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A pioneer of public health, Bernardino RamazziniAnn Ig 2013; 25: 273-280 doi:10.7416/ai.2013.1929273 A pioneer of public health, Bernardino Ramazzini (1633-1714) G. Franco Key words: History of medicine, History of public health, Bernardino Ramazzini Parole chiave: Storia della medicina, Storia della sanità pubblica, Bernardino Ramazzini Abstract 2014 marks the tercentenary of the death of Bernardino Ramazzini, an academic who lived in the Duchy of Modena in the second half of the seventeenth century. This event represents an occasion to remember his thinking, which is remarkably anticipatory of some concepts and trends of modern public health. Although the main merit of Bernardino Ramazzini lies in his contribution to the knowledge of occupational diseases, which granted him the title of father of Occupational Medicine, his work deserves a more detailed and complete consideration. In fact, the systematic approach to the clinical presentation of diseases and their relationship to work, gathered in the famed treatise De Morbis Artificum Diatriba, resulted in little attention being paid to the preventive aspects of his thinking. The free spirit, the tension for searching, the love for the discussion characterize his scientific attitude, which spans from the anticipation of an epidemiologic approach to studies on the impact of air and climate, from workplace surveillance to suggestions for the protection of health, from proposals of primary prevention tools to recommendations of lifestyle behaviour, from educational issues to health promotion. His scientific, cultural and humanitarian stature is evidenced by his overall scientific works revealing the modernity of his thinking in the light of the present trend of public health focusing on the needs of people and promoting occupational health as an integral component of the health concept. He who ignores the past has no roots and he who has no roots has no future (Antonio Grieco, 1931-2003) Introduction Arnaldo Maggiora, in the last century, exalted the figure of a scientist operating 2014 marks the tercentenary of the in the broader context of what is presently death of Bernardino Ramazzini, an known as public health. In his opening eminent figure of doctor and scientist who address to the academic year 1901-1902 lived in the Duchy of Modena in the second of the University of Modena, the eminent half of the seventeenth century. Although hygienist outlined the figure of Ramazzini he is now internationally recognized with as a scientist, defining the extent of his the attribute of father of occupational contribution in various fields of science medicine (1), it must be remembered that (2) (Figure 1). * Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Modena, Italy 274 G. Franco Fig. 1 - “In foreseeing the real goal of Hygiene and convinced that the doctor’s duty is not only caring for the sick but also to prevent diseases and to encourage the general health improvement, he adapted most of his wise and wonderful scientific industry to these concepts” (2). This essay aims at highlighting an attractive personality. He evidenced an the lesson of Ramazzini, best known original spirit when he felt inconvenient for his contributions to the field of to dedicate himself to vacuous topics with occupational medicine, by outlining no practical use, when he criticized the some aspects within the broader field of over-elaborate recipes of his colleagues or public health that so far did not enjoy when he did not hesitate to dispute with wide consideration. However, already other doctors. The free spirit, the tension in the past his hygienistic approach was for searching, the love for discussion mentioned. In fact, the historian Arturo characterized his scientific attitude that was Castiglioni judged Ramazzini “the first accompanied by his love for literature. He and greatest among the teachers who had a clear clinical insight and deep sense taught hygiene with a deep knowledge of of observation and was acute also in other the evils and a high vision of the purposes fields. In fact, he was not only an able doctor, of social medicine”(3). Similarly, but also an astute scientist, whose interest Adalberto Pazzini in his treatise on the spanned from medicine to other fields of history of medicine included Ramazzini science. Although his fame is mainly owed among scholars who, such as Jenner and to the Diatriba (5, 6), the overall scientific Frank, gave special contributions in the contribution covers a wider range of topics field of hygiene, stressing that his works so far not yet well known and accounts for represent a “hygienic concept embracing his eclectic personality (7). any expression of social life”(4). The epidemiological approach Already Maggiora emphasized that The scientific and humanitarian Ramazzini’s observations were based thinking on an epidemiological approach (2). In fact, the Magister of Carpi anticipated Bernardino Ramazzini, born in Carpi the epidemiological principles based on in 1633, was a physician of great skill and the observation of pathological events in A pioneer of public health, Bernardino Ramazzini 275 communities. According to a well-defined breast”(13). Also this observation reveals method (8, 9), he focused the risk of disease a population-based approach, allowing in groups of individuals rather than in to recognize the awareness Ramazzini individuals, thus showing the originality had about the importance of lifestyle, of his thinking for, as a clinician, he was thus anticipating the observation of the used to deal with individual patients. relationships between nulliparity and Although his observations were mainly hormonal status of women (15). based on anecdotal case reports and However, the epidemiological numerical data are lacking, Ramazzini attitude of Ramazzini was not limited was accurate in describing the association to the Diatriba. Other papers follow between occupation or exposure and this approach. In the Costitutiones he disease (10). He reported that posture, described the epidemics of epizootic repetition of movements, weight lifting occurring in Modena in a 5-year period. and muscular overload were responsible The Costitutiones of 1690 and 1691 for a variety of musculoskeletal disorders, caught the attention of European scholars which presently represent a major cause and were published by the renowned of lost time from work and workers’ Academia Naturae Curiosorum. His disability (11, 12). He anticipated those achievement as a clinician and as an observations presently known as clusters acute observer well deserved the name when reporting an excess of mortality of of Hippocrates III given to him as a the inhabitants living in the proximity member of the Academia in view of the of a chemical laboratory in comparison studies of epidemic patterns according to to people living elsewhere. In fact, he the Hippocratic tradition (7). For these observed that “...it appeared that many reasons, Ramazzini was given the title more persons died in that quarter and of epidemiologist ante litteram (16) and in the immediate neighbourhood of his contribution is presently recognized the laboratory than in other localities. by epidemiology scholars (17). Moreover the doctor gave evidence that the residents of the neighbourhood Risk prevention, health protection and usually died of wasting diseases and promotion diseases of the chest; this he ascribed to Ramazzini focused his attention on a the fumes given off by the vitriol, which topic certainly unconventional and unusual so tainted the air near by...” (13). The at that time: the protection and promotion report was a proof of the open-minded of health. In the Diatriba’s preface, he approach towards a problem, which was stated that his main aim was “to suggest not peculiar of working environments medical precautions for the prevention and being also of public health concern. treatment of such diseases as usually affect Ramazzini was aware that lifestyle the workers” (13). He knew that dangerous was an important factor affecting women materials (such as mineral dusts, vegetal health (14), when he reported that particles and vapours) could be inhaled or “…cancerous tumors are very often absorbed through the lungs and identified generated in women’s breasts, and tumors different physical agents (such as noise of this sort are found in nuns more than excess, heat, cold and humidity) as in any other women. Now these are responsible for illnesses. Being aware caused…by their celibate life. For I have of the need to recommend preventing known several cases of nuns who came to measures, he showed a surprising attitude pitiable end from terrible cancers of the for a clinician. He suggested the adoption 276 G. Franco of preventive measures to eliminate Ramazzini encouraged the prince to follow hazards, although such measures cannot a beneficial lifestyle to prevent serious be considered much more than primitive illness and to achieve good old age. Another and not very effective interventions. He “text of good hygiene” (18) appeared in recommended to improve ventilation 1714, the year of his death: the commentary (“In order to purify that imprisoned air on Cornaro’s De Vita Sobria. In this work infected by the exhalations emitted from Ramazzini supplemented the text with his the minerals …superintendents of mines comments, focusing the praises of sobriety, regularly expel the thick stale air and providing personal hygiene advices and force in fresh and purer air

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