De Morbis Artificum Diatriba

The De Morbis Artificum Diatriba (Dissertation on Workers' Diseases) is the first book exploring working environments with the aim to identify the hazards that could harm health and cause specific disorders in individuals and in groups of workers who carried out the same activity (occupational diseases)(Di Pietro P 1999, Carnevale F et al. 2009). It was written in Latin by Bernardino Ramazzini and published in Modena in 1700. In 1713 the second edition was printed in Padua. For this work Ramazzini is the acknowledged father of occupational medicine (Pagel JL 1891; Garrison FH 1934) and the Diatriba has been cited by Adam Smith, Karl Marx, and Cotton Mather.

The birth of the Diatriba
The book describes Ramazzini’s observations made as a doctor and as an investigator of the territory, combining clinical remarks of the patient-worker with the description of working conditions and techniques, and related risks to health (Di Pietro P 1999). In 54 chapters the book reports health risks faced by workers in more than one hundred occupations and currently it is considered the first textbook of occupational medicine (Franco G 1999; Carnevale F et al 2009, Carnevale F 2016) and a precursor of  occupational health (Franco G 2021).

The Diatriba describes specific disorders in individuals and in groups of workers carrying out the same activity. Whereas some clinical pictures deserve only a historical interest, several disorders represent even today a health problem for specific groups of workers. Ramazzini proposed several precautions for the prevention of diseases whose basic idea, mostly based on common sense, was correctly conceived.

Musculoskeletal disorders
Much space is dedicated to the discussion of musculoskeletal disorders in workers employed in many jobs. Ramazzini understood that different morbid pictures were associated with postures, movement repetition, weight lifting, muscular load, which today define the ergonomic factors (Franco G & Fusetti L 2004). The Diatriba lists 26 different occupations, from brick-makers to sailors and from printers to writers and notaries, affected by all kinds of musculoskeletal disorders (Franco G 2010).

Stress-related health disorders
Ramazzini identified stress-related health disorders associated with circumstances involving high job demands and repetitive job activity. In addition to the continuous sitting responsible for sedentariness issues, he detected in accounting clerks the psychological stress to avoid mistakes or cause loss to their employers and keenly noted that an intense application of the mind harmed those workers (Franco G 2020a).

Breast cancer in nuns
Ramazzini described consumptive affections mostly in heavy occupations such as miners. However, he also made an explicit reference to tumors. In fact, he reported that breast cancers were very often found in nuns’ breasts more than in any other women. He explained that it might be due to their celibate life. This remark anticipated the observation between nulliparity and hormonal status of women by centuries. For this remark, Ramazzini has been acknowledged as a precursor in the search for the prevention of neoplastic diseases (Bode AM & Dong Z 2009).

Sensory system diseases and other disorders
He also observed diseases associated with the sensory system such as visual fatigue problems in people who did small objects (Franco G 2011), deafness among workers exposed to noise (Paladino ME et al 2023) and voice disorders and disphonia involving intense voice exercise (Franco G 2008).

The Diatriba reports morbid forms such as dust-related lung problems and serious neurological disorders associated with lead and mercury exposure (Riva MA et al 2018). It reports still existing clinical pictures and important widespread health problems: bronchopulmonary pictures such as asthma in millers and hypersensitivity pneumonitis, of which he understood the pathophysiological mechanisms (Bisetti A 1985). The book describes risks from excessive exposure to heat and sunlight and night work health troubles (Galimberti E et al 2014) and it was the first to report headaches from chemical substances.

Environmental pollution
The Diatriba reports an episode of chemical pollution associated with pathological pictures affecting the inhabitants who lived near a polluting site thus revealing that Ramazzini’s attention was not limited to the working environment but extended to the context of life. The episode is one of the earliest examples of chemical pollution associated with an increase in disease. Reporting of unexpected health damages represented yesterday and represents today, an alarm signal of a potential environmental problem of interest for public health. These observations have been valued as they anticipated modern epidemiological tools in work and living environments (Zocchetti C 2000).

Inequalities and vulnerability
Much attention was given to inequality and above all to the vulnerability that today remains a topic of great concern. He described health-related problems in ethnic minorities of that time and women. Women were usually employed in different occupations entailing exposure to dangerous materials and ergonomically challenging works, in agriculture and transport of stones and bricks, although they were committed to the production of commodities such as pasta, bread and clothing items (Franco G 2012).

Risk prevention and health protection
The Diatriba goes well beyond the identification of health risks in workplaces and description of the work-related diseases and also deals with risk communication, risk prevention and health promotion (Carnevale F et al 2015; Franco G 2021). It foreshadowed many interventions that are well established today: removing the polluted air emitted from the minerals and carrying out the work in spacious places, interrupting the prolonged posture, reducing the working time to limit the exposure to hazards, using personal protective tools (Franco G 2020b).

