Department of medical history Ramazzini and workers’ health

G Franco

Introduction Occupational illnesses and injuries have long been a preventable blight to health.1 WHO estimates that 217 million cases of occupational illness and 250 million cases of injuries at work occur each year worldwide, including 33 0 000 deaths.2 Observation of the relation between occupational hazards and poor health dates back several centuries, but a systemic description of diseases according to occupational causes was made only in the final years of the 17th century3, 4 by Ramazzini, the acknowledged father of occupational .5, 6 Bernardino Ramazzini was born in Carpi, a small town near Modena, on Oct 4, 1633. After graduating in philosophy and medicine, he spent several years practising in and, at the end of 1676, he moved to Modena, where a renowned university had been founded in 1175. On invitation from Duke Francesco d’Este, Ramazzini was appointed to the Chair of the Theory of Medicine in 1682. Even though he began his university career at the age of 49, Ramazzini then taught for 32 years, during which time his scholarly interest was attracted by several topics, focussing attention on occupational health. In addition to his teaching, Ramazzini also wrote several works including his famed treatise of workers’ health De Morbis Artificum Diatriba. In 1700, Ramazzini was invited to the , where he taught until his death, on Nov 5, 1714, of an “apoplectic fit”.7, 8 The link between occupation and health Figure 1: Bernardino Ramazzini (Anonymous, Carpi School) By kind permission of the Museo Civico, Carpi. Ramazzini’s interest in occupational health dated back to his student years, when his attention was drawn to workers in foundries and tanneries. After he moved to Modena, despite his busy life as a practitioner and his “Ego quidem . . . neque indecorum credidi in viliores Officinas duties as a professor of medicine, Ramazzini devoted his pedem quandoque immittere, & . . . Artium Mechanicarum attention to workers’ diseases. For nearly 20 years, he secreta contemplari” (. . . and have not thought it beneath me investigated the subject in depth, visiting workplaces, to step in workshops of the meaner sort now and again and study the obscure operations of the mechanical arts)4 observing workers’ activities, and discussing with workers their illnesses. His extensive investigation of working This view was unusual in the second half of the 17th activities made him an expert on the topic: during the century, and Ramazzini met with the sarcasm and academic year 1690–91 the official records of the derision of other doctors. Now, the practice of University of Modena show that his course of medicine occupational health requires a comprehensive knowledge was specifically dedicated to occupational disorders.8 10 of the workplace,11 including factory visits by health years later, the first edition of De Morbis Artificum Diatriba professionals, so that physicians are aware of working was printed in Modena.3 The second edition appeared in conditions.12 Ramazzini anticipated this need, and Padua in 1713.4 Ramazzini, as a scholar devoted to the supported the view throughout his treatise that workplace analysis of working conditions, integrated his information analysis can identify potential and actual hazards to carefully with already existing knowledge.9 The De Morbis workers’ health. is based on intensive research into sources, as is apparent The idea for his treatise came when Ramazzini’s from more than 500 quotations,10 and on the author’s attention was attracted by the speed with which a sewage personal experience of visiting workplaces. worker emptied the sewer at Ramazzini’s house. When Ramazzini claimed that he did not think it degrading to questioned about the reason for such speed, the man visit workplaces, however menial: answered that too long a stay in such a place would cause blindness. This remark prompted Ramazzini to Lancet 1999; 354: 858–61 investigate the case. He found that sewage workers Postgraduate School of Occupational Medicine, Department of showed severe reddening of the eyes and that many of Internal Medicine, School of Medicine, University of Modena and them, after years of such work, became blind. Ramazzini Reggio Emilia, Largo del Pozzo, 71, I-44100 Modena, Italy linked the pathology to acidic substances (ammonia (Prof G Franco Hon FFOM; e-mail: [email protected]) vapours) present in the sewer.

858 • Vol 354 • September 4, 1999 Workers whose disorders are included in the De Morbis Artificum Diatriba Miners Corpse-workers Voice-trainers and singers Gilders Midwives Farmers Healers by inunction Nurses Fishermen Chemists Vintners and brewers Soldiers Potters Starch-makers The learned Tinsmiths Corn-sifters and measurers Printers Glass-makers Stone-cutters Writers and notaries Painters Laundresses Confectioners Sulphur-workers Hemp, flax, and silk-workers Weavers Blacksmiths Bathmen Coppersmiths Plasterers and lime-workers Salt-workers Carpenters Apothecaries Workers who stand Razor and lancet grinders Cleaners of cesspits Sedentary workers Brick-makers Fullers Runners Well-diggers Oilmen, Tanners Horsemen Sailors and rowers Cheese-makers Porters Hunters Lutestring-makers Athletes Soap-makers Tobacco-workers Workers on minute objects

