Ramazzini and the birth of occupational medicine
Lucia Dal Bianco
Bernardino Ramazzini, considered to be the founder of occupational and industrial medicine, was born in 1633 in Capri, a little town in the north of Italy, known nowadays because of its ceramics. Following the important innovations of the Paduan school of anatomy (Vesalius, Fabricius d’Acquapendente, and Harvey), he spearheaded the revival of the medical sciences, but encountered strong resistance from the adherents of the ancient Galeno-humoral theories.
Observations that one’s occupation or environment could cause disease may be traced back to antiquity. Already, in Ancient Egypt it was known that blacksmiths were literally “baked” in the furnaces they worked in, and that they protected themselves with rudimental face masks made of animal bladder.
The Roman poet and philosopher Lucretius (ca. 99–55 BC), writing in De rerum natura (On the Nature of Things), commented on the problems of working in gold mines, often leading to disease and death:
What direful stenches, too, from down below,
When men pursue the veins of silver and gold,
With pick-axe probing round the hidden realms
Deep in the earth?- Or what of deadly bane
The mines of gold exhale? O what a look,
And what a ghastly hue they give to men!
Georgius Agricola (1494–1555), born in Saxony, studied medicine at Leipzig and then at Bologna and Padua. In 1527 he began to practice medicine at Joachimsthal, an important silver mining center. There he studied the health conditions of miners, describing their diseases in De re metallica and suggesting preventive measures such as ventilation and wearing handkerchiefs over the face. He stated in his introduction:
“I have omitted all those things which I have not myself seen, or have not read or heard of from persons upon whom I can rely.”
||Girolamo Fracastoro (Fracastorius) (1478–1553) physician and scholar, was born in Verona and became professor at the University of Padua at age 19. In 1546 he proposed that epidemics were transmitted through direct or indirect contact by tiny particles or “spores,” perhaps chemicals rather than living particles. His theory remained influential for several centuries and was eventually replaced by the germ theory.||
Paracelsus, born in 1493 in Switzerland as Theophrastus Philippus Aureolus Bombastus von Hohenheim, started studying medicine in Basel at the age of 16. He may have gained his doctorate degree from the University of Ferrara. He held the chair of medicine at the University of Basel for less than a year and spent most of his life wandering through various parts of Europe. In 1525, after visiting mines in Hutenberg and Schwaz, he described the damage caused by exposure to poisoned air.
Bernardino Ramazzini graduated with doctorates in philosophy and medicine from the University of Parma in 1659. For twelve years he practiced as a public physician, but in 1663 was forced to come home because of malaria. For seven years he was a medical practitioner in Capri. In 1671 he moved to Modena, becoming an assistant to the physician of Duke Francesco II of Este, and was then elected full professor of medicine at the University of Modena. In 1691 he was promoted to “court physician.”
After the publication in Modena of his De Morbis Artificum in 1700, Ramazzini was invited by the Venetian Senate to become the chair of Practical Medicine. He became one of the leading professors at the Padua Medical School, remaining active until his death in 1714. He had become practically blind and had his grandsons help him by reading to him and taking dictation. He was buried in an “unmarked tomb” in the church of Beata Elena Enselmini in Padua, a convent of nuns for whom he had doctored. In 1914 at the bicentennial of his death, professor Arnaldo Maggiora of Padua University examined the remains buried in his tomb but thought they were not Ramazzini’s because “…who[ever] died at the age of eighty years could have hardly maintained such a robust and barely worn dentition and whose lean body certainly could not have produced such quantities of adipocere.” But in 2002, Professor of Medical History Zanchin and Professor of Pathology Terribile Wiel Marin at the University of Padua, Italy found in the same tomb a cranial segment of an old man “with a rather wide, tall and voluminous head.” This was carbon dated as 255 years old, compatible with the date of Ramazzini’s death.
Ramazzini’s early interest was in epidemiology, especially in the various plagues then ravaging his part of Italy. Expanding his studies to malaria, he was one of the first to support the use of the cichona-bark (plant from which quinine is derived), saying that quinine had done for medicine what gun powder had done for war, but stressing it should be used only for malaria because of potential damage when used indiscriminately for other diseases. He also studied and described chick-pea poisoning (lathyrism), characterized by spastic paralysis and pricking skin paresthesiae.