His main precept was given in 1711 in his ''Oratio xiii. De contagiosa epidemia''. On that occasion, he pronounced the well-known precept “far better to prevent than to cure”. This expression evokes the phrase he used some years later in the dissertation on nuns’ health that appeared in the 1713 edition of the Diatriba. He explained, with other words, the idea already expressed earlier, preaching this new message fully and with courageous perseverance.

Specific References
Bisetti A. La pneumopatia dell'agricoltore o malattia di Ramazzini [Farmer's lung or Ramazzini's disease. Med Lav. 1985;76:192-200 ]

[https://pubmed.ncbi.nlm.nih.gov/19536108/ Bode AM, Dong Z. Cancer prevention research - then and now. Nat Rev Cancer 2009;9:508-16]

Carnevale F, Mendini M, Moriani G. Introduzione. In: Ramazzini B. Opere mediche e fisiologiche. Cierre Edizioni, Verona 2009

[https://pubmed.ncbi.nlm.nih.gov/25504887/ Carnevale F, Iavicoli S. Bernardino Ramazzini (1633-1714): a visionary physician, scientist and communicator. Occup Environ Med 2015;72:2-3]

Carnevale F. Annotazioni al Trattato delle malattie dei lavoratori di Bernardino Ramazzini. Firenze: Edizioni Polistampa 2016

Di Pietro P. Bernardino Ramazzini. Biography and bibliography. Eur J Oncol 1999;4:255-317

[https://pubmed.ncbi.nlm.nih.gov/10485743/ Franco G, Ramazzini and workers' health. Lancet 1999;354:858-861]

[https://pubmed.ncbi.nlm.nih.gov/14985142/ Franco G, Fusetti L. Bernardino Ramazzini’s early observations of the link between musculoskeletal disorders and ergonomic factors. Appl Ergonom 2004;34:67-70]

[https://pubmed.ncbi.nlm.nih.gov/18656745/ Franco G. Ramazzini and workers' voice disorders. Otolaryngol Head Neck Surg 2008;139:329]

[https://pubmed.ncbi.nlm.nih.gov/20539112/ Franco G Work-related musculoskeletal disorders. A lesson from the past. Epidemiology 2010;21:577-9]

[https://pubmed.ncbi.nlm.nih.gov/21173140/ Franco G. Health disorders and ergonomic concerns from the use of microscope: A voice from the past. Am J Clin Pathol 2011; 135:170-1]

[https://pubmed.ncbi.nlm.nih.gov/22467901/ Franco G. Bernardino Ramazzini and women workers’ health in the second half of the seventeenth century. J Public Health 2012;34:305-8]

Franco G. Prevention is far better than cure - Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini (1633-1714) in public health. YCP 2020 (a)

[https://pubmed.ncbi.nlm.nih.gov/32087420/ Franco G. Revisiting the past strengthens the present: Bernardino Ramazzini and the new occupational health. Public Health. 2020;181:180-1 (b)]

[https://pubmed.ncbi.nlm.nih.gov/34483193/ Franco G. Bernardino Ramazzini's De Morbis Artificum Diatriba on Workers' Health-the Birth of a New Discipline. J UOEH 2021]

[https://pubmed.ncbi.nlm.nih.gov/24677127/ Galimberti E, Manzini F, Riva MA. Bernardino Ramazzini (1633-1714): an often forgotten pioneer in maritime health. Int Marit Health. 2014;65:41]

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1965705/ Garrison FH. Life as an Occupational Disease. Bull NY Acad Med 1934;12:679-94]

Pagel JL. Über Bernardino Ramazzini und seine Bedeutung in der Geschichte der Gewerbehygiene. Dtsch Med Wschr 1891;17:224-6

[https://pubmed.ncbi.nlm.nih.gov/37646190/ Paladino ME, Belingheri M, Mazzagatti R, Riva MA. Noise-induced hearing loss in pre-industrial era. Early contributions in "De Morbis Artificum" by Bernardino Ramazzini (1633-1714). J Laryngol Otol. 2023;30:1-11]

[https://pubmed.ncbi.nlm.nih.gov/29327285/ Riva MA, Belingheri M, De Vito G, Lucchini R. Bernardino Ramazzini (1633-1714). J Neurol. 2018;265:2164-5]

[https://pubmed.ncbi.nlm.nih.gov/11219205/ Zocchetti C. Bernardino Ramazzini epidemiologo ante litteram. Epidemiol Prev 2000;24:276-81]