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Bernardino Ramazzini (1633–1714): De Morbis Artificum
Historical Note
BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM Cesare G. Tedeschi, M.D.*
When a doctor arriv6s to attend some patient of the working class, he ought not to feel his pulse the moment he enters, as is nearly ahvays done without regard to the circumstances of the man who lies sick; he should not remain standing while he considers what he ought to do, as though the fate of a human being were a mere trifle; rather he should sit down . . . question the patient carefully and find out what the rtdes of his own profession and his duty to humanity require him to know. He shottld venture to add one more question: IVhat occupation does he follou ~t 9
.
by his c o n t e m p o r a r i e s and he was richly r e w a r d e d d u r i n g his lifetime with positions and emoluments. Nonetheless, the priceless worth o f his contribution did not b e c o m e a p p a r e n t nntil o u r times, when the
.
T h e postulate o f T h o m a s Aquinas that reason a n d faith are reconcilable finds a concrete example in this message o f h u m a n kindness and scientific vision. Indeed the study o f the life, deeds, attd sayings o f B e r n a r d i n o Ramazzini is an inspiration for all times a n d n o b o d y questions his claim to the nfighty title o f "amiens h u m a n i generis" bestowed on him by R. l'rosser White. However, he would ,tever have succeeded in e a r n i n g a p e r m a n e n t place in medical history if toward the end o f his life he had not t m d e r t a k e n the task o f depositing thirty years o f observation and u n h u r r i e d thinking in his De Morbis d r t ~ c u m - t h e first formal treatise on the Diseases of Tradesmen (1700). T h e vahte o f this work was recognized
Figure 1. Bernardino Ramazzini (1633-1714).
*Clinical ProFessor of Pathology, Boston University School of Medicine, Boston. Director of Laboratories, Research, and Education, Fra,ninghanl Union t lospital, Framinghanl, Massachusetts. -~From the preface of De MorbisArtificum. The Latin text of 1713 revised, with translation and notes by Wihner Cave Wright. Chicago,,The University of Chicago Press, 19t0.
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holistic concept of medicine gained almost universal acceptance. The irrevocable contribution of Ramazzini indeed lay in his having conceived the guiding principle that disease must not be looked upon in terms of organs or processes, but rather as complex interactions between the host, the agent, and the environment. Of all the environmental factors to which man is exposed, none is more intimate than the air he breathes. This did not escape the acute mind of Ramazzini, and many of the chapters of his De Morbis Artificum unequivocally bring forward, much ahead of his time, the recognition that volatile and solid wastes that pollute the air can be responsible for puhnonary disease. The characterization of the Seventeeuth Cent.ury as the age in which almost all seeds of science found fertile soil for colonization applies equally to Ramazzini's coherent scheme of pulmonary disease as a manifestation of occupational or environmental disorder. His praise of Olaus Borchius' opinion that the sharp particles found in the hmgs o f the stonecutters must be a conglomeration produced by the inhaled dust rather than a quid formed in the body itself; his conclusion, at the discussion of the postmortem findings in a potter of Copenhagen (reported in Acta Hafniensia) that the two major threats in the potter's trade are paralysis (due to lead poisoning) and lung disease (due to silicosis) and his general statement that "sharp and acid particles" introduced "per os et nares" can be responsible for pulmonary mortality and morbidity are the first fi'uits of the concept of the biologic causation of disease. With an independence of mind, able to inspire others with the faith and the conviction of an apostle, Ramazzini cannot be called a follower of any school of Iris time. At best he can be called a neoHippocratic, and it is not accidental that Lucas Schr6ck, the president of the Academie Caesareo-Leopoldina of Vienna (Curiosi Natnrae), bestowed upon him the mighty title of Hippocrates III. Breaking through the convention of centuries, he scorned the nebulous argumentations of the metaphysicists and in all his endeavors he applied exactitude and rigor of method. He thought it no indignity to descend into the wellsprings of Modena
and into the pits of the mines of the Apennines, taking careful notes on the fluctuations in pressure and temperature that occur at different depths and seasons. Overall, he became a friend of the workers, investigated the nature o f their occupations, and became acquainted with their miseries, needs, and physical disabilities. T h e method pursued by Ramazziniin essence, the rationalization of sciencewas within the culture and climate of his times. Among his contemporaries were the physicists Galileo, Newton, and Liebnitz, the astronomer Keppler, and the chemists Boyle, Kunkel, and Lemery. In the field of natural and medical sciences, Harvey, Malpighi, Valsalva, and Lancisi were making discoveries of epochal import. Easy interchange of scientific thought was being provided by printing with movable type, and an additional method for mutual exchange of experiences was being supplied by the rapidly expanding scientific societies, such as the renowned Academia dei Lincei in Rome, the Academia del Cimento in Florence, the Royal Society in London, t h e Acad6mie des Sciences in Paris, and the Hungarian Academia Natural Cureisorum. It was in the midst of cultural and scientific effervescence in the Seventeenth Century, on the fifth of November of the year 1633, that Bernardino Ramazzini was born. After attending a preparatory school in his native Carpi, a small town of high cuhural standards situated in the Duchy of Modena (North Italy), at the age of n i n e t e e n he enrolled at and attended for three )'ears the school of philosophy of the nearby University of Parma. Attracted both by law and medicine, at the end he resolved to follow the latter, and on February 21, 1659 (according to Koelsch, March 21), he received his diploma of Master of Arts and Doctor o f Medicine. Rome, an important medical center at the time, attracted him, and under the patronage Of the papal court he began medical practice in Canino and Marta, two small towns near Rome, in the province of Viterbo. Here he acquired malaria and he was advised to return to his native town, where he remained until 1671. During Iris stay in Carpi he met Francesca Righi, the descendant of a noble family of the town, who became his wife and the devoted
BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM--TEDESCm c o m p a n i o n o f his life. T h e y h a d three children, a boy who died at the age o f eight months a n d two daughters, Cecilia and Sigismnnda, who both became wives o f physicians. It was not long before Ramazzini made his entrance onto t h e stage o f academic life and to his r e n d e z v o u s with medical history. T h e Duche o f Este, Francis II, who was ruling at that time over the city o f Modena (a few miles f r o m Carpi), had just set the c o r n e r s t o n e o f an ambitious university (1678). A few ),ears later (1682) Ramazzini was invited to occupy the newly established chair o f T h e o r y o f Medicine. It was in M o d e n a that he met the physicist Leibnitz, who in 1690, as historiographer to the Duke o f Brunswick, was looking for evidence that the Houses o f Bruns~,'ick a n d Este descended f r o m the same stock. Leibnitz certainly exercised a great influence on the work that Ramazzini had u n d e r t a k e n on the oscillation o f m e r c u r y in the Torricelli tube. A humanist in the true sense, and a highly stimulating teacher, by word o f m o n t h a n d example he carried into the classroom the awareness that certain occupations are harmful and that it is the physician's duty to look for corrective methods to minimize the d a n g e r o f life that lurks in the depths o f the mines and in the ateliers o f the artisans. As he was about to publish Iris treatise on the "Diseases o f T r a d e s m e n , " he received the invitation f r o m the senate o f the Republic o f Venice to accept the second chair o f l'rolizssor o f Practical Medicine at the University o f Padua (1700). Ramazzini was sixty-seven years old. "An old tree always suffers if transplanted," he said, but he could hardly resist the h o n o r to sncceed Sanctorius, the father o f iatromechanics, and he accepted the chair. T w o years later (1702), at the summit o f his glory, the life o f the great master was t h r e a t e n e d by a h e a r t ailment to wlfich he almost succumbed. As Goodman says, "What a life he was spared for!" -Toward the end o f 1703 he began to suffer f r o m persistent headaches, and simuhaneously he lost partial vision o f his right eye a n d finally o f his sight ahogether. H e bore painflflly the loss o f reading, and
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Figure 2. Title page of original Latin edition (1700) of De Morbis Artificum.
progressively his m e m o r y failed him. U n d e r these conditions he t h o u g h t to retire, but the Council of the Republic insisted on his staying, n a m e d him I'resident o f the College o f Venice,* and coi)ferred on him the first chair o f Practical Medicine just m a d e vacant by the resignation o f his friend and colleague, Francesco Spoleti, who also had lost his sight following a violent blow on the head while attending the Venetian envoy to the T u r k s in Constantinople.'~ T h e s e ntis*This important college, founded in 1616, consisted of tile eight most distinguished professors of philosophy and medicine at the University. l'In his De Sedibus, Epistola XI1, Morgagni mentions that Spoleti was one of the two cases of blindness he had seen (the other was that of tile Count Aeneas Suardo) "when some parts of the brain subservient to the optic nerves are vehemently shaken or disturbed .... "
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HUMAN I'ATHOLOGY--VOLUME 1, NUMBER 2 June 1970 fortunes he b o r e with philosophic fortit u d e a n d he c o n t i n u e d to teach and to write. O f this period is the 1713 edition o f his De Morbis Artificum e n r i c h e d by twelve new chapters, fifty-two in all; an essay on the poet Ludovico Ariosto; the editing o f the fifteen a n n u a l orations a d d r e s s e d to his P a d u a n students; a "Treatise on the H e a l t h o f Princes" (De p~qncipum valetudine); a n d a dissertation against the excessive use o f China C h i n a (quinine), very m u c h in v o g u e at the time, which he dedicated to Iris affectionate nephew, B a r t o l o m e o Ramazzini, a u t h o r o f Iris V.ita, t h e n a practitioner in Modena. O n N o v e m b e r 5, 1714, on his eightyfirst birthday, as he was p r e p a r i n g to address his students, he suffered a violent attack o f apolSlexy, which in twelve hours' time put an e n d to his fife. Morgagni, Vallisneri, a n d A l e x a n d e r Knips M a c o p p e (who in 1727 succeeded to Ramazzini's chair) hastened to his house but their efforts were useless. It is a strange coincid e n c e that a whole t r a d i t i o n o f Italian scholars, Valsalva, M o r g a g n i ' s teacher, a n d Valsalva's teacher, Malpighi, Morgagni's most intimate friend, Ramazzini, a n d s o m e years later (1771) M o r g a g n i himself, all died o f that a p o p l e x y to the u n d e r s t a n d ing o f which they all h a d given so mttch t h o u g h t and effort. Ramazzini's mortal r e m a i n s are i n t e r r e d at the C h u r c h o f St. H e l e n in Padua. Ramazzini's case history, t o g e t h e r with that o f two o t h e r professors at Padua (Spoleti a n d Vallisneri), is p r e s e r v e d in Morgagni's The Seats and Causes of Diseases in the section Diseases of the Head, u n d e r the subtitle Apoplexy (Epistola I I I 9-9). T h e m o r e i m p o r t a n t parts o f the record, both an e p i t a p h to the distinguished colleague a n d an edifying perusal o f medical writing, are worth transcribing f r o m the English translation o f W i l m e r Cave Wright.