“Acidum volatile esse illud, quod, hujusmodi Camarina The ability to establish a link between hazard and disease commota, expiret, mihi proclive est arbitrari” (I . . . think that (the clincal paradigm) allowed Ramazzini to stress the some volatile acid is given off by this vault of filth when they disturb it)4 relation between workers’ injuries and exposure to several environmental conditions, and to classify disorders He also suggested possible remedies. The way Ramazzini according to the health risk present in each working introduces the topic suggests that he knew that his situation.9 colleagues would not appreciate his new approach, Ramazzini knew that dangerous materials (“noxios because it required getting one’s hands dirty: alitus ac tenues particulas” [noxious vapous and very fine “Dubius hic haereo, num Medicos . . . ad Latrinas invitando, in particles]4) such as mineral dusts for miners and eorum nasum bilem conciere possim” (I hesitate and wonder stonecutters, vegetable particles for tobacco and carding whether I shall bring bile to the noses of the doctors . . . if I workers, and vapours for vintners and confectioners, 4 invite them to come to the latrines) could be inhaled or absorbed through the lungs or (like Ramazzini used his new approach (workplace inspection, mercury ointment) could penetrate the skin (“quin questioning workers, advising on remedies) to investigate mercuriales atomi corium . . . pervadant” [impossible . . . to more than 50 occupations (panel). In general, each prevent the mercurial atoms from penetrating]4). As well chapter of his work starts with a short description of the as excess noise affecting coppersmiths (“ex continuo illo disorders associated with a particular occupation. These strepitu, aures male affici” [the ears are injured by that disorders, which had been described occasionally by other perpetual din]4), Ramazzini reports in the whole treatise authors, were more often directly observed by Ramazzini, other physical agents (heat, cold, humidity) as potential who did not mind questioning workers about their causes of illnesses for people such as glassworkers, bakers, complaints to correlate them with known disorders. brickmakers, and laundresses. However, he realised that Thus, in addition to the questions recommended by it was not possible to ascribe all disorders directly to the about the kind of pain or illness, about chemical and physical characteristics of the working cause, and about duration, Ramazzini also used to ask his environment, and he observed that several common patients the nature of their occupation: disorders could follow from prolonged, violent, and “liceat quoque interrogationem hanc adiicere, & quam artem irregular physical motions and sustained postures of the exerceat” (I may venture to add one more question: what worker’s body. Although he did not develop a detailed occupation does he follow?)4 assessment of the factors associated with work-related suggesting that doctors always ask their patients this musculoskeletal disorders, Ramazzini understood the question. relation between posture, repetition of movements, lifting After description of each disorder, Ramazzini’s weights, and particular disorders: systematic approach included analysis of technical aspects “quibus aliis causis, velitu situ quondam membrorum, ac of each job and the clinical aspects of the disorder’s motionibus corporis incongruis, morbosi affectus succrescunt” pathology, a literature review, and suggestions for therapy (certain morbid affections . . . from other causes, some and workplace rules. particular posture of the limbs or unnatural movements of the body)4 Classification of occupational disorders These pathologies were ascribed to the sustained according to cause maintenance of stationary or unnatural postures (as in The association between hazard and disease pointed out workers who stand, sedentary workers, grooms, scribes, by Ramazzini is based on intuitions and logical weavers) and to activities requiring heavy muscular deductions that anticipated the modern scientific performance (porters, woodworkers). approach based on epidemiological principles. The later Ramazzini was also concerned about pollution in the method is based on the observation of pathological events workplace that affected the general environment, as is in groups of workers and not in individuals, and this evident from a dispute between a citizen and the owner of shows the originality of Ramazzini’s thought, for, as a a chemical laboratory producing sublimate, which clinician, he was used to dealing with individual patients. polluted the surroundings with vitriol:

