Monday, January 25, 2016

1700: Ramazzini describes occupational asthma

Figure 1 --
Bernardino Ramazzini (1613-1714)
Hippocrates was supposedly the first to write about a possible link between asthma and occupation.  Yet Bernardino Ramazzini was an Italian physician who defined occupational asthma as a common industrial lung disease.

Ramazzini was born in Carzi in 1633 and studied medicine at the University of Parma where he first became interested in occupational diseases.  He was the professor of practical medicine at the University of Moderna from 1682 to 1700 where he was appointed chair of theory of medicine.  It was during this time he extensively studied workers in various industries. He observed their working conditions, the symptoms they complained about, and he questioned them about their illnesses. (1)

Among his earlier investigations involved patients who developed sore, red, and burning eyes.  In an effort to help these patients, he  traveled to their workplace, which so happened to be among the sewage system.  By questioning workers, and investigating the workplace, he discovered a trend of severely red eyes among the workforce.  (4)(9, pages 95-107)

Perhaps it was this successful endeavor that set him off on a quest to investigate other occupations. He recognized that there were two types of diseases most prevalent among the occupations he studied, such as those associated with:

1.  "Certain violent and irregular motions and unnatural postures of the body." (9, page 5).

His work in this regard spotlighted a variety of occupations whereby the workers had diseases of their joints and bones. He therefore was the first to recognize the importance of good posture at work. (4)

2.  "Harmful character of the materials that they handle, for these emit noxious vapors and very fine particles inimical to human beings and induce particular diseases. (9, page 15)

His work in this regard spotlighted a variety of occupations whereby the workers had diseases of the eyes, mouth, nose, lungs, and other internal organs as a result of inhalation of fumes, gases, and dust at work. He therefore was the first to recognize the importance of good ventilation at work. (in 1743 Dr. Stephen Hales invented "The first mechanical ventilator")

In 1700, the same year he was appointed professor at the University of Moderna, the results of his observations were published as De Morbis Artificum Diatriba (Diseases of Workers), and then subsequently discussed among the medical community. (2)

Although, as J.S. Felton explains, it was not until the English translation of the Latin version of the book in 1940 by Wilmer Cave Wright that his works became "widely known." (2)

Of this, Felton said:
"Familiarization with the new English version led to multiple references to the wisdom of Ramazzini, probably the most frequently cited aphorism being an addition to the counsel of Hippocrates to physicians regarding the initial visit to a patient: 'When you come to a patient's house, you should ask him what sort of pain he has, what caused them, how many days he has been ill, whether the bowels are working and what sort of food he eats.' Following this citation, Ramazzini writes, 'I may venture to add one more question: What occupation does he follow?" (2)(9, page 15)
Wright's translation of "Diseases of Workers" was an easy read, and by reading it one should quickly garnish respect for the amplitude of work that went into his study of diseases of the workplace.  In his preface, Ramazzini explains: 
 "For we must admit that the workers in certain arts and crafts sometimes derive from them grave injuries, so that where they hoped for a subsistence that would prolong their lives and feed their families, they are too often repaid with the most dangerous diseases and finally, uttering curses on the profession to which they had devoted themselves, they desert their post among the living.  While I was engaged in the practice of medicine, I observed that this very often happens, and so I have tried my utmost to compose a special treatise on the diseases of workers." (9, page 7)
The first chapter of his book is dedicated to those most likely to develop high rates of mortality and morbidity due to their occupation, and this would include those working in poorly ventilated areas, such as would be the case for miners of gold, silver, copper, silver, etc. They, for example, and according to Ramazzini, inhale the dust, powder and fumes created deep under the earth, increasing their chances of developing...
Figure 2 --
Claudius Galen (129-200 A.D)