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Apoplexy carried off within twelve hours our distinguished colleague Ramazzini. Some time before, two aneurysms no larger than a bean had developed, one on the back of each hand and in precisely the same position, which is very rare. They were at the vertex of the angle made by the thumb and index finger. I remember that the good old man would often show them to me; they had appeared in the last years of his life. He told me too about the
violent palpitations of the heart that he suffered from earlier, and the no less violent hemicrania that followed these; and that Masieri, a surgeon of great experience, as we can see from his published works, had discovered what was very remarkable in so old a man, a separation of the sutures of the skull. I know that there are many cases of this in Bonnet, Supulchretum, Ettmtiller and others, but I do not know a case where it occnrred to such an extent in a man of 70, whicJa was'then Ramazzini's age. I am aware how hard it is, even by all the power of art, to disunite the sutures in old men. Before the apoplexy, when the palpitations aud hemicrania had ceased, he lost the sight, first of one eye then the other, and remained blind to the end. These iufirmities he wonld describe to me, for lie had an amiable opinion of nay abilities. Taking into account all the facts, I thought it highly probable timt the same cause that had formerly set up palpitations of the heart lind induced the hemicrania; that the bloodin certain arteries and perhaps in the choroid plexus also, was obstructed on account of those painful contractions, and these arteries were attacked by the same disorder (vitium) that was visible on each hand. As this gradually increased and pressed on the tlmlami of the optic nerves, it brought on the blinduess..At last, the coats of these small arteries burst, blood poured into the ventricles of the brain and caused the fatal apoplexy. As the body of this good old man was not dissected, I do not know whether or not my conjecture is correct. T h e w o r k o f Ramazzini unquestionably convinced Morgagni o f the value o f giving consideration to the occupations o f the subjects o f his dissections. O n e o f the indices o f the De Sedibus is specifically on the occupations o f the subjects that he dissected "so that if in the fi~ture a n y o n e wants to e x p a n d Ramazzini's T r e a t i s e De Morbis Artificum, he m a y h e r e find similar trades a n d the d a m a g e discovered in their cadavera." Despite the f a m e acquired as an e x e m plary p r a c t i t i o n e r o f xnedicine a n d dedicated teacher, Ramazzini would n e v e r have succeeded in e a r n i n g a p e r m a n e n t place a m o n g the benefactors o f m a n k i n d if he h a d not a d d e d new d i m e n s i o n s to the traditional medical a p p r o a c h , first by giving f o r e m o s t consideration to the socioeconomic factor in health a n d disease a n d second, by stressing the ecological a p p r o a c h in the relationship o f m a n to Iris total e n v i r o n m e n t . T h e fifty-two c h a p t e r s o f Iris De
BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM--TEDrSCHI
Morbis Artificum are organized according to a c o h e r e n t scheme and contain an epidemiologic truism universally appreciated today. Cleaners o f privies and cesspits, corpse bearers, wet-nurses, midwives, and learned m e n are i n t r o d u c e d in the pag.es o f his mighty treatise. However, his major c o n c e r n is for the miners and the artisans. Tile accurate r e f e r e n c e to the work o f others is indicative o f his perfectionism. T h e work o f Cesalpino "On Metals," o f Ettmiiller "On Respiratory Ailments," Jfingken "On Experimental C!lemistry," Kircher's "Subterranean World," Cesi's "Mineralogia," Valle's "Epidemics," Helmont's "On A s t h m a and the Cough," and many others are quoted again and again, humbly and courteously, and w h e n e v e r the occasion arises, he gives credit a n d pays h o m a g e ' t o the old masters. No topic is a p p r o a c h e d superficially or cursorily. T h e chapter on the tobacco workers (Chapter XVII) could have been written in o u r d a y s . T h e lungs o f the smoker and o f tlle tobacco worker, he says, "are m a d e flaccid and d r y . . . and gradually wither . . . . " But philosophically he adds, "This vice will always be cond e m n e d and always c h m g to." H e did not lack a sense o f h u m o r . In the c h a p t e r on the asthma and Cough o f the s u l p h u r workers (Chapter X), he mentions tlle story o f "an unfaithful wife who, when her h u s b a n d came home, hid her lover u n d e r the bed; to cover u p h e r crime, she threw over him a garntent that had been cleaned with sulphur, but by this she betrayed herself for the lover was choked by the smell o f fresh s u l p h u r and could not help c o u g h i n g and sneezing violently." But far worse fate, he writes, awaits the glass workers and m i r r o r makers (Chapter VII), who "in tile end join tile ranks o f consumptives, since their lungs become ulcerated, as has been clearly shown by the dissection o f their corpses." T h e same flmdamental questions posed by man's pollution o f the air in m o d e r n times are given intense scrutiny in Ramazzini's Treatise. T h e "case" described in C h a p t e r IV could be e n t e r e d with equal argumentations in the records o f any "court" operating in o u r time. A few years ago a violent dispute arose
