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Bernardino Ramazzini and his treatise of the diseases of tradesmen

Authors:
To be plain with you, I’ll tell you the Accident, from
which I took Occasion to write this Treatise of
Tradesmen ... I took notice of one of ‘em, that work’d
with a great Deal of Anxiety and Eagerness, and being
mov’d into Compassion, ask’d the poor Fellow why he
did not work more calmly and avoid overtrying himself
with too much Straining. This said, the poor Wretch
lift’d up his Eyes from the Dismal Vault, and reply’d,
that none but those who have try’d it could imagine the
Trouble of staying above four hours in the place, it being
equally troublesome with the striking of one blind.
This conversation began when Bernardino Ramazzini
entered the House of Office (or cesspit) at his home during its
triennial cleansing.
1
The only remedy for the cleaner, he was
told, was to run immediately home and spend a day in a dark-
ened room, washing the eyes now and then with warm water.
Other symptoms enquired into by Ramazzini were absent: no
heat in the throat, difficulty of respiration or headache; the
odour did not affect the sense of smell or occasion a
“Squeamishness”, but the worker volunteered the information
that he would be blind in a short time if he continued. Brass
and silver coins in the workers’ pockets blackened as did “Brass
vessels plac’d in Kitchens near the House of Office”, so that
Ramazzini suspected that a volatile acid arose from such places
when stirred, and he advised the use of transparent bladders
over the faces, “as they do who polish Red Lead, or to spend
less time ... or leave off that Business, and apply themselves to
some other Trade, for fear of being oblig’d, for the sake of sor-
did Lucre, to lose their Eyes, and so beg their Bread.”
Aware that some ‘Arts entail no small mischiefs upon the
respective Artisans, and that some means which keep up Life
... hurry them out of the World’, he ‘bent all my Force and
Thoughts upon writing a Treatise of the Diseases of
Tradesmen or Artificers’
1
As a result Ramazzini thought it not beneath his dignity to
visit the lowliest workshops and study for himself the mysteries
and medical hazards of metal miners, gilders, mercury
masseurs, potters, tinsmiths, glass workers, painters, sulphur
workers, blacksmiths and those who work with lime or gypsum.
In place of a twelfth chapter the author adds a cautionary foot-
note:
1
Thus far I have given an Account of such workmen as
are thrown into various diseases by the Malignity of the
Minerals and Fossils that they handle and use in the way
of their business ... This, therefore, is the chief Caution
to be observed in the Care of such Workmen, that it must
be short and expeditious, ... if Tradesmen do not recov-
er speedily, they will return to their Shops with the
Sickness upon them, and afterwards elude the prolix
Cures of Physicians.
With this astute warning he resumes his description of the
diseases afflicting apothecaries, fullers, oil-pressers, tanners,
cheese-makers and other slovenly trades, tobacco and snuff
workers, corpse bearers (never ‘an old one’), midwives, wet-
nurses, vintners and brewers, bakers and millers, starch makers,
stone masons, laundresses, flax and silk workers, bathmen, salt-
makers, workers who stand or who sit long, dealers in second-
hand clothes, couriers, grooms, postilions, wrestlers, those
working with small, minute things that strain the eyes, musi-
cians and singers, farmers, fishermen and soldiers.
He concluded his first History of the Diseases of Artificers
and Tradesmen with a short view of those of the Learned
World, hoping that the Men of Letters will not take it ill to
find themselves ranked in the Class of Tradesmen.
To the revised edition [1713] were added weavers, printers,
scribners, confectioners, coppersmiths, carpenters, steel-
grinders, brick-makers, well-diggers, sailors and oarsmen,
hunters and soap makers.
2
The first English translation
appeared anonymously in 1705,
1
and in 1746 Robert James
[1705-1776] included biographical details provided by
Ramazzini’s nephew with his version.
2
Illustrative excerpts
That the chemists were a danger to others as well as themselves
is obvious in an anecdote about a mighty Quarrel in Modena
when a Citizen sued a Merchant to move his Laboratory out
of town because of vitriol polluting the air so as to render it
unfriendly to the Lungs. .. [but] at last the Judge favour’d the
Merchant.