"...dyspnoea, phthisis, apoplexy, paralysis, cachexy, swollen feet, loss of teeth, ulcerated gums, pains in the joints, and palsy. Hence, the lungs and brain of that class of workers are badly affected, the lungs especially, since they take in which the air mineral spirits and are the first to be keenly aware of the injury. Presently, when those vapors have gained entrance to the dwelling-house of life and are mixed with the blood, they pervert and pollute the natural composition of the nervous fluid, and the result is palsy, torpor, and the maladies above mentioned. Hence, the mortality of those who dig minerals in mines is very great, and women who marry men of this sort marry again and again." (9, page 18)
Figure 3 --
Georg Wolffgang Wedel (1656-1721)
He was a German professor of
medicine and alchemy.
Such workers, especially those who mine or work with mercury, are also at high risk for developing asthma.  Ramazzini explains that he was not the first to recognize this.  He said Hippocrates described it, and he said Galen once told a story about how he entered the mine and observed the workers.  Ramazzini said:
Galen, in properties of simple medicaments, describes a cave that he saw was in Cyprus from which water was being carried out by the workmen for making green vitriol, and he says that he went down into a depth of about one-eighth of a mile and observed drops of green water dripping into a pool and was keenly aware of a suffocating and almost intolerable odor. He adds that he saw that the workmen, who were naked, carried out the water with utmost haste and ran back quickly; nothing, in fact, is worse for the lungs than acid of whatever kind, and vitriol there is a great deal of acid."
Figure 4 --
Daniel Sennert (1572-1637)
He was professor of medicine
at the University of Wittenberg,
and author of books on alchemy.
While ancient authors mentioned the harms caused by poisonous gases in mines, Ramazzini also gives credit to other authors.  Ramazzini said:
(Jean Baptist van) Helmont in his treaties On asthma and cough describes a kind of asthma which he classifies as something between dry and humid asthma and says that miners and refiners of metals, minters, and other such workers are liable to that asthma because of the 'metalic gas' that they inhale, which is so powerful that the vessels of the lungs are obstructed. Wedel (figure 3) in his Pathologia medica dogmatica (1692) speaks of 'miner's asthma' and says that workers in mines are liable to this ailment; he also says that Stockhausen published a whole treaties on this kind of asthma wherin he ascribed the cause of the malady to mercury of lead; for much mercury is present in lead and makes it heavy.  The same author explains how those metallic fumes bring about the cruel monster 'miner's asthma' by drying up the bronchia, but this is also caused, he thinks, by their being blocked by sooty smoke. Sennert (figure 4) in his work On the agreement and disagreement of chemists and Galenists (1619) relates that a doctor whose practice was at the metal mines of Meissen told him that in the corpses of miners had been found the metals that in life they had toiled to dig.  Statius (figure 5) in his invitation to Maximus Junius (Vibius) who was then living in Dalmatian Mountains, wittily describes that company of men doomed to Acheron who come up from the mines, as he says: "Pale from the sight of Dis (Pluto) and yellow as the gold unearthed." (9, pages 22-23)
Figure 5 --
Publius Papinius Statius (45-96 A.D.)
He was a Greek Poet.
So physicians observed long before Ramazzini the undesirable affects of inhaling fumes, dusts and powders from deep underground.

Ramazzini said efforts were sometimes made to protect workers, such as noted in the following passage:
In order to purify that imprisoned air infected by the exhalation emitted from the minerals and the bodies of the miners, also by the fumes of lighted lamps, superintendents of mines regularly expel the thick stale air and force in fresh and purer air by means of certain ventilating machines which they connect by shafts with the bottom of the mine...  It is evident that the ancients also paid great attention to the safety of miners, for, according to Julius Pollus (Emperor Commodius appointed him chair of rhetoric in the 2nd century), they used to cover their heads with sacks.  Over their faces they did loose bladders so that they could see through them without inhaling the pernicious dust; Pliny (the elder) says that this is done by polishers of inium.  Nowadays, especially in arsenic mines, they wear glass masks, a safer and neater device mentioned by (Athanasius) Kircher (in The subterranean world)(1665)." (9,page 27-8)
Athanasius Kircher (1601-1680)
He was a German author of 40 books
some of which were on medicine.
The inhalation of minerals, and the diseases caused thereby, are in no way, according to Ramazzini, limited to miners, as any person whose occupation involves working with minerals is at risk of disease, including all those who... (9, page 15)
"...shovel, smelt, cast, and refine the material that has been mined.  They are liable to the same diseases, though in less acute form, because they perform their tasks in the open air.  However, in the course of time the metallic fumes that they breathe make them short winded, splenetic (depressed), lethargic (tired), and in the end they pass into the class of consumptives (appearing to waste away)."  (9, page 31).
This class likewise includes "goldsmiths, alchemists, distillers of aqua fortis, potters, mirror makers, founders, tinsmiths, painters, and others." (9, page 15)

It also includes people who lived in areas around mines, or those who work or live near where such work is done.