between a citizen of Finale, a town in the dominion of Modena, and a certain businessman, a Modenese, who owned a huge laboratory at Finale where he manufactured sublimate. The citizen of Finale brought a lawsuit against tbis manufacturer and demanded that he should move his workshop outside tile town or to some other place, on tile ground that he poisoned the whole neighborhood whenever his workmen roasted vitriol in the furnace to make sublimate. To prove the truth of his accnsation, he produced tile sworn testimony of the doctor of ~Finale and also the parish register of deaths, from which it appeared that many more persons died annually in that quarter and in the immediate neighborhood of the laboratory than in other localities. Moreover, the doctor gave evidence that the residents of that neighborhood usually died of wasting disease and diseases of the chest; this he ascribed to the fumes given offby the vitriol, which so tainted the air nearby that it was rendered unhealthy and dangerous for the lungs. Dr. Bernardino Corradi, the commissioner of ordnance in the Duchy of Este, defended the manufacturer, wlfile Dr. Casina Stabe, then tile town-physician, spoke l%r the plaintiff. Various cleverly worded documents were published by both sides, and tiffs dispute, which was literally "about tbe shadow of smoke," as the saying is, was hotly argued. In the end the jury sustained the manufacturer, and vitriol was found not guilty. Whether in this case the legal expert gave a correct verdict, I leave to the decision of those who are experts in natural science. It is not surprising that t h e first chapter o f the book is dedicated to the diseases o f the miners. After all, he had descended many times to the depths o f the earth and m a d e m a n y friends a m o n g the miserable lot who d u g minerals. "I am sure," h e says, "that many of our own physicians would laugh at any other professor of the natural sciences if they saw him run the risk of descending to explore regions underground so as to investigate the bidden redesses of nature. I know how they laughed me to scorn when I was exploring tile sources from which the springs of Modena gush forth, a risky venture, and again when I went down into our petroleum wells situated among the nlountaius."
And he proceeds to describe the dyspnea (miner's asthma, dry and humid), phthisis, and cachexy that ~4ere harvesting suffering and death.
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H U M A N P A T H O L O G Y - - V O L U M E I, NUMBER 2 June 1970 " W o m e n who m a r r y men o f this sort," he writes, " m a r r y again and again. According to Agricola at the mines in the Carpatltian mountains, women have been known to marry seven times." I n all C h a p t e r s t h e r e is a n a p p e a l i n g h u m a n t o u c h . T h e subjec.ts o f R a m a z z i n i r e p o r t s a r e p r i m a r i l y d i s c u s s e d as p e o p l e r a t h e r t h a n as scientific m a t t e r . T h u s t h e book becomes the story of the pilgrimage o f a p h y s i c i a n s e e k i n g to p e n e t r a t e t h e suffering and anguish of mankind. Although Ramazzini did not revol u t i o n i z e m e d i c i n e as d i d M o r g a g n i , Bichat, or Virchow, he did far transcend t h e l i m i t a t i o n s o f his t i m e s . His i r r e v o c a b l e a n d p r i c e l e s s c o n t r i b u t i o n to m e d i c i n e lay in tim e c o l o g i c a l a p p r o a c h o f t h e r e l a t i o n s h i p b e t w e e n m a n a n d his o c c u p a t i o n a l a n d u r b a n en,~'ironment. I n so d o i n g , h e provided the foundations for the future development of two other disciplines: occupational and preventive medicine on which rest the foundations of modern s a n i t a r y science.
REFERENCES 1. Crookshank, F. G.: A Medico Literary Causerie: Bernardo Ramazzini and His Book. London, The Practitioner, New Series X, 1899, p. 300. 2. di Pietro, P.: B. Ramazzini, Epistolario. Modena, Stabilimento Tipografia Toschi, 1964. 3. Donoghue, F. D.: Bernardo Ramazzini. New Eng. J. Med., 207:695, 1932. 4. Farber, S. M., and Wilson, R. H. L. (eds): The Air We Breathe. A Study of Man and His Environment. Springfield, Illinois, Charles C Thomas, 1961. 5. Ramazzini, B.: De Mobis Artificum (Diseases of Workers). The Latin text of 1713 revised, with translation and notes by Wilmer Cave Wright. Chicago, The University of Chicago Press, 1940. 6. Ramazzini, B.: Diseases of Tradesmen. New York, Medical Lay Press, 1933. 7. Ramazzini, B.: Nel II1 Centenario Della Nascita (1633-1933). Commissione Internazionale Permanente Per La Medicina Del Lavoro (Collected Papers). Societa Italiana Di Medicina Del Lavoro. Milan, Tipografia Antonio Cordanl, 1934. 8. Tedeschi, C. G.: Giovanni Battista Morgagni, the founder of pathologic anatomy. The Boston Medical Quarterly, September, 1961. 9. White, R. P.: Ramazzini. Med. Lavoro, 24:328, 1933.