1
The case of a chymist of some Note, a trembling, blear-ey’d,
Toothless, short-breath’d rotten Fellow, whose very Looks
derogated from the Fame and Repute of the Cosmetick
Medicines that he us’d to sell, did not deter Ramazzini from
closing his chapter on the diseases of chemists ironically:
1
I should be sensible of offering an affront to the Chymists,
if I propos’d any Remedy whether Preservative or
Corrective for the injuries sustain’d in the way of their
Profession; upon Consideration that there ‘s scarce any
Disease, for which the Chymical Storehouse has not a
ready and effectual Remedy.
Childbirth was still largely in the hands of women so that
competitive acrimony did not arise with midwives who were
advised:
1
CS Breathnach
Department of Human Anatomy and Physiology, University College Dublin, Earlsfort Terrace, Dublin.
Bernardino Ramazzini and his treatise of the
diseases of tradesmen
68
literary & historical
“In fine, the Midwives that would perform their Office
without the Danger of Infection ought every now and
then, when they have any respite, to wash their Hands
and Arms in Water and Wine; after their Business is over
they ought to wash their Face and Hands in Water and
Vinegar, and shift themselves, and in a Word they ought
to take a nice care all a long to have clean Things about
‘em.
Ablutions were to protect the attendant, not the patient; the
admonition presaged Halsted’s concern for his scrub nurse in
1889,
3
not the insight into puerperal fever vouchsaved to
Semmelweis in 1847.
4
Nonetheless he understood that when
brick-makers ran a fever the remedy was not the purging and
venesection used for patrician patients but fresh water baths to
remove the grime and dirt caked on the skin, and so permit
sweating and the lowering of fever heat.
Like the midwives, the nurses who succeed them, Ramazzini
noted, are subject to various diseases in the course of suckling.
Long suckling could easily cause a consumption, regardless of
“whether it [milk] be generated of the Blood according to the
Ancients, or rather of the Chyle according to the Moderns”.
1
With Martianus, he “rejects the vulgar Error of tying up the
Nurses from their Husbands Embraces” citing erogeneity
among numerous reciprocal instances in the “wonderful
Sympathy between the Womb and the Breasts”.
The Mechanical Contrivance of Nature, by which Milk is
bred in the Breasts as soon as the Foetus is brought forth, and
even before as if it were contrived by some intellectual Being
[is beyond] the Ingenuity of Mankind, and all the Application
of Anatomists is not able to canvass it.
1
The secret that has
been sought after in vain by so many towering Geniuses before
1700 could safely be made the subject of a prize in 1665 when,
flushed after successful trials on the Thames, the inventor of the
double-bodied boat, boasted to Samuel Pepys:
5
..Among others, Sir Wm Petty did tell me that in good
earnest, he hath in his will left such parts of his estate to
him that could invent such and such things - as amongst
others, that could discover truly the way of milk coming
into the breasts of a woman – and he that could invent
proper characters to express to another the mixture of rel-
ishes and tastes....
Admittedly, the catamaran was subsequently wrecked in a
storm at sea, but the adventurer’s final will made on 2 May
1685, two years before he died a wealthy man, contains no
such bequests.
5
A gynaecological digression in the chapter on
the diseases of fullers, who used urine to clean wool and
woollen garments, may be noticed here:
1
Having upon this Occasion dwelt so long upon
Consideration of Urine, I can’t forbear mentioning what
I’ve observ’d oftener than once of the aperient Power of
Urine and its efficacy in bringing down the Terms. I know
several Nuns that after labouring under a suppression of
the Terms for several Months, without any relief from the
common Topicks, have recover’d a clear, light
Complexion by drinking their own Urine, which unlock-
’d the Obstructions and set the Terms agoing; in so much
that they make a familiar use of this Remedy.
The professions
Dirty trades were not the only source of danger, and his longest
section addresses the sedentary habits of those besprent with
learned dust – from which his colleagues are spared by accident
if not by sagacity:
1
The Physicians fare much better, I mean those of ‘em that
run about and visit their Patients, and mind chiefly the
Practice of Physick, for they are not subject to such a
Train of Diseases; and if they happen to be ill, they owe
their illness not to standing or sedentary Life, but to their
constant walking and running about. I have oftentimes
wonder’d how it came to pass, that when Epidemical
Diseases, such as malignant Fever, Pleurisies and other
popular Sicknesses, were raging all about, the
Practitioners of Physick ‘scaped free from a certain
Privilege as ‘twere tacked to their Profession; and upon
mature Consideration I am of the Opinion, this their
good Luck is not owing to the Caution, [but] to their
great Exercise; and to the Chearfulness of their Mind,
when they return with full Pockets from their Patients. In
earnest, I never observ’d the Physician to be so much out
of Order, as when no Body else is sick.