So, as you can see, his book was, as noted by the authors of
the first comprehensive work on occupational diseases, outlining the health hazards of irritating chemicals, dust, metals, and other abrasive agents encountered by workers (6).
The book went through two editions.  The first, published in 1700, was a compilation of 42 "groups of workers."  The second, published a year before his death in 1713, was an enlarged version that included 12 more "groups of workers."  (11, page vii)

The following are the common occupations, or "groups of workers," he discovered to be linked to asthma and other pulmonary and similar disorders:
  • Miners: Inhalation fine particles of dust, powders and fumes of minerals in non-ventilated areas deep under the earth; they are closest to these elements, and are most likely to suffer the direst consequences, including asthma and other respiratory ailments. (9, pages 15, 21)
  • Gilders: They adorn objects with metals like gold to make them more beautiful. They inhale the fumes of the burned off metals, such as mercury, which is harmful to the entire body, especially the lungs and brain. (9, page 33)
  • Tinsmiths: Inhaling fumes while making such lightweight objects such as milk pails, basins, cake pans, bells, swords, etc. When it is heated, fumes of mercury are also inhaled, and this ultimately leads to respiratory complications, such as asthma. (9, page 59, 61)
  • Glass workers and mirror makers:  Caused by standing "continually half-naked in freezing winter weather near very hot furnaces... and at the day's end when work is over they must pass from that fiery workshop to colder places. Now no constitution however strong and robust can long endure such violent and sudden changes of temperature.  Pleurisy, asthma, and a chronic cough are the natural result... those who make mirrors become palsied and asthmatic from handling mercury." (9, page 63,65)
  • Gypsum and lime workers: They build columns for buildings and other structures of lime and gypsum, thereby inhaling the fumes and dust. He notes that "I have observed that those who persist in this kind of work nearly always die asthmatic and cachectic." (9, page 85)
  • Tanners: They inhaled fumes of decaying carcasses and chemicals used to tan hides, such as in the preparation of materials like leather, strings of musical instruments, etc. (9, page 131, 132)
  • Bakers: Inhalation of wheat, rye, and flour dust.  "Those who separate the flour from the bran with sieves or shake and turn over sacks, however they may protect their faces, cannot help taking in floating particles of flour with the air they breathe; these ferment in the salivary juice and stuff up not only the throat but the stomach and lungs too with a sort of paste, which makes them very liable to coughs, short of breath, hoarse, and finally asthmatic, because the trachea and pulmonary passages become lined with this crust and it hinders the free circulation of air." They also have a tendency to ailments such as colds and pneumonia due to working in places "kept very warm (as in winter)... and then going out into the cold air where "pores of the skin are seriously constricted."(9, pages 226, 227)
  • Millers: They develop asthma due to the inhalation of grain dust. "They must be continually whitened by the floating particles of flour; the grain is ground into the finest powder and the flying particles fill the mill-house, so that, willy nilly, the mouth, nostrils, eyes, and ears, in fact every part of the body is besprinkled with flour.  I have known many to become asthmatic from this cause and finally to lapse into dropsy."  (9, page 231)  Many credit this passage as the first description of baker's asthma. 
  • Grain sifters:  Fine particles of dust from wheat, similar grains, volatile salts, and "the residual dust and decay caused by the grubs, borers, and wevils (a beetle) that consume the grain and by other such corn pests and their excrements" in granaries and barns are inhaled.  "The pulmonary passages become coated with crust formed by dust, and the result is a dry and obstinate cough... and almost all who make a living by sifting or measuring grain are short of breath and cachectic and rarely reach old age; in fact they are very liable to lapse into orthopnoea and finally dropsy."  (9, pages, 243, 249)
  • Stone cutters (sculptors, quarrymen, etc): "When they hew and cut marble underground or chisel it to make statues and other objects, they often breathe in the rough, sharp, jagged splinters that glance off; hence they are usually troubled with a cough, and some of them contract asthmatic affections and become consumptive." Sand is sometimes found in their lungs, so the best remedy is "to to be as careful as possible not to breathe in those minute fragments by the mouth." (9, pages 249, 251, 253)
  • Carders: Those who comb and clean fibers of wool or silk before spinning, and particularly those who card flax and hemp, are exposed to "foul and poisonous  dust" that "flies out of these materials, enters the mouth, then the throat and lungs, makes the workmen cough incessantly, and by degrees brings on asthmatic troubles." Men who make silk rolls of silkworms, or otherwise comb them into fine threads, often die as consumptives, living short lives. (9, pages 257, 259)
  • Ragmen: A person who collects and sells rags that have been "wetted through with urine many a time and otherwise polluted, and in shaking and combing it they take in by the mouth a great deal of foul dust."  Others, such as the Jews, collect old rags to sell to paper makers.  In the process of stuffing them "into great sacks... there comes from it a wonderful and horrible stench, almost beyond belief.  From this sort of work they contract coughs, asthma, nausea, and vertigo."  (9, page 291)
  • Runners: Moderate running is fine, but "when one runs very fast the vesicle so the lungs are overinflated, and the blood flowing back through the... heart is checked in its course... so that it cannot flow freely into the vessels of the lungs; hence of necessity it stagnates in the head and provokes serious diseases" such as hernia and asthma.  They are also at risk for pneumonia due to exposure to the "wind and rain and clad in garments that furnish little protection; they are drenched with sweat, then chilled through, and thus the pores of the skin are stopped up, so that they cannot but be attacked by fatal diseases, especially of the respiratory organs which in running work hardest and become overheated. "This is why, nowadays, when runners have reached the age of forty, they are retired as unfit for this service and dismissed to public life."    ( (9, page 295)
