term "spastic antemia of the hards". ,' she found 34 of 38 limestone workers, 45 of 50 granite corkers and 44 of 78 marble workers to be affected by it. Site described bow the blanching of the fingers usually dev eloped early in the morning and passed off during work, liuv it developed after years of work and disappeared lowly after the sufferer left the trade. She considered that li seemed to be caused by three factors: cold, cramping of the fingers, and vibration, and recognized that the two bis-r-mentioned factors would be hard to separate, because - ii tool that vibrated most would have to be held most 'rhtly. i/ake stated categorically that, when the mills were .ii-itid soon after commencement of work, most of the ip'riitors showed blanching of the fingers. He thought ramping of the hand was more likely to be important hm . ibraiion. lie recognized that it was not exclusive in ini'i'iiuic tool operators, and he mentioned the (ii: i cnee of the condition in a boilermaker who had :i vt*i- used such a tool. Edsall confirmed the presence of symptoms at the comiit :n, cnient of work, and noted that sometimes the fingers were cyanosed instead of blanched. He recognized that men had suffered from the same trouble before the introduction f pneumatic tools, hut thought that their introduction had increased the trouble considerably. He attached more importance to constriction of the grip than to vibration as a cause. Barnes, perhaps, made the most pertinent observations of all. He clearly recognized that the condition existed b'foro the Introduction of air tools, and his comments are worth quoting verbatim: That it is not due to the pneumatic hammer directly and pi in,only is proven by the fact that the condition mi known oxirt prior to the introduction of this tool. Tha; i to* nil It dinner may have added Somewhat to if< e.-siiry of its occurrence, as compared with ' in i-r' ' i win-!' `ho chisel and mnilet were used i.'Umio;, in pose lido, but not proven. An extensive no | study, niiich circumstances naturally made .lit" ih e, could alone settle this question. iicrriiii, would not look further than cold as a cause of : a; condition and stated: The condition which the men have' termed ' "whitefingers" ts simply a reaction of the skin and underlying ( blood vessels to the stimulation of the cold. If we look at the investigation as a whole, it Is surpris ing that none of the more serious manifestations of Raynaud's disease was found, and It is also surprising that a group of physicians, some so prominent, should fail to recognize that the malady had been described by Raynaud. They laboured under the misapprehension that Raynaud's disease was always a dread disease leading to gangrene. Even Alice Hamilton, the grandmother of occupational medicine in the U.S.A., made this mistake. The consensus of the opinion of all the investigators was that this was a disease hitherto not known to medicine, always benign, for which cold was a necessary condition, and which was aggravated, perhaps, by Interference with the circulation by the pressure of the grip and also, perhaps, by vibration. In 1924, Dr Bridge and Dr Middleton,7 Medical Inspectors of Factories in Great Britain, together examined four masons with the complaint, and provisionally concluded that it was produced by two factors operating together: the pressure of the pneumatic tool impeding the circula tion of the fingers, and the action of the cold. Again In 1930, Dr Middleton* Investigated workerB in the boot and shoe industry using pounding-up machines, and attributed their trouble to the preseure of grasping. He dismissed vibration as a factor of Importance: Vibration as such is not an Important factor except in so far as if calls for an excess of statio resistance In opposing- the tendency to displacement of the object. In the meantime. In 1925, Teleky* of Vienna reported cases among iron foundry fettlers using pneumatic chisels; one had gangrene of the left little finger, and another had severe Raynaud's disease of the left hand. In the late 1920's, a number of Investigators In Germany reported caaes occurring among operators using the pounding-up machines in boot factories. They showed that the Incidence of the condition increased with years of work and decreased with the years after the cessation of work. In 1931, Maria Seyring1 of Germany reported the results of an investigation of the disease among pneumatic tool operators -- fettlers, riveters and moulders -- in iron foundries. Stating that