Ramazzini and Workers' Health

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 medicine.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 Italy 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 University of Padua, 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 THE LANCET • 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 Hippocrates 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

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