  • Horseback Riders: Anyone who grooms (breaks or trains) or rides horses is likely to develop asthma for many of the same reason that runners develop asthma.   (9, page 303)
  • Porters:  They are likely to develop asthma due to the strain they put on their bodies from "loading and unloading merchandise from the cargo-ships...When a porter is in the act of hoisting a load on to his shoulders, he takes a deep breath, but from then on he breathes out very little; hence the pulmonary vesicles are far to much inflated, so that the vessels of the lungs that transmit and receive the blood cannot, owing to the pressure, perform their function properly; so it is no wonder that the blood vessels are easily ruptured from excessive distension... from the same cause, when the tonus of the thoracic muscles breaks down and the texture of the lungs becomes flaccid, porters soon become asthmatic..."  (9, page 311)
  • Farmers:  Mainly due to exposure to "the inclemency of the weather." They are at high risk of pleurisy, pneumonia, and asthma. Due to such exposure, "the whole mass of humors is excited to a febrile effervescence, and thus in the vessels of the lungs into which flows all the venous blood, thick and viscid humors readily stagnate.  This is why, as I have often noticed, whenever an epidemical constitution of lung disease begins to assault us, it gives the signal to attack first the country-people and completely dominates them." (9, page 337)
  • Professors/ Orators: They develop asthma because "all through the winter and spring they lecture from their platforms till they are hoarse, trying to instruct young students, and at the end of the season they demonstrate by their uneasy and asthmatic condition what serious ailments of the chest can be caused by such a strain on the voice; this applies to all whose occupation obliges them to overwork the voice. (9, page 389)
  • Athletes:
    Titus Maccius Plautus (254-14 B.C.)
    Ramazzini said he became exhausted and dyspneic
    after running too fast. Galen, Celsus, and Paul of Aegina,
    and Settalla and Guastavini, as well as others,
    also mentioned exercise induced injuries. 
    Vessels become congested, causing hernias, the often burst,
    causing pulmonary hemorrhage (spitting up blood)
    or hemorrhage of other parts of the internal body.
    Celsus advised runners with kidney trouble not to run.
    (9, pages 295-299)
    They are susceptible to apoplexy, cardiac syncope, suffocative catarrh, rupture of the vessels of the chest, and other causes of sudden death (probably even asthma).  "The principle cause of these maladies was excessive plethora (large amount) of the humors and distension of the blood vessels so that the circulation of the blood was either excessively retarded or altogether inhibited; there ensued in the veins 'interceptions' to use the Hippocratic term, i.e. stagnation of the blood and stoppge of all the fluids so that sudden death was the inevitable consequence." (9, page 319)  Due to linking athletics, running, and horseback riders to certain ailments Ramazzini is often considered the father of sports medicine.
  • Alchemists: From the inhalation of fumes they often become "palsied, blear-eyed, toothless, short of breath, and disgusting... for they must stand by and observe the whole process, enduring the test of fire and the fumes of coal, if their medicaments are to be properly prepared and prescribed with safety."
  • Potters: People who make pottery are exposed to the fumes of metals, particularly of "roasted or calcined lead for glazing their pots... their mouths,nostrils, and the whole body take in the lead poison that has been melted and dissolved in water; hence they are soon attacked by grievous maladies."  They become paralytic, splenetic (depressed), lethargic (tired), cachectic (thinned), toothless, and pthisical (wasting). 
  • Tobacco workers: "Those who make tobacco, breathe freely those bad odors and the flying particles of dust which when very fine are correspondingly sharp, so that they prick and dry up the delicate coats of the lungs and trachea." (9, page 143)
  • Painters: They develop asthma, chachexia, and melancholy from "the materials of the colors that they handle and smell constantly, such as red lead, cinnabar (a product of mercury), white lead, varnish, nut-oil and linsed oil which they use for mixing colors; and the numerous pigments made of various mineral substances." Painters make their paints using various metals because this makes them last longer, although they are also forced to inhale their fumes.  (9, age 67, 69)
  • Well diggers:  They are at risk of diseases of the chest, catarrh and cachexia because "every day they are hauled up drenched with sweat, partly from the digging, partly from the heat that settles in the well." (9, page 457)
  • Copper Smiths: They develop severe affections of the lungs (asthma?), for while they beat the copper with hammers, poisonous emanations arise from the hammered  copper and by the mouth enter the stomach and lungs, as they themselves admit." (9, page 437)
  • Printers:  They are susceptible to "pleurisy, pneumonia, and other diseases of the chest; for in winter they have to spend the whole day in rooms that are carefully shut up and as hot as an oven, if they are to do the work properly and dry the printed sheets.  When, later, they go from these warm rooms into the cold outer air they are very apt to incur constriction of the pores of the skin and perspiration is suddenly checked; hence ensue the ailments mentioned above." (9, page 419)
Ramazzini was a physician whose ideas were ahead of his time, or about 250 years ahead of his time.  Had his ideas been accepted, this would have probably prevented much morbidity and mortality, perhaps improving the quality of life, and the longevity of life, for workers exposed occupational hazards.  