her attention was first directed to the problem when she diagnosed a few cases of Raynaud's disease in fettlers, she made no further mention of Raynaud; but she recognized quite clearly that the disease she was dealing with was one fairly common in the general population. She confirmed the fact that the incidence increased with years of employment, and she showed that it was most extensive in those whose work was hardest. She knew that the exciting cause of each attack was cold, and realized, too, that the fingers of the fettlers were constantly exposed to a blast of cold air from the tool; yet she rejected this as a predisposing cause because the digits most subjected to the cold blast were not those most affected by the malady. She also rejected pressure on the ulnar artery as a predisposing cause because this occurred in other trades, AS I 000016034 732 THE MEDICAL JOURNAL OF AUSTRALIA September 23t and she argued, too, that, had it been the cause, the attacks would have occurred at work. Having thus eliminated what she considered to be all other possibilities, she accepted vibration as the predis posing cause ot the disease. Important to her argument was her alleged finding that the attacks occurred as a rule outside working hours. This finding is at variance with that ot the Indiana survey, and even with her own statement that "some fettlers reported that their white fingers became soft and warm again by working with the chisel as It became warm again during operation", which implied that the attack was present at work. In 1934, Professor Lorlgau of Rome published the first review on the subject under the title of "Pneumatic Tools" in the International Labour Office's "Occupation and Health", Although his report in 1911 had been the first to associate the disease with the use of pneumatic tools, Loriga's opinion in 1934 was that "vibration would not appear to have any particular significance". I.nter, in 1933, Dr Teleky1' of Vienna rewrote this article for tho International Labour Office's "Occupation and HealLli" supplement. This review Is neither critical nor profound. Under the influence of Seyrlng, Teleky endeavoured to use the alleged general absence of attacks at work and their excitation by cold as devious argument In favour of vibration being the cause. The difficulties Into which his logic leads him can be illustrated by his concluding remark: / To summarize, it may be said that vascular disturb ances affecting chiefly the Angers of the hand holding the tool are of widespread occurrence; that these derangements occur more especially among workers working in a low temperature and that, if the workroom is heated, serious symptoms of the kind are of extremely rare occurrence. The vascular troubles are therefore a typical consequence of the shocks and vibrations to which these workers are subjected In the course of their occupation. In the early 1930's, Raynaud's disease had been the subject of considerable clinical research in England, and, In 1934, Sir Thomas Lewis and G.' W. Pickering11 published a review summarizing the results of their Investigations. They followed Hutchison in fragmenting the disease Into many separate entitles, and set the pattern, followed to this day, of distinguishing between the "disease" and the "phenomenon". Under the heading "Raynaud's phenomenon following lottg continued vibration", they referred to attacks as being common In those using vibrating tools, and stated that tho Injurious factor had been proved by Seyrlng to be vibration. A few years later, Lewis irmoi porated those views Into his hook "Vascular Disorders of the Limbs".1* Tt cannot be said that the contribution of Lewis and Pickering was entirely negative. They did show that local dulling of a digit could Induce an attack in that particular <11 dt. ami, conversely, that chilling of the body failed to produce nn attack in a warmed band. They also produced the first estimate of the incidence of the disease aiming the general population, by questioning medical students and nurses and finding 2S% of them to be affected. Contemporarily with Lewis and Pickering, another Englishman, John Hunt, was Investigating the disease clinically, and his findings were, published as a critical review in 1936/ and a few" years later In the article on this disease In the "British Encyclopaedia ot Medlra1 Practice"." Hunt took It for granted that vibrating tool* caused the disease, and yet he has this to say about cold: The only factor which precipitates an attack