Framingham Union Hospital Framingham, Massachusetts 01701
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BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM Cesare G. Tedeschi, M.D.*
When a doctor arriv6s to attend some patient of the working class, he ought not to feel his pulse the moment he enters, as is nearly ahvays done without regard to the circumstances of the man who lies sick; he should not remain standing while he considers what he ought to do, as though the fate of a human being were a mere trifle; rather he should sit down . . . question the patient carefully and find out what the rtdes of his own profession and his duty to humanity require him to know. He shottld venture to add one more question: IVhat occupation does he follou ~t 9
.
by his c o n t e m p o r a r i e s and he was richly r e w a r d e d d u r i n g his lifetime with positions and emoluments. Nonetheless, the priceless worth o f his contribution did not b e c o m e a p p a r e n t nntil o u r times, when the
.
T h e postulate o f T h o m a s Aquinas that reason a n d faith are reconcilable finds a concrete example in this message o f h u m a n kindness and scientific vision. Indeed the study o f the life, deeds, attd sayings o f B e r n a r d i n o Ramazzini is an inspiration for all times a n d n o b o d y questions his claim to the nfighty title o f "amiens h u m a n i generis" bestowed on him by R. l'rosser White. However, he would ,tever have succeeded in e a r n i n g a p e r m a n e n t place in medical history if toward the end o f his life he had not t m d e r t a k e n the task o f depositing thirty years o f observation and u n h u r r i e d thinking in his De Morbis d r t ~ c u m - t h e first formal treatise on the Diseases of Tradesmen (1700). T h e vahte o f this work was recognized
Figure 1. Bernardino Ramazzini (1633-1714).
*Clinical ProFessor of Pathology, Boston University School of Medicine, Boston. Director of Laboratories, Research, and Education, Fra,ninghanl Union t lospital, Framinghanl, Massachusetts. -~From the preface of De MorbisArtificum. The Latin text of 1713 revised, with translation and notes by Wihner Cave Wright. Chicago,,The University of Chicago Press, 19t0.
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HUMAN PATHOLOGY--VOLUME 1, NUMBER 2 June 1970
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holistic concept of medicine gained almost universal acceptance. The irrevocable contribution of Ramazzini indeed lay in his having conceived the guiding principle that disease must not be looked upon in terms of organs or processes, but rather as complex interactions between the host, the agent, and the environment. Of all the environmental factors to which man is exposed, none is more intimate than the air he breathes. This did not escape the acute mind of Ramazzini, and many of the chapters of his De Morbis Artificum unequivocally bring forward, much ahead of his time, the recognition that volatile and solid wastes that pollute the air can be responsible for puhnonary disease. The characterization of the Seventeeuth Cent.ury as the age in which almost all seeds of science found fertile soil for colonization applies equally to Ramazzini's coherent scheme of pulmonary disease as a manifestation of occupational or environmental disorder. His praise of Olaus Borchius' opinion that the sharp particles found in the hmgs o f the stonecutters must be a conglomeration produced by the inhaled dust rather than a quid formed in the body itself; his conclusion, at the discussion of the postmortem findings in a potter of Copenhagen (reported in Acta Hafniensia) that the two major threats in the potter's trade are paralysis (due to lead poisoning) and lung disease (due to silicosis) and his general statement that "sharp and acid particles" introduced "per os et nares" can be responsible for pulmonary mortality and morbidity are the first fi'uits of the concept of the biologic causation of disease. With an independence of mind, able to inspire others with the faith and the conviction of an apostle, Ramazzini cannot be called a follower of any school of Iris time. At best he can be called a neoHippocratic, and it is not accidental that Lucas Schr6ck, the president of the Academie Caesareo-Leopoldina of Vienna (Curiosi Natnrae), bestowed upon him the mighty title of Hippocrates III. Breaking through the convention of centuries, he scorned the nebulous argumentations of the metaphysicists and in all his endeavors he applied exactitude and rigor of method. He thought it no indignity to descend into the wellsprings of Modena
and into the pits of the mines of the Apennines, taking careful notes on the fluctuations in pressure and temperature that occur at different depths and seasons. Overall, he became a friend of the workers, investigated the nature o f their occupations, and became acquainted with their miseries, needs, and physical disabilities. T h e method pursued by Ramazziniin essence, the rationalization of sciencewas within the culture and climate of his times. Among his contemporaries were the physicists Galileo, Newton, and Liebnitz, the astronomer Keppler, and the chemists Boyle, Kunkel, and Lemery. In the field of natural and medical sciences, Harvey, Malpighi, Valsalva, and Lancisi were making discoveries of epochal import. Easy interchange of scientific thought was being provided by printing with movable type, and an additional method for mutual exchange of experiences was being supplied by the rapidly expanding scientific societies, such as the renowned Academia dei Lincei in Rome, the Academia del Cimento in Florence, the Royal Society in London, t h e Acad6mie des Sciences in Paris, and the Hungarian Academia Natural Cureisorum. It was in the midst of cultural and scientific effervescence in the Seventeenth Century, on the fifth of November of the year 1633, that Bernardino Ramazzini was born. After attending a preparatory school in his native Carpi, a small town of high cuhural standards situated in the Duchy of Modena (North Italy), at the age of n i n e t e e n he enrolled at and attended for three )'ears the school of philosophy of the nearby University of Parma. Attracted both by law and medicine, at the end he resolved to follow the latter, and on February 21, 1659 (according to Koelsch, March 21), he received his diploma of Master of Arts and Doctor o f Medicine. Rome, an important medical center at the time, attracted him, and under the patronage Of the papal court he began medical practice in Canino and Marta, two small towns near Rome, in the province of Viterbo. Here he acquired malaria and he was advised to return to his native town, where he remained until 1671. During Iris stay in Carpi he met Francesca Righi, the descendant of a noble family of the town, who became his wife and the devoted
BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM--TEDESCm c o m p a n i o n o f his life. T h e y h a d three children, a boy who died at the age o f eight months a n d two daughters, Cecilia and Sigismnnda, who both became wives o f physicians. It was not long before Ramazzini made his entrance onto t h e stage o f academic life and to his r e n d e z v o u s with medical history. T h e Duche o f Este, Francis II, who was ruling at that time over the city o f Modena (a few miles f r o m Carpi), had just set the c o r n e r s t o n e o f an ambitious university (1678). A few ),ears later (1682) Ramazzini was invited to occupy the newly established chair o f T h e o r y o f Medicine. It was in M o d e n a that he met the physicist Leibnitz, who in 1690, as historiographer to the Duke o f Brunswick, was looking for evidence that the Houses o f Bruns~,'ick a n d Este descended f r o m the same stock. Leibnitz certainly exercised a great influence on the work that Ramazzini had u n d e r t a k e n on the oscillation o f m e r c u r y in the Torricelli tube. A humanist in the true sense, and a highly stimulating teacher, by word o f m o n t h a n d example he carried into the classroom the awareness that certain occupations are harmful and that it is the physician's duty to look for corrective methods to minimize the d a n g e r o f life that lurks in the depths o f the mines and in the ateliers o f the artisans. As he was about to publish Iris treatise on the "Diseases o f T r a d e s m e n , " he received the invitation f r o m the senate o f the Republic o f Venice to accept the second chair o f l'rolizssor o f Practical Medicine at the University o f Padua (1700). Ramazzini was sixty-seven years old. "An old tree always suffers if transplanted," he said, but he could hardly resist the h o n o r to sncceed Sanctorius, the father o f iatromechanics, and he accepted the chair. T w o years later (1702), at the summit o f his glory, the life o f the great master was t h r e a t e n e d by a h e a r t ailment to wlfich he almost succumbed. As Goodman says, "What a life he was spared for!" -Toward the end o f 1703 he began to suffer f r o m persistent headaches, and simuhaneously he lost partial vision o f his right eye a n d finally o f his sight ahogether. H e bore painflflly the loss o f reading, and
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progressively his m e m o r y failed him. U n d e r these conditions he t h o u g h t to retire, but the Council of the Republic insisted on his staying, n a m e d him I'resident o f the College o f Venice,* and coi)ferred on him the first chair o f Practical Medicine just m a d e vacant by the resignation o f his friend and colleague, Francesco Spoleti, who also had lost his sight following a violent blow on the head while attending the Venetian envoy to the T u r k s in Constantinople.'~ T h e s e ntis*This important college, founded in 1616, consisted of tile eight most distinguished professors of philosophy and medicine at the University. l'In his De Sedibus, Epistola XI1, Morgagni mentions that Spoleti was one of the two cases of blindness he had seen (the other was that of tile Count Aeneas Suardo) "when some parts of the brain subservient to the optic nerves are vehemently shaken or disturbed .... "
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HUMAN I'ATHOLOGY--VOLUME 1, NUMBER 2 June 1970 fortunes he b o r e with philosophic fortit u d e a n d he c o n t i n u e d to teach and to write. O f this period is the 1713 edition o f his De Morbis Artificum e n r i c h e d by twelve new chapters, fifty-two in all; an essay on the poet Ludovico Ariosto; the editing o f the fifteen a n n u a l orations a d d r e s s e d to his P a d u a n students; a "Treatise on the H e a l t h o f Princes" (De p~qncipum valetudine); a n d a dissertation against the excessive use o f China C h i n a (quinine), very m u c h in v o g u e at the time, which he dedicated to Iris affectionate nephew, B a r t o l o m e o Ramazzini, a u t h o r o f Iris V.ita, t h e n a practitioner in Modena. O n N o v e m b e r 5, 1714, on his eightyfirst birthday, as he was p r e p a r i n g to address his students, he suffered a violent attack o f apolSlexy, which in twelve hours' time put an e n d to his fife. Morgagni, Vallisneri, a n d A l e x a n d e r Knips M a c o p p e (who in 1727 succeeded to Ramazzini's chair) hastened to his house but their efforts were useless. It is a strange coincid e n c e that a whole t r a d i t i o n o f Italian scholars, Valsalva, M o r g a g n i ' s teacher, a n d Valsalva's teacher, Malpighi, Morgagni's most intimate friend, Ramazzini, a n d s o m e years later (1771) M o r g a g n i himself, all died o f that a p o p l e x y to the u n d e r s t a n d ing o f which they all h a d given so mttch t h o u g h t and effort. Ramazzini's mortal r e m a i n s are i n t e r r e d at the C h u r c h o f St. H e l e n in Padua. Ramazzini's case history, t o g e t h e r with that o f two o t h e r professors at Padua (Spoleti a n d Vallisneri), is p r e s e r v e d in Morgagni's The Seats and Causes of Diseases in the section Diseases of the Head, u n d e r the subtitle Apoplexy (Epistola I I I 9-9). T h e m o r e i m p o r t a n t parts o f the record, both an e p i t a p h to the distinguished colleague a n d an edifying perusal o f medical writing, are worth transcribing f r o m the English translation o f W i l m e r Cave Wright.
