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Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier


Tens of thousands of chemicals in the workplace as well as important physical and biologic hazards may be encountered in the general environment ( Table 17-2 ). Several of these hazards are of major current concern in industrialized countries.

TABLE 17-2   — 

Hazard Health Effects of Greatest Concern Comments
Metals Neurotoxicity, cancer Most can be measured in blood or urine to assess dose
Organic solvents Respiratory and dermal irritation, neurotoxicity, hepatotoxicity Benzene and a few others have unique effects
Organohalides (e.g., DDT, PCBs) Cancer population concern Ubiquitous suspect carcinogens of high
Herbicides and pesticides Rare acute neurotoxicity, unknown long-term effects Widespread hazards of high population concern
Electromagnetic radiation Leukemia, glioblastoma Ubiquitous exposures with unproven effects
Mold Allergy High population concern regarding putative chronic effects
Mineral dusts (e.g., asbestos, silica) Cancer Old hazards still of high concern

DDT = dichlorodiphenyltrichloroethane; PCBs = polychlorinated biphenyls.


Exposures to lead and arsenic ( Chapter 20 ), once commonplace in industry, are now generally controlled; concern remains highest for environmental settings, especially for children. There is now greater concern for mercury—entrained in large ocean fish worldwide—and manganese ( Chapter 20 ), a potent neurotoxin in welding fumes and various alloys. For most metals—manganese being a notorious exception—blood or urine tests are available to quantify a patient’s burden, but these tests must be mindful of timing, the form of metal, and possible “confounders” such as the largely benign form of arsenic excreted in urine for several days after even a single shellfish meal.

Organic Solvents ( Chapter 111 )

These petroleum derivatives remain ubiquitous in workplace and household products. All are irritating, potentially neurotoxic, and, to varying degrees, hepatotoxic. A few, such as trichloroethylene and n-hexane, are more potent but no longer are widely used. Benzene and the ethers of ethylene glycol are bone marrow toxins ( Chapter 171 ).


Although these complex organic pesticides and industrial materials are no longer made and sold in developed countries, their remarkable biopersistence has resulted in entrainment into everyone’s fat. Worse, the dread byproduct dioxin, once associated with herbicide manufacture, has now been recognized as a predictable consequence of combustion of any chlorine-containing materials. All are suspect carcinogens, although debate remains whether this effect is limited to soft tissue sarcomas ( Chapter 213 )—a relationship established for dioxin—or promotes cancers more globally.

Herbicides and Pesticides ( Chapter 111 )

The acute neurotoxicity and irritant properties of most herbicides and pesticides have been well studied. These agents are generally well controlled, although both occupational and residential overexposures occasionally occur.

Electromagnetic Radiation ( Chapter 18 )

Electric wires, appliances, and, notoriously, cell phones emit lowfrequency electromagnetic radiation at levels far below those that cause local thermal injuries. These radiations are nonionizing, but there is some epidemiologic evidence of an increased risk of childhood leukemia with high-level exposure from household wiring and of excess brain tumors in adult workers with regular exposures. Moreover, recent reports from Europe suggest excess brain cancer in cell phone users. These data are difficult to interpret because study results differ according to how exposure is assessed; the only conclusion is that there is basis for concern and need for further study but not cause for widespread alarm or action other than precaution in the placement of new heavy power lines near schools and residences.


Molds are ubiquitous and long known for their unpleasant odors and potential for inducing allergic responses ( Chapter 270 ), including asthma. Recently, concern has arisen over potential for serious effects from various mycotoxins, long problems in veterinary medicine when domestic animals consume contaminated feed; however, a consensus panel concluded that there is no evidence of human risks beyond those well established from living or working in a moldy environment. Mold formation should be prevented wherever possible, especially in schools and offices, where molds contribute to problems with indoor air quality. Identification, with eradication of leaks and other sources of water accumulation, is key.

Mineral Dusts

Although asbestos has been largely abated, silica and man-made mineral fibers remain widely distributed in the environment. Silica ( Chapter 93 ), present in virtually every form of “rock,” is a potent cause of lung injury and cancer, so respiratory exposure should be carefully controlled in every setting. The evidence of serious risk from fibrous glass, mineral wool, and other man-made mineral fibers is less clear; probably only the finest fibers, such as slag wool, have cancer-causing potential, but many are potent dermal and upper respiratory irritants and should be well controlled for that reason alone.

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