THE LANCET • Vol 354 • September 4, 1999 859 also by the fumes of lighted lamps, superintendents of mines regularly expel the thick stale air and force in fresh and purer air)4 Ramazzini anticipated the need to limit the exposure time to hazard as a measure to prevent injuries.14 Periodic interruption of working activity and shorter duration was recommended to prevent eye injuries among craftsmen who made very small objects, and for a number of jobs requiring a standing position “Qui ergo Statariis Artibus addicti sunt . . . monendi sunt, ut cum possunt, continuatam stationem interrumpant, vel . . . vel . . . sedendo, vel . . . deambulando, vel . . . corpus movendo” (We must advise men employed in standing trades to interrupt . . . that too prolonged posture by sitting or walking about or exercising the body)4 or severe muscular effort (eg, bricklayers, woodworkers, printers). Moreover, Ramazzini suggested moderation in working as the best safeguard against occupational illness “Praesidium itaque ad mala advertenda esset tam viris, quam mulieribus in opere tam arduo moderatio; illud enim vulgatum “ne quid nimis, nimis mihi placet” (Therefore in work so taxing moderation would be the best safeguard against these maladies, for men and women alike; for the common maxime “Nothing in excess” is one of which I excessively approve)4 Nowadays, these remain sound concepts. As a result of observation of an increasing number of musculoskeletal disorders—the occupational epidemic of the 1900s15 among workers employed in apparent safe tasks—the need to adapt the workplace to ensure personal health and safety has become of major concern.14 The use of personal protective devices, such as face masks and ear plugs, is now a statutory requirement.16 Figure 2: Title page of the De Morbis Artificum Diatriba, Ramazzini suggested the implementation of such measures Modena (1700) and understood that the use of protection should take into account the nature, extent, and effect of hazards. Although “qui fumum Vitrioli exhalantem maxime culpabat & proximum Aerem inquinantem” (this he ascribed to the fumes given off by his suggested tools were not much more than primitive and the vitriol, which so tainted the air)4 were not very effective, Ramazzini recommended the use of masks for sewage workers: and led to an excess of mortality: “ut Vesiculas translucidas ori apponant” (to fasten transparent “multo plures in illo Vico, & in locis proximioribus, quam in bladders over the face),4 aliis, quotannis interiise” (it appeared that many more persons died in that quarter and in the immediate neighbourhood of bakers and millers: 4 the laboratory than in other localities) “illorum consuetudinem fascia linea os sibi obvelandi commendo, Even in the 17th century, there was marked appreciation ast id non satis est, quin una cum aere ispirato farinae atomi of public-health problems. pectoris penetralia irrepant” (their habit of covering the mouth with a linen bandage is a good one, but it is not enough to prevent . . . flour making its way into the innermost recesses Risk prevention and workers’ health protection of the chest along with the inspired air4), The inspection and analysis of workplaces allowed Ramazzini to establish a link between hazards and and sifters and bricklayers. illnesses, but it also allowed him to suggest preventive Throughout his text, Ramazzini felt the need to inform measures. Now, occupational-risk prevention has three workers about risks. His terminology, mostly aimed at stages: elimination of hazards; selection of engineering advising workers about appropriate attitudes, is that of controls; and use of personal protective devices.13 the clinician asking the patient to limit himself, to be Ramazzini illustrated several precautions to limit moderate, and to avoid risks. There are passages, exposure to hazards, and described measures to limit however, where the informative message is made more airborne dust exposure. For example starch-makers were explicit to promote greater awareness of professional risks advised to work in open places: and appropriate behaviours both inside and outside the working environment. This aspect is clear, for example, “in ampliori spatio, non in conclusis locis, opus huiusmodi when Ramazzini tries to persuade vintners to refrain from perficiant” (to carry on this sort of work in . . . spacious drinking: places, not in confined quarters)4 “Ego igitur . . . suasor sum ut a Vino, eo magis a Vini spiritu and the need to improve ventilation was stressed abstineant, ac prorsus abstemii fiant, per totum illud tempus “Fodinarum Praefecti ad emendadum Aeruem illum conclusum, saltem, quo tali ministerio operam suam locarint” (I advise & infectum, tum ob halitus, qui a minerali materia, & a them to abstain from wine and still more from brandy, in Fossorum Corporibus expirant” (to purify that imprisoned air fact to be completely abstemious, at any rate for the period . . . emitted from the minerals and the bodies of the miners, for which they have hired themselves to do this work)4