In 1700 the first edition of his monumental book De Morbis Artificum Diatriba, in 42 chapters plus the last chapter, ”Caput ultimum,” was published in Modena. It went through 21 editions, was translated into many languages and included in the Opera Omnia (Geneve 1714; London 1705; Padua 1918). An English translation appeared in London only a few years after the original Italian edition of 1700.
Diatriba, according to the ancient traditions was a critical satire of social relations, serving as a literary model for books of the 16th and 17th century in which the occupations of the time were characterized and satirized according to their individual vices (Goldman S. Sudhoffs Arch 1990;74 :1-21).
In his Diatriba, Ramazzini describes the health hazards of chemicals, dust, metals, and other agents. He also gives a valuable vignette of the social history of the working classes of his time. He thought it should not be beneath the dignity of a physician to visit the poorest workshops and study their medical hazards because “the shops or work-houses of trades-men are the only schools in which we can find any satisfactory knowledge of these matters.” It was only through such a direct approach that knowledge could be acquired and problems discovered. By his own reaction to bad smells in grim shops he recognized the relationship between migraine and osmophobia—the fear, aversion, or hypersensitivity to smells.
Ramazzini advised physicians:
“…..When you come to a patient’s house, you should ask him what sort of pains he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats… I may venture to add one more question: what occupation does he follow?” (CS Breathnach, Bernardino Ramazzini and his treatise of the diseases of tradesmen)
Ramazzini’s studies of occupational diseases and protective measures for workers were instrumental in factory safety and workmen’s compensation laws. For several hard jobs he recommended limiting exposure to toxic materials by periodically interrupting the working activity and reducing its duration. He first observed the musculoskeletal problems caused by inactivity or bad posture inherent in some jobs (carpenters, sawers, carvers, cobblers, tailors). He noted that midwives were subject to various diseases while breast feeding and risked causing infection during childbirth, and he recommended they wash their hands and arms in water and wine. He also studied the overtaxed minds of “learned men,” evincing an early understanding of psychosocial factors.
To his colleague physicians he recommended walking and running, and to the chair-bound dons he said:
“…The professors of Learning ought therefore to pursue the Study of Wisdom with Moderation and Conduct, and not be so eager upon the improvement of their Mind, as to neglect the body; they ought to keep an even Balance, so that the Soul and the body may like Landlord and Guest observe the due Measure of Hospitality, and do mutual Offices, and not trample one another under Foot.”
(Ramazzini, “A treatise of the diseases of tradesmen, and now done in English.” London. Andrew Bell and others. 1705).
Bernardino Ramazzini was ahead of his time: many of his recommendations were eventually adopted, especially in England, where the process of modernization was more advanced. Because of his concern for the safety of workers in their jobs, particularly in mines and in workshops, he is rightly considered the father of occupational and environmental medicine.
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DR. LUCIANO DALIENTO received his medical and post-graduate degrees in Cardiology and Internal Medicine at the University of Padua. Since 1986, he has worked as the Director of the Section of Pediatric Cardiology and the GUCH Unit, Division of Cardiology at the University of Padua. Presently, Daliento is a full professor at the Graduate Medical School, Director of Post-Graduate School of Cardiology, and Director of Post-Graduate Courses—all at the University of Padua. He has written various papers, abstracts and chapters in national and international journals and books on cardiology. He is also a member of GUCH-ESC Task Force and of the Consensus Conference in 2000. Additionally, he has served as a member of the Scientific Board of National Congress of Italian Society of Pediatric Cardiology (in the last 10 years), European Congress of Cardiology (1997, 1998, 1999 and 2000), and the II and III World Congress of Pediatric Cardiology and Cardiac Surgery (1997 and 2001).
LUCIA DAL BIANCO
Highlighted in Frontispiece Winter 2010 – Volume 2, Issue 1
Winter 2010 | Sections | Physicians of Note