  1. Franco, Giuliano, Francesca Franco, "Bernardino Ramazzini: The Father of Occupational Medicine," American  Journal of Public Health, September, 2001, 91(9), page 1382
  2. Felton, J.S., "The Heritage of Bernardino Ramazzini," Occupational Medicine, 1997, volume 47, number 3, pages 167-179
  3. Navarra, "Encyclopedia of Asthma and Respiratory Disorders," 2003, New York, 
  4. "Bernardino Ramazzini Facts,",, accessed 7/13/13
  5. Bernstein, David, editor "Asthma in the workforce," 1999, 2nd edition, New York, Marcel Dekker Inc. 
  6. "Bernardiino Ramazzini,",, accessed 7/13/13
  7. Hirschmann, Jan V., Sudhaker N.J. Pipavath, J. David Godwin, "Hypersensitivity Pneumonitis: A Historical, Clinical, and Radiologic Review," Radiographics,, November, 2009, Volume 29, Number 7, pages 1921-1938
  8. Jackson, Mark, "Asthma: A Biography," 2009, New York, Oxford University Press, page 67
  9. Ramazzini, Bernardino, writer,  "Disease of Workers," Wilmer Cave Wright, translator, 1964, New York, Hafner, page 243
  10. Ramazzini, op cit, pages 87-89; original quote by Plato from the following: Plato, "Republic," Book III.  A few passages later, Homer writes: "What profit would there be in his life if he were deprived of his occupation... but with the rich man this is otherwise, of him we do not say he has any specially appointed work which he must perform, if he would live.  He is generally supposed to have nothing to do.... if a man was not able to live in the ordinary way he (the god Asclepius) had no business to cure him; for such a cure would have been of no use either to himself, or to the State."  The Republic is a discussion between the Greek writer and philosopher Plato and his teacher, the Greek philosopher Socrates.
  11. Rosen, George, introduction to the 1964 reprint of Ramazzini's work "Diseases of workers," translated by Wilmer Cave Wright, pages v-ix
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