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Apoplexy carried off within twelve hours our distinguished colleague Ramazzini. Some time before, two aneurysms no larger than a bean had developed, one on the back of each hand and in precisely the same position, which is very rare. They were at the vertex of the angle made by the thumb and index finger. I remember that the good old man would often show them to me; they had appeared in the last years of his life. He told me too about the
violent palpitations of the heart that he suffered from earlier, and the no less violent hemicrania that followed these; and that Masieri, a surgeon of great experience, as we can see from his published works, had discovered what was very remarkable in so old a man, a separation of the sutures of the skull. I know that there are many cases of this in Bonnet, Supulchretum, Ettmtiller and others, but I do not know a case where it occnrred to such an extent in a man of 70, whicJa was'then Ramazzini's age. I am aware how hard it is, even by all the power of art, to disunite the sutures in old men. Before the apoplexy, when the palpitations aud hemicrania had ceased, he lost the sight, first of one eye then the other, and remained blind to the end. These iufirmities he wonld describe to me, for lie had an amiable opinion of nay abilities. Taking into account all the facts, I thought it highly probable timt the same cause that had formerly set up palpitations of the heart lind induced the hemicrania; that the bloodin certain arteries and perhaps in the choroid plexus also, was obstructed on account of those painful contractions, and these arteries were attacked by the same disorder (vitium) that was visible on each hand. As this gradually increased and pressed on the tlmlami of the optic nerves, it brought on the blinduess..At last, the coats of these small arteries burst, blood poured into the ventricles of the brain and caused the fatal apoplexy. As the body of this good old man was not dissected, I do not know whether or not my conjecture is correct. T h e w o r k o f Ramazzini unquestionably convinced Morgagni o f the value o f giving consideration to the occupations o f the subjects o f his dissections. O n e o f the indices o f the De Sedibus is specifically on the occupations o f the subjects that he dissected "so that if in the fi~ture a n y o n e wants to e x p a n d Ramazzini's T r e a t i s e De Morbis Artificum, he m a y h e r e find similar trades a n d the d a m a g e discovered in their cadavera." Despite the f a m e acquired as an e x e m plary p r a c t i t i o n e r o f xnedicine a n d dedicated teacher, Ramazzini would n e v e r have succeeded in e a r n i n g a p e r m a n e n t place a m o n g the benefactors o f m a n k i n d if he h a d not a d d e d new d i m e n s i o n s to the traditional medical a p p r o a c h , first by giving f o r e m o s t consideration to the socioeconomic factor in health a n d disease a n d second, by stressing the ecological a p p r o a c h in the relationship o f m a n to Iris total e n v i r o n m e n t . T h e fifty-two c h a p t e r s o f Iris De
BERNARDINO RAMAZZINI (1633-1714): DE MORBIS ARTIFICUM--TEDrSCHI
Morbis Artificum are organized according to a c o h e r e n t scheme and contain an epidemiologic truism universally appreciated today. Cleaners o f privies and cesspits, corpse bearers, wet-nurses, midwives, and learned m e n are i n t r o d u c e d in the pag.es o f his mighty treatise. However, his major c o n c e r n is for the miners and the artisans. Tile accurate r e f e r e n c e to the work o f others is indicative o f his perfectionism. T h e work o f Cesalpino "On Metals," o f Ettmiiller "On Respiratory Ailments," Jfingken "On Experimental C!lemistry," Kircher's "Subterranean World," Cesi's "Mineralogia," Valle's "Epidemics," Helmont's "On A s t h m a and the Cough," and many others are quoted again and again, humbly and courteously, and w h e n e v e r the occasion arises, he gives credit a n d pays h o m a g e ' t o the old masters. No topic is a p p r o a c h e d superficially or cursorily. T h e chapter on the tobacco workers (Chapter XVII) could have been written in o u r d a y s . T h e lungs o f the smoker and o f tlle tobacco worker, he says, "are m a d e flaccid and d r y . . . and gradually wither . . . . " But philosophically he adds, "This vice will always be cond e m n e d and always c h m g to." H e did not lack a sense o f h u m o r . In the c h a p t e r on the asthma and Cough o f the s u l p h u r workers (Chapter X), he mentions tlle story o f "an unfaithful wife who, when her h u s b a n d came home, hid her lover u n d e r the bed; to cover u p h e r crime, she threw over him a garntent that had been cleaned with sulphur, but by this she betrayed herself for the lover was choked by the smell o f fresh s u l p h u r and could not help c o u g h i n g and sneezing violently." But far worse fate, he writes, awaits the glass workers and m i r r o r makers (Chapter VII), who "in tile end join tile ranks o f consumptives, since their lungs become ulcerated, as has been clearly shown by the dissection o f their corpses." T h e same flmdamental questions posed by man's pollution o f the air in m o d e r n times are given intense scrutiny in Ramazzini's Treatise. T h e "case" described in C h a p t e r IV could be e n t e r e d with equal argumentations in the records o f any "court" operating in o u r time. A few years ago a violent dispute arose