With a light touch he advises the chair-bound dons:
1
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.
Tis a pleasant and witty Saying that Plutarch says
Democritus was wont to have, viz: ‘That if the Body and
Soul were to sue one another for Damages ‘twould be a
doubtful Question whether the Landlord or the Guest
69
Figure 1: Title page of ‘The Diseases of Tradesmen’.
(Reproduced with permission of the President and Council of
the Royal College of Physicians of Ireland.)
were most Faulty’. And indeed we seldom find a just
Moderation between ‘em ... So that Plato’s Caution is very
just, namely, that we ought not to exercise the Body with-
out the Soul, nor the Soul without the Body.
Plato’s Soul, of course, being synonymous with our mind.
Author’s preface
The succeeding editions of The Diseases of Occupations, first
published by Donald Hunter [1898-1978] in 1955, provides
sufficient evidence of how the world of workers has changed,
and continues to change, since 1700,
6
but there is a timeless-
ness–and timeliness–about Ramazzini’s prefatory remarks.
Progress has a price:
1
So that we may justly assent,
that this necessity that inspires
the very Irrational Animals
with Ingenuity, as the source of
all Arts, whether Mechanick or
Liberal; which indeed are no
Trivial Good to Mankind, tho
this Good, like all other
human Things, is not without
Tincture of Evil. For we must
needs own that some Arts
entail no small mischiefs upon
the respective Artisans, and
that the same means which
keep up Life, and maintain
their Faculties, are oftentimes
the cause of grievous
Distempers, which hurry them
out of the World. Now, having
observ’d this frequently in the
course of my Practice, I bent
all my Force and Thoughts
upon writing a Treatise of the
Diseases of Tradesmen or
Artificers.
Aware that his own experience
could not be universal, he
implored:
1
So, I freely confess that what I
now publish is but an imperfect Performance, or rather an
Incitement to others to lend their helping hands, till an
intire and compleat Treatise is obtain’d, that may deserve
a place in the Commonwealth of Physick. Questionless,
we owe this piece of Service to the miserable Conditions
of Trademen, whose Handy-Works, even those of the
meanest and most sordid Production, are so advantageous
and necessary to Mankind: That debt, I say, is due from
Medicine, the subtlest of all Sciences, as Hippocrates calls
it, which gives relief to the Poor, and dispenses Cures
gratis.
Subtlety here is penetrative sagacity not beguiling craftiness:
In the mean time I hope all candid Physicians will excuse
my Imperfections, upon the Consideration that all Trades
are not follow’d and practis’d in one City or Country,
there being divers Trades according to the variety of
Countries that may give rise to Disease. The Shops or
Work-houses of Trades-men are the only Schools in which
we can find any satisfactory Knowledge of these Matters;
and out of such Places I have endeavour’d to pick what-
ever might best please the Taste of the Curious; and chiefly
indeed to suggest such Cautions as may seem to prevent
and cure the Diseases to which Tradesmen are usually
subject.
And he closes his preface:
1
When you come to a sick Person’, says Hippocrates, ‘it
behoves you to ask what Uneasiness he is under, what was
the Cause of it, how many Days he has been ill, how his
Belly stands, and what Food he
eats’: To which I’ll presume to
add one Interrogation more,
namely, what Trade he is of.
For tho’ this Question may fall
under the morbific Cause, yet I
reckon it very convenient, and
necessary indeed, when we
have to do with vulgar ordi-
nary Patients: but I find ‘tis sel-
dom minded in the common
Course of Practice, or if the
Physician knows it without
asking, he takes but little notice
of it: Tho’ at the same time a
just regard to that, would be of
great Service facilitating the
Cure. So I choose to publish
this Treatise of mine for the
good of the Republic, or at
least for the benefit of
Tradesmen: And tho’ ‘tis not
very Artfully writ, I hope the
Reader will vouchsafe it a civil
Reception
Da veniam Scriptis, quorum
non Gloria nobis Causa, sed
Utilitatis, officiumque fuit.