Is cold. Many of these men will say that vibration of the Instru ment Itself will make their hands go pale and numti. but careful enquiry reveals that this is only on cold days. His contributions were also not entirely negative, in that he did demonstrate that chilling of the body was necessary to produce an attack, as well as chilling of the hand. After the work of these English Investigators, there followed a decade of almost complete quiescence on the subject, due, no doubt. In part to the intervention of the Second World War. The quiescence was broken by the first serious attempt to study the etiology of the disease, which was undertakes by the Department of Research In Industrial Medicine ot the Medical Research Council of the U.K. Their first paper was published in 1946 by Donald Hunter and others," and was followed by several others'* " in tho next few yean. Although those writers admitted the Importance of chill ing as an exciting cause ("the symptoms were moat pronounced and certainly aggravated by cold weather"), their study was rendered sterile by their gratuitona assumption that vibration was the more significant cause. Their efforts were, therefore, mainly confined to a scrutiny of the parameters of vibration that might be relevant, and they advanced the hypothesis that the range of vibration frequency of between 2,000 and 5,000 per minute was the most dangerous. Since that time, the number of published papers has been Increasing exponentially year by year and has now reached astronomical proportions. A recent interrogation of Medlars reveals that papers on the health aspects of exposure to vibration are now being published at the rate of about 60 per year. It has not been possible for me to subject these papers to the close scrutiny to which I have subjected the earlier ones; yet I think It would be fair to comment that the underlying aseumption of all of this later research has been that vibration was the cause of the condition. Those later investigators have been generally still willing to concede that attacks do not occur so frequently In warm weather; yet the parameters relating to vibration have usually been documented in detail, while those relating to temperature have been Ignored. Typical of modern attitudes Is that revealed by Donald Hunter" In his eight-page review of the subject under the heading "Effects of Vibration Tools" In his book "Diseases of Occupation" (1969), In this review, cold gets barely a mention. DISCUSSION Ono remarkable oversight which can be noted on review ing tho literature Is the failure to perceive the Interrelation of pressure of the grip and chilling of the fingers. The, Interrelation of pressure of grip and Intensity of vibration was realized by Hamilton as long ago as 1919, ASI 000016035 -r.rii 'iBeB 23, 1972 THE MEDICAL JOURNAL OF AUSTRALIA 733 f,,jt the obvious fact that pressure of the grip would inter:.c ivitli the blood supply and thereby aggravate the ,! u1 of chilling M'cuib to have escaped notice. Perhaps the, must significant point to be noted in review,15 tbo literature is the change that took place In r!titudes to aetiology in about 1930. Earlier Investigators, acmplifled by Alice Hamilton, attached more importance a cold and cramping of the fingers than to vibration. >,:iter investigators, exemplified by Lewis and Hunt in the id 1930's, believed that vibration was all-important. Anpoiently ihe change can be attributed to the work of '.'ring in 1931, she was firmly convinced that vibration .3' the cause, and was apparently so successful In conira ing others that this view has not been questioned to 'is Jay; but her work fell far short of the extensive com.iroiive study that Barnes bad suggested In 1919 as being accessary to establish any claim that vibration was an itiological factor. It is apparent, therefore, that this hange of opinion around 1930 attributable to Seyrlng was ot .'cioutillcally validated and. furthermore, has not been alidatnd to this day. This being the case, it Is fitting to ask what valid ,,gumptions can be made In respect to the aetiology of this disease. It can be assumed that two conditions must be present lor an attack to take place, and these are chilling of the body and chilling of the hands. Furthermore, there Is an occupational factor predisposing (0 attacks, the effect of which is cumulative over a period of years and persists for some years after removal of the factor. It Is quite clear that vibration Is not a necessary predis posing factor, as attacks