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Papers that have changed the practice of occupational medicine: 'Pulmonary disease due to inhalation of derivatives of Bacillus subtilis containing proteolytic enzyme' by M.L.H. Flindt. 1969.

Dr Michael Flindt’s work in Manchester in the late 1960s and his Lancet paper of 1969 (along with its companion paper) proved to be seminal in a number of respects for the emerging field of occupational respiratory allergy [1,2]. First, inhaled occupational dust contaminated with enzymes from Bacillus subtilis (alcalase and maxatase) was shown to be a potent (very potent) cause of asthma, not merely an irritant that triggered symptoms nonspecifically in subjects who were already asthmatic. Secondly, the mechanism was shown to be one of allergy not toxicity. Thirdly, asthmatic reactions were noted in most cases to follow exposure onset after a period of several hours (and often after the work shift was completed), a feature of occupational asthma that had previously done much to disguise the causal nature of ‘asthmagenic’ occupational environments. Fourthly, a close and timely partnership with Professor Jack Pepys at the Brompton Hospital in London proved to be a catalyst for what became an explosion of clinical and laboratory study in industrially developed countries. This showed that asthma of allergic origin has become the principal cause of occupational lung disease in modern society— now responsible for 25–30% of all incident cases [3,4].