Life and labours
Bernardino Francesco Ramazzini
was born into a well-to-do family
in Carpi, 10 miles (16 km) north
of Modena, itself 20 miles westnorthwest of Bologna, on 4
October 1633.
2
After a classical education under the local
Jesuits, he entered the university of Parma in 1652, and gradu-
ated with doctorates in philosophy and medicine in 1659. For
12 years he practised as a public physician in the towns of
Canino and Marti, 40 miles northwest of Rome. He married
Francesca Righi, from Carpi, in 1665, and after an attack of
malaria he returned to the north to settle and practised in
Modena in 1671. After the 12th century university was restored
in 1678 he was appointed professor of theoretical medicine in
1682.
2
Ramazzini described an outbreak of lathyrism (chicken-pea
poisoning) in 1690 and several severe epidemics of malaria
between 1690 and 1695. It was his Modena colleague
Francesco Torti [1658-1741], professor of clinical medicine,
who in his 1712 treatise on the pernicious malarial fever intro-
duced the use of cinchona bark (quinine) into Italian practice as
well as the term malaria. However, it was Giovanni Maria
Lancisi [1655-1720] in describing the 1715 epidemic in Rome
who, while stating the doctrine of miasmata, had a clear
70
Figure 2: Bernardino Ramazzini. [1633-1714].
(Reproduced from Donald Hunter’s The Diseases of
Occupations. 1955. p 29. With permission from Arnold
publishers).
understanding of contagion and even hinted at the possibility of
transmission by mosquitoes (Culices).
4
De Morbis Artificum was published in Modena in 1700, and
its author was invited by the Venetian Senate to take the chair
of medicine in Padua. His eyesight began to fail in 1703 and in
1709 when he asked permission to retire he was promoted pres-
ident of the Venetian College. The extended, revised second
edition of De Morbis Artificum came out in 1713, a year before
his death.
2,6
Farrington can be excused for overstating Ramazzini’s undy-
ing claim to fame when he avers that Ramazzini was the
prophet of a new era, superceding the medical science and the
medical practice of two thousand years, by clear enunciation of
the view that medicine has a special duty to perform in safe-
guarding the health of the workers.
7
Less polemical but strik-
ingly memorable is Sigerist’s verdict that the place of the 1700
monograph in the history of occupational disease is equal to
that of the Vesalian De Humani Corpis Fabrica [1543] in
anatomy, Harvey’s De Motu Cordis [1628] in physiology, and
in pathology the De Sedibus et Causis Morborum [1761], in
which Morgagni describes Ramazzini’s fatal apoplexy.
2,8
Before and since
Occupational medicine had been included in De Re Metallica,
[1556] the work of Georg Bauer, more widely known as
Georgius Agricola [1494-1555], and in Bergsucht und anderen
Bergkrankheiten [1567], the posthumous treatise ‘on miner’s
consumption’ by Aureolus Theophrastus Bombastus von
Hohenheim, self-styled Paracelsus [1493-1541]. Although the
Paracelsian monograph excelled in clinical description, it was
the earlier publication which stressed the importance of dust,
remarking upon the high mortality in dry mines such as those
in the Carpathian Mountains where women are found who
have married seven husbands, all of whom this terrible con-
sumption has carried off to a premature death.
6
When the Paris hospital was re-established under the
Revolution, Xavier Bichat [1771-1802] and his industrious suc-
cessors had the benefit of a French translation Essai sur les mal-
adies des artisans prepared in 1777 by Antoine FranÁois
Fourcroy [1755-1809], the chemist-revolutionary who inex-
plicably failed to save Lavoisier from the guillotine in 1794.
9
From his appointment to the Necker [1816] and Charité
[1823] Hospitals in Paris until his death, René Théophile
Hyacinthe Laennec [1781-1826] introduced the wholly new
departure there of including patients’ occupations in progres-
sively more precise form in the case notes; records were sketchy
and incomplete in 108 cases but for 328 men (the majority
from building trades) and 234 women (mainly from clothing
services) occupation was faithfully recorded.
10
As Duffin has also shown this notable feature was excised by
Forbes in his mutilated ‘translation’ of De L’Auscultation
Médiate,
10
and was more honour’d in the breach than the
observance by William Stokes [1804-1878] in An Introduction
to the Use of the Stethoscope [1825] for it appears in but two of
the 16 cases culled from the literature in exemplification.