take place in persons who have not been exposed to it Surely the occupational factor that stands out as being the most likely predisposing cause Is repeated chilling of the body and/or of the bands. Until It has been shown, in a carefully controlled stndy, that more attacks occur with vibration and cold than lust with cold alone, it cannot be claimed that vibration is a predisposing cause of the disease. APPENDIX Another occupational disorder which has been popularly wioiatcd with Raynaud's disease in recent years deserves i brief" mention. This time the o liolf'gical factor is not sought In vibrstlon i.uL in exposure to some as yet unknown toxte chemical iff ximg persons handling freshly made polyvinyl chloride. I.ike Alice Hamilton In 1919, the lnveatigntors have erred m believing that they have found a new disease, and they Ikivo given it tho impressive title of "occupational aero"`.teolysis". The aero-osteolysis refers to Osteolytic changes revealed radlologlcaily in the terminal phalanges ot the fingers. Here the situation Is worse than with "vibration disease". In that chilling Is not mentioned, and there is no documenta tion whatsoever of parameters relating to temperature. The occurrence of such osteolytic changes In Raynaud's disease was noted In a textbook as far back as 1934," and It haa been documented many times since." Heed any more be said about ''occupational acro-osteolysls"7 REFERENCES 'Raynaud, M. (1882), "On Local Asphyxia and Symmetrical Gangrene of the Extremities", and Raynaud, M. (1871), "New Researches on the Nature and Treatment of Local Asphyxia of the Extremities", both translated by Barlow, T. (1888), "Collected Monographs", New Sydenham Society, London, 121: 1. Barlow, T. (1899), "Raynaud's Disease", In "A System of Medicine", edited by Allbutt, T. C,, Macmillan, London, Volume 8: 677. Hutchison, J. <1901), "Raynaud's Phenomena", Sled. Press, 123: 803. 'Lohioa, G. (1911), "II lavro dcpll teapeltinl cot martelli pneu- matici", quoted by Lorlga, G. (1934)." Bramwell, B. (1914), "Dlffufle Sclerodermia: Its Frequency; Its Occurrence in Stonemasons, etc.'', Edlnb, med. J., 12; 38T. 'Anonymous (1918), "Effect of the Air Hammer on the Hands of Stonecutters", In "Bulletin of the U.S, Bureau of Labor Statistics", Number 238, Washington, D.C. 'Anonymous (1926), "Annual Report of the Chief Inspector of Factories and Workshops for the Tear 1924", H.M.S.O., London; 86. `Anonymous (1931), "Annual Report of the Chief Inspector of Factories and Workshops for the Tear 1930", H.M.S.O., London: 119. * Teleky, L. (1927), quoted by Teleky, L. (1938), loo. oit. ' "Seyrino, M. (1930), "Srkrankungen duroh Arbeit mit Presslu/twerkseur/en". Arch. Gcwerbrpath. Gewerbrhyp., 1; 396. "Lorica, G. (1934), "Pneumatic Toole", In "Occupation and Health", I.L.O.. Geneva, Volume 2: 670. "Teleky, L. (1938), 'Pneumatic Tools". In "Occupation and Health Supplement", September, 1938, I.L.O., Geneva. "Lewis, T,, and Pickering, G. W. (1938-4), "Observations upon Maladies In which the Blood Supply to the Digits Ceases Intermittently or Permanently, and upon Bilateral Qangrene of the Digits; Observations Relevant to So-called `Raynaud's Disease' ", Clin. Sol., 1: 327. "Lewis, T. (1936), "Vascular Disorders of the Llmba", Macmillan, London. Hunt, J, H. (1938), "The Raynaud Phenomena: A Critical Review", Quart. J. Med., 6: 399, "Hunt, J. H. (1962), "Raynaud's Phenomenon", in "The British Encyclopedia of Medical Practice", Butterworth, London: 632. ''Hunter, d., McLaughlin, A. I, G.. and Perry, K. M. A. (1946), "Clinical Effects of the Uee of Pneumatic Tools", Brit. J. industr. Med., 2: 10. '* Agate, J. N., Drubtt, H. A., and TOMBlesoN, J. B. L. (1946), "Raynaud's Phenomenon In Grinders of Small Metal Castings", Brit. J. industr, Med., 3: 167. "Agate, J, N. (1949), "An Outbreak of Cases ot Raynaud's Phenomenon of Occupational Origin", Brit, J. industr. Med., 6: 144. *>Hunter, D. (1969), "Effects ot Vibrating Tools", in "The Diseases of Occupations", by Hunter, D., English Unlv. Press, London; 886, Brailsforp, J, F. (1984), "Radiology of Bones and Joints", Churchill. London: 27. s McLaren, J. W. (1927), "Disability of Workers Using Pneu matic Drills with Special Reference to Radiological Changes", Lancet, 2: 1296, Tho students in law and .Medicine ot the University of Liege have Invited the -tuiii-nts nf all Europe to attend a philanthropic congress for the discussion of various great social questions.--Medical News, I.ancct. 1865, 2; 163 (August 6). ASI 00016036