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 by means of suggesting healthy lifestyle behaviour (7). certain ventilating machines”)(13), to These concepts were covered also in the wear masks (“Their habit of covering dissertation on health protection of nuns. the mouth with a linen bandage is a good Although his aim was to write, according one, but it is not enough to prevent the to the traditional Diatriba’s approach, a atoms of flour of making their way into chapter on diseases of the nuns, he preferred the innermost recesses of the chest along to devote to them an essay on health with the inspired air”) (13) or to limit the protection because longe gloriosus esse…a exposure time to dusts (“it is a good plan morbis præservare, quam eosdem curare, to stop working for a few hours in order a concept that will be resumed (…longe to breathe fresh air”) (13). præstantius est præservare quam curare…) Foreseeing the importance to enhance in the XIII Oratio given in 1711. health in term of personal resilience, Ramazzini encouraged healthy behaviours, Air, climate and water as when he advised “workers to abstain Since it was usual for a seventeenth from wine and still more from brandy” century doctor to extend his knowledge (13). Ne quid nimis (nothing in excess) beyond the professional activity, was his recommendation. This advice Ramazzini expanded his interest in permeated his medical writings as an studying the relationship between man and invitation to avoid exaggeration and to the outside world, analysing in particular seek moderation in all things: “Therefore the influence that environmental factors in work so taxing moderation would be may have on life and health. the best safeguard against these maladies, The theme of the unhealthy air was for men and women alike; for the common a constant of his works and included maxim “Nothing in excess” is one of an analysis of environmental factors to which I excessively approve” (13). assess their pathogenicity in order to A treatise on princes’ health (De prevent their effects. In addition to the Principum valetudine tuenda) was conceived already quoted episode of pollution, following the success of the Diatriba and other contributions are worthy to be appeared in 1710. The text followed the cited. In fact, he criticized the practice of pattern of investigation into workers’ burying the dead in churches, responsible diseases, by looking for the causes of illness for the disorders of gravediggers. This in a particular category of individual: the observation led to a revision of burial prince. What Ramazzini wrote was “true and rules according to a law requiring the good hygiene” (18). He wanted the body of definitive sealing of tombs in churches the prince to grow and keep healthy, but (7). An example of his interest in confined also for the prince to develop a strong and environment is shown in the dissertation oriented to the public good will. Therefore, about nuns’ health, when he recommended A pioneer of public health, Bernardino Ramazzini 277 keeping the air in the dormitory clean to possible and not to gaze at the iron while it avoid breathing air contaminated by bubbles and glows” (13). However, other exalations from their bodies. passages are more compelling (“...they He studied the climatic aspects of the must take every possible precaution…” Modena area in relation to the disease, and “we must advise men employed in following the hippocratic “On Airs, Waters, the standing trades to interrupt when and Places” model. He was among the they can that too prolonged posture by first to follow the trend of atmospheric sitting or walking or exercising the body pressure, humidity and weather conditions in some way or other”) (13). Elsewhere (sun, rain, wind) throughout the seasons. the message is more explicit to promote The data, systematically collected and greater awareness of risks and proper properly tabulated, were used to study the behaviours, as when he tried to persuade influence of climate. In the course of these the vintners to refrain from drinking or studies (which represented the basis for the when he insisted on the need to modify scientific study of the climate, a method that the working habits of the tobacco- many would later develop), he proposed workers. a change to the Torricellian barometer in Furthermore, Ramazzini realised that order to increase its sensitivity (7). prevention implied the joint effort of Another field of study is represented different stakeholders. In fact, he required by research on the springs in Modena. He other doctors to cooperate with him in undertook a geological and hydrological a joint effort to discover the causes of survey of the waters of subsoil published workers’ diseases (“the work...is merely in the De Fontium Mutinensium admiranda intended to incite others to lend a helping scaturigine (1691), including also medical hand until we obtain a really complete and notes. In discussing the hygienic quality thorough treatise”) (13). But he felt the of the water he showed to be aware of the need to cooperate also with experts in non- protective layers of clay and of the causes medical fields. As stressed by Maggiora of pollution of wells (18). (2), “hygienists of our time are convinced of the need not to limit the scope of their Education and cooperation investigations to the diseases that