11
In
the wake of the Industrial Revolution Charles Turner Thackrah
[1795-1832], the general practitioner who was the moving
spirit behind the foundation of the Leeds medical school, pub-
lished a more extensive and complete monograph than
Ramazzini’s
.6,12
The first edition of The Effects of the Principal Arts, Trades
and Professions, and of Civic States and Habits of Living, on
Health and Longevity, with Suggestions for the Removal of
many of the Agents which produce Disease and shorten the
Duration of Life appeared in 1831 and an enlarged edition
came out the following year.
12
Donald Hunter’s Diseases of
Occupations, first printed in 1953, now in its eight edition
[1994] shows the same broad concept of occupational medi-
cine as Thackrah and Ramazzini.
6
As Franco has stressed, Ramazzini’s arresting, innovative
analysis of clinical presentation has overshadowed his perceptive
suggestions for prevention in hazardous occupations, an early–
if not the earliest – expression of the ‘modern’ concern for the
promotion of health and safety at work.
13
But the fumes which
blinded Chinese workers loading guano into ships’ holds on the
Pacific coast of South America in the nineteenth century and
the hazards facing farm-labourers cleaning liquid manure tanks
are modern reminders of the noxious vapours which first
aroused Ramazzini’s sympathetic attention and stimulated him
to compose his classic Treatise of the Diseases of Tradesmen in
1700.
14
Acknowledgements
Figures 1 and 2 are reproduced by kind permission of Arnold
Publishers (incorporating English Universities Press) and the
President and Council of the Royal College of Physicians in
Ireland respectively. I am grateful to Mr Robert Mills, Librarian
RCPI, for his bibliographic help, and to Mr Brendan Leeson
who prepared the illustrations.
References
1. Ramazzini B. A treatise of the diseases of tradesmen, and now done
in English. London. Andrew Bell and others 1705. pp. i-ii, v-vi, 28-
29, 54, 60-66, 76, 107, 108, 114-123, 261-2, 273.
2. Sakula A. Ramazinni’s De morbis artificum and occupational lung
disease. Br J Dis Chest. 1983; 77: 349-361, (includes bibliography
with quotations from W C Wright’s bilingual reprint published by
Haffner, New York in 1940).
3. Bloodgood JC. Halsted 36 years ago. Am J Surg 1931; 14: 89-
148.
4. Garrison FH. An introduction to the history of medicine.
Philadelphia. Saunders. 1917, 2nd ed. pp. 282, 300, 313, 370; 446.
5. Pepys S. The diary of Samuel Pepys, transcribed by R Latham and
W Matthews London. Bell and Hyman 1985; 6: 63
6. Hunter D. Diseases of Occupations. London. English Universities
Press. 1955. pp.24-33.
7. Farrington B. Medicine from ancient Greece to Soviet Russia,
Bristol Med-Chir J. 1942; 31: 45-56.
8. Sigerist H. Historical background of industrial occupational dis-
eases. Bull N Y Acad Med. 1936; 12: 597-609.
9. Fourcroy AF. Essai sur les maladies des artisans. Paris. Moutard.
1777.
10. Duffin J. To see with a better eye: A life of RTH Laennec.
Princeton. Princeton University Press. 1998:. 111-117, 212-213.
11. Stokes W. An introduction to the Use of the Stethoscope.
Edinburgh. MacLachlen and Stewart. 1825.
12. Black D. The spirit of occupational medicine. BMJ. 1979; 2:
1623-1626.
13. Franco G. Ramazzini and workers’ health. Lancet, 1999; 354:
858-61.
14. Zenz C, Cardasco EM. Hydroge sulfide in occupational medi-
cine, ed. C Zenz, OB Dickerson, EP Horvarth Jr. St Louis. Mosby.
1994; 3: 666.
This paper will form the subject of Dr Breathnach’s
valedictory address to the section of the History of
Medicine on a date to be arranged.
71
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‘There are many things that a doctor, on his first visit to a patient, ought to find out, either from the patient or from those present. For so runs the oracle of our inspired teacher: “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.” So says Hippocrates in his work Affections. I may venture to add one more question: what occupation does he follow? … I find that attention is hardly ever paid to this matter, or if the doctor in attendance knows it without asking, he gives little heed to it, although for effective treatment evidence of this sort has the utmost weight.’