860 THE LANCET • Vol 354 • September 4, 1999 Conclusion 3 Ramazzini B. De morbis artificum diatriba. Mutinae: Typis Antonii Capponi, 1700. 17 The main merit of the “magister of Carpi” is his 4 Ramazzini B. Diseases of workers: Latin text of 1713 revised masterly clinical observations, still valid today.18 with translation and notes by Wilmer Cave Wright. New York: Ramazzini showed that establishment of a link between The Classics of Medicine Library, Division of Gryphon Editions, 1983. working conditions and disorders is best made by 5 Murray R. Man and his work. In: Raffle PAB, Lee WR, investigation of the working activities of each patient. McCallum RI, Murray R, eds. Hunter’s diseases of occupations. History-taking to ascertain an occupational origin of a London: Hodder and Stoughton, 1987: 1–61. disorder is now taught to medical students,19 although it 6 Rom WN. The discipline of environmental and occupational medicine. In: Rom WN, ed. Environmental and occupational is not known whether all doctors have mastered this medicine. Boston: Little Brown, 1983: 3–6. 20 skill. 7 Volini IF, Flaxman N, Bernardino Ramazzini (1633–1714) the father Assessment of whether exposure to an occupational of industrial medicine. In: Ramazzini B. Diseases of workers, Delran, hazard may have contributed to the development of an New Jersey: The Classics of Medicine Library, Division of Gryphon Editions, 1995. occupational illness was not, however, the only scope of 8 Di Pietro P, Bernardino Ramazzini: on the CCCL anniversary of his the De Morbis. Ramazzini did not limit himself to injury birth. Bologna: Grafiche Veronesi, 1983. diagnosis, because he aimed not only to describe the 9 Carnevale F. Prefazione. In: Ramazzini B. Le malattie dei lavoratori. pathological events and to clarify occupational cause, but Roma: La Nuova Italia Scientifica, 1982: 9–26. 10 Di Pietro P. Le fonti bibliografiche nella De Morbis Artificum also to provide workers with care and preventive Diatriba di Bernardino Ramazzini. Hist Philosophy Life Sci 1981; 3: measures 95–114. “quibus Artifices tentari solent, tum curatione, tum 11 Roberts MA. The workplace walk-through. In: Greaves WW, Bunn WB, eds. Occupational and environmental medicine: pearls of praeservatione suggerere” (to suggest medical precautions for the specialty. Beverly: American College of Occupational and the preventions and treatment of such diseases as usually Environmental Medicine, OEM Press: 1996: 38. affect workers)4 12 Welter ES. The role of the primary care physician in occupational medicine: principles, practical observations, and recommendations. Ramazzini’s innovative analysis of the causal relation In: Zenz C, ed. Occupational medicine. Chicago: Year Book Medical between working activities and disease has, however, Publisher, 1988: 62–73. eclipsed the preventive side of his work. 13 Hoffman H, Gray DC. The establishment of an occupational health program. In: McCunney R, ed. A practical approach to In the recent past, many improvements in health and occupational and environmental medicine. Boston: Little Brown, safety at work have been made. Ramazzini’s main work 1994: 48–59. reveals his contribution to hazard prevention, and 14 Tichauer ER. Ergonomics. In: Clayton GD, Clayton FE, eds. Patty’s although preventive measures are not extensively industrial hygiene and toxicology. Vol 1 part B. New York: John Wiley and Sons, 1991: 743–842. described in the work in contrast to clinical measures,21 15 Herington TN, Morse LH. Cumulative trauma-repetitive motion 13 they are similar to modern preventive measures. In injuries. In: Herington TN, Morse LH, eds. Occupational injuries: foreseeing the importance of instruments designed to evaluation, management and prevention. St Louis: Mosby, 1995: prevent injuries, Ramazzini’s work is remarkable for its 333–45. 16 Reinert BD. Personal protective equipment. In: Harris RL, Cralley LJ, similarity to modern occupational health, which also Cralley LV, eds. Patty’s industrial hygiene and toxicology. Vol 3 part focusses on hazard prevention and personal protection, A. New York: John Wiley and Sons, 1994: 181–89. addresses environmental and social issues, and promotes 17 Ambrosi L, Fo`a V. Trattato di medicina del lavoro. Torino: Utet, occupational health and safety as an integral component 1996. 2 18 Mastromatteo E. From Ramazzini to occupational health today from of public health. an international perspective. J Occup Med 1975; 17: 289–94. 19 Institute of Medicine (US). Curriculum content. In: Environmental References Medicine: integrating a missing element into medical education. 1 Hansenne M. Preface. In: Stellman JM, ed. Encyclopaedia of Washington: National Academy Press, 1995: 14–21. occupational health and safety. Geneva: International Labour Office, 20 Waldron HA. Lecture notes on occupational medicine. Oxford: 1998: v. Blackwell Scientific Publications, 1990. 2 WHO. The World Health Organization Report 1998: life in the 21st 21 Parmeggiani L. L’opera di Bernardino Ramazzini nel campo della century: a vision for all. Geneva: WHO, 1998. medicina del lavoro. Med Lavoro 1983; 74: 426–32.

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