between a citizen of Finale, a town in the dominion of Modena, and a certain businessman, a Modenese, who owned a huge laboratory at Finale where he manufactured sublimate. The citizen of Finale brought a lawsuit against tbis manufacturer and demanded that he should move his workshop outside tile town or to some other place, on tile ground that he poisoned the whole neighborhood whenever his workmen roasted vitriol in the furnace to make sublimate. To prove the truth of his accnsation, he produced tile sworn testimony of the doctor of ~Finale and also the parish register of deaths, from which it appeared that many more persons died annually in that quarter and in the immediate neighborhood of the laboratory than in other localities. Moreover, the doctor gave evidence that the residents of that neighborhood usually died of wasting disease and diseases of the chest; this he ascribed to the fumes given offby the vitriol, which so tainted the air nearby that it was rendered unhealthy and dangerous for the lungs. Dr. Bernardino Corradi, the commissioner of ordnance in the Duchy of Este, defended the manufacturer, wlfile Dr. Casina Stabe, then tile town-physician, spoke l%r the plaintiff. Various cleverly worded documents were published by both sides, and tiffs dispute, which was literally "about tbe shadow of smoke," as the saying is, was hotly argued. In the end the jury sustained the manufacturer, and vitriol was found not guilty. Whether in this case the legal expert gave a correct verdict, I leave to the decision of those who are experts in natural science. It is not surprising that t h e first chapter o f the book is dedicated to the diseases o f the miners. After all, he had descended many times to the depths o f the earth and m a d e m a n y friends a m o n g the miserable lot who d u g minerals. "I am sure," h e says, "that many of our own physicians would laugh at any other professor of the natural sciences if they saw him run the risk of descending to explore regions underground so as to investigate the bidden redesses of nature. I know how they laughed me to scorn when I was exploring tile sources from which the springs of Modena gush forth, a risky venture, and again when I went down into our petroleum wells situated among the nlountaius."
And he proceeds to describe the dyspnea (miner's asthma, dry and humid), phthisis, and cachexy that ~4ere harvesting suffering and death.
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H U M A N P A T H O L O G Y - - V O L U M E I, NUMBER 2 June 1970 " W o m e n who m a r r y men o f this sort," he writes, " m a r r y again and again. According to Agricola at the mines in the Carpatltian mountains, women have been known to marry seven times." I n all C h a p t e r s t h e r e is a n a p p e a l i n g h u m a n t o u c h . T h e subjec.ts o f R a m a z z i n i r e p o r t s a r e p r i m a r i l y d i s c u s s e d as p e o p l e r a t h e r t h a n as scientific m a t t e r . T h u s t h e book becomes the story of the pilgrimage o f a p h y s i c i a n s e e k i n g to p e n e t r a t e t h e suffering and anguish of mankind. Although Ramazzini did not revol u t i o n i z e m e d i c i n e as d i d M o r g a g n i , Bichat, or Virchow, he did far transcend t h e l i m i t a t i o n s o f his t i m e s . His i r r e v o c a b l e a n d p r i c e l e s s c o n t r i b u t i o n to m e d i c i n e lay in tim e c o l o g i c a l a p p r o a c h o f t h e r e l a t i o n s h i p b e t w e e n m a n a n d his o c c u p a t i o n a l a n d u r b a n en,~'ironment. I n so d o i n g , h e provided the foundations for the future development of two other disciplines: occupational and preventive medicine on which rest the foundations of modern s a n i t a r y science.
REFERENCES 1. Crookshank, F. G.: A Medico Literary Causerie: Bernardo Ramazzini and His Book. London, The Practitioner, New Series X, 1899, p. 300. 2. di Pietro, P.: B. Ramazzini, Epistolario. Modena, Stabilimento Tipografia Toschi, 1964. 3. Donoghue, F. D.: Bernardo Ramazzini. New Eng. J. Med., 207:695, 1932. 4. Farber, S. M., and Wilson, R. H. L. (eds): The Air We Breathe. A Study of Man and His Environment. Springfield, Illinois, Charles C Thomas, 1961. 5. Ramazzini, B.: De Mobis Artificum (Diseases of Workers). The Latin text of 1713 revised, with translation and notes by Wilmer Cave Wright. Chicago, The University of Chicago Press, 1940. 6. Ramazzini, B.: Diseases of Tradesmen. New York, Medical Lay Press, 1933. 7. Ramazzini, B.: Nel II1 Centenario Della Nascita (1633-1933). Commissione Internazionale Permanente Per La Medicina Del Lavoro (Collected Papers). Societa Italiana Di Medicina Del Lavoro. Milan, Tipografia Antonio Cordanl, 1934. 8. Tedeschi, C. G.: Giovanni Battista Morgagni, the founder of pathologic anatomy. The Boston Medical Quarterly, September, 1961. 9. White, R. P.: Ramazzini. Med. Lavoro, 24:328, 1933.
Framingham Union Hospital Framingham, Massachusetts 01701
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