occur in Ramazzini anticipated the educational humans, but to extend them...to infection role of health professional (19). He was of animals...since many forms of disease a good interpreter of the physician’s role are common to humans and animals... towards education and felt the need to therefore hygienist felt the need to involve inform workers about risks. This attitude veterinarians to acquire the knowledge was permeated by a sense of paternalism necessary for defence against infectious typical of the clinician who has oriented diseases”. This concept was very much his activity as a duty towards workers. present in the mind of Ramazzini, who in His terminology was that of the clinician the Constitutiones epidemicae Mutinensis soliciting the patient to limit himself, annorum quinque, after describing the to be moderate and to avoid risks. weather events of the period 1690-95, This phraseology is simple and clearly provided an account of the infectious given. Workers must take precautions diseases afflicting humans and animals. (“workers of this class must take all This kind of observations continued until possible precautions not to inhale”) (13) the law made it mandatory to produce and should be warned (“the men should annual or extraordinary reports, entrusting be warned to turn their eyes as much as the task to health officials (18). 278 G. Franco

His attitude to cooperate was shown testifies a clear philanthropic attitude. For also by his research on the bovine this reason he was called a precursor of epidemics. In fact, in his XIII Oratio the Enlightment and his work represents De contagiosa epidemia, Ramazzini, a concrete medical and social conquest ruling out the causes generally advanced of that century (22). (air, pasture, astrological influence), recognized the sources of disease in sick animals and suggested “to bury the Conclusion carcasses of infected animals as deep as possible” (7). These observations Whereas Ramazzini’s Diatriba had a account for his ability to synthetize and great impact in the development of medical to interpret the data. sciences (5, 23) and its importance for hygiene is regarded to have the same value Community health and primary care of Morgagni’s text for pathology (24), Ramazzini’s scientific thinking other medical contributions account for his developed in the context of the Este fame. His overall scientific contribution is duchy in Modena in the second half of remarkable given the modern trend of public the seventeenth century. This period health. The modernity of Ramazzini’s was characterized by a deep recession thinking may be well appreciated by affecting every aspect of life in the browsing the topics covered in recent territory. Cultural, environmental and books of hygiene and public health used humanitarian aspects of health community for educating medical students and health stimulated his practice and research (20). professionals (25). In fact, most of the Although at that time medicine was a topics (from epidemiology to disease privilege of the rich, he displayed a deep prevention, from health protection to interest towards the poor, as proved by health promotion and adoption of healthy the choice to exercise his activity as a lifestyles, from the impact of environmental doctor in the countryside (7). In his III factors to health issues in education) were Oratio he encouraged young doctors to anticipated by Ramazzini. In conclusion, look after common people, who show a his scientific, cultural and humanitarian greater attitude to listen and to follow stature gives an account of the attribute medical cure and advice than noble and of pioneer of public health as he foresaw eminent people. Finally, his interest in several aspects of the classical Winslow’s community health was shown by his public health definition “the science and concern in describing the episode of art of preventing disease, prolonging pollution from a chemical laboratory, life and promoting health through the evidencing that already in the seventeenth organized efforts and informed choices of century a remarkable sensibility to public society, organizations, public and private, health problem existed. The great attitude communities and individuals” (26). of the Magister towards different aspects of community health is remarkable for a clinician, particularly of that time. In fact, Riassunto historians of the past (3, 4) and modern Un antesignano della sanità pubblica, Bernardino scholars (21) agree that Ramazzini had a Ramazzini (1633-1714) superior talent. His paternalistic attitude, accompanied by a sensibility towards Nel 2014 cade il trecentesimo anniversario della morte women (14) and vulnerable groups (20), di Bernardino Ramazzini, medico e scienziato vissuto A pioneer of public health, Bernardino Ramazzini 279 nel Ducato di Modena nella seconda metà del XVII 5. Rosen G. A history of public health. Baltimore: secolo. L’evento rappresenta l’occasione per ricordare The Johns Hopkins University Press, 1993. la sua opera anticipatrice delle attuali tendenze della 6. Ramazzini B. De morbis artificum diatriba. sanità pubblica. Modena: Capponi, 1700. 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Corresponding author: Prof. Giuliano Franco, Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia, Largo del Pozzo 71, 41100 Modena, Italy e-mail: [email protected]