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Work-related Musculoskeletal Disorders: A Lesson From the Past

Franco, Giuliano

doi: 10.1097/EDE.0b013e3181e0c6f4
History: Commentary

From the Department of Medicine and Medical Specialties, University of Modena and Reggio Emilia–School of Medicine of Modena, Modena, Italy.

Correspondence: Giuliano Franco, Department of Medicine and Medical Specialties, University of Modena and Reggio Emilia–School of Medicine of Modena, Largo del Pozzo 71, 41100 Modena, Italy. E-mail

Ramazzini's De Morbis Artificum Diatriba (Diseases of workers),1 published in 1700, has been described as a contribution to the development of occupational health as important as the contributions of what Vesalius' work to anatomy and Morgagni's to pathology.2 Bernardino Ramazzini (1633–1714) went beyond the study of usual health problems of his time (typhoid, smallpox, and plague),3 describing instead the health problems suffered by workers in particular occupations.4

Furthermore, Ramazzini understood that occupation hazards were not limited to exposure to chemicals (such as mineral dusts, organic particles, and vapors inhaled through the lungs or absorbed through the skin) or physical agents (such as noise, heat, cold, and humidity) but also included the effects of awkward body positions and movements:

“...the cause I ascribe to certain violent and irregular motions and unnatural posture of the body, by reason of which the natural structure of the vital machine is so impaired that serious diseases gradually develop therefrom” (Chapter I - Diseases to which miners of metal are exposed)

and the maintenance of prolonged stationary postures or postures requiring heavy exertion:

“I now wish to turn to other workers in whom certain morbid affections gradually arise from other causes, ie, from some particular posture of the limbs or unnatural movements of the body called for while they work” (Chapter XXX - Diseases of those who work standing).

Ramazzini understood how posture, repetition of movements, weight lifting, and muscular load could contribute to certain disorders (sciatica, gibbus, valgoid condition, hernia, pain in different parts of the body, fatigue, arthritis, paralysis, lameness, shoulder dislocation, and muscular tension). This allowed him not only to describe the anatomic site of the health problem, but also to identify intensity and duration of the risk factor in diverse occupations (Table).



Ramazzini observed that biomechanical overload and awkward postures caused disabilities in miners, and that musculoskeletal stress is a major cause of disease among potters,

“who sit at the wheel and turn it to shape the vessels...from excessive fatigue of the feet they are often subject to sciatica” (Chapter V - Diseases of potters)

and in porters,

“whose work is indispensable for loading and unloading merchandise from the cargo-ships...From carrying huge weights on their shoulders they too often suffer from various and even very serious diseases...the dorsal vertebral are constantly bent forward and become set in that position” (Chapter XXXV - Diseases of porters).

Prolonged stationary posture was associated with fatigue in pressmen, who

“have to stand incessantly at very fatiguing, for almost the whole body must be exerted in such a task; hence these workmen inevitably suffer from lassitude and intense fatigue” (Supplementum - Chapter I - Diseases of printers).

Ramazzini observed that standing

“even for a short time, proves so exhausting compared with walking and running, though it be for a long time” (Chapter XXX - Diseases of those who work standing)

and proposed a pathophysiological mechanism to explain the observation:

“It is generally supposed that this is because of the tonic movement of all the antagonist muscles, both extensors and flexors, which have to be continually in action to enable a man to keep standing erect” (Chapter XXX - Diseases of those who work standing).

Clinical consequences of unnatural postures are also described for sedentary workers

“who...while they work at their job, become bent, hump-backed, and hold their heads down like people looking for something on the ground...” (Chapter XXX - Sedentary workers and their diseases)

In particular,

“Tailors...often subject to numbness of the legs, lameness, and sciatica, because while they are sewing garments they are almost of necessity obliged to keep one of the legs back against the thigh” (Chapter XXXI - Sedentary workers and their diseases).

Ramazzini observed health disorders in writers and notaries:

“the maladies that afflict the clerks aforesaid arise...from constant sitting...the incessant movement of the hand and always in the same direction” (Supplementum - Chapter II - Diseases of scribes and notaries)

and concluded that the muscular overload of the arm led to a progressive impairment of the function:

“...incessant driving of the pen over paper causes intense fatigue of the hand and the whole arm because of the continuous and almost tonic strain on the muscles and tendons, which in course of time results in failure of power in the right hand” (Supplementum - Chapter II - Diseases of scribes and notaries).

In these workers Ramazzini recognized the potential for psychologic stress:

“the strain on the mind from the effort not to disfigure the books by errors or cause loss to their employers when they add, subtract, or do other sums in arithmetic)” (Supplementum - Chapter II - Diseases of scribes and notaries).

Ramazzini felt the need to provide workers with advice and recommendations advising the patient to limit himself, to be moderate and to avoid risks:

“Therefore in work so taxing, moderation would be the best safeguard against these maladies...; for the common maxim “Nothing to excess” is one that I excessively approve...” (Supplementum - Chapter IV - Diseases of weavers),

to limit the working activity:

“...we must advise men employed in the standing trades to interrupt when they can that too prolonged posture by sitting or walking about or exercising the body in some way” (Chapter XXX, Diseases of those who work standing),

and to do physical exercise:

“They should be advised to take physical some extent counteract the harm done by many days of sedentary life” (Chapter XXXI - Sedentary workers and their diseases).

In light of the recent increase of musculoskeletal disorders, representing a major cause of lost time from work, workers' disability, compensation claims and health care costs,5 it is appropriate to recall the lessons of Ramazzini. He anticipated the utility of epidemiology for discovering health problems, investigated the working environment to improve it, and provided workers with sound hygienic measures—sound even from the perspective of modern occupational health.

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1. Ramazzini B. De Morbis Artificum Diatriba. (Diseases of Workers). The Latin text of 1713, revised with translation and notes by Wilmer Cave Wright. (Chicago: The University of Chicago Press; 1940. Republished by: New York: The Classics of Medicine Library, Division of Gryphon Editions, Special edition; 1983.
2. Rosen G. A History Of Public Health. Baltimore: The Johns Hopkins University Press; 1993.
3. Franco G. Ramazzini's “De Morbis Artificum Diatriba” and society, culture, and the human condition in the seventeenth century. Int J Occup Environ Health. 2000;6:80–85.
4. Franco G. Ramazzini and workers' health. Lancet. 1999;354:858–861.
5. National Research Council and Institute of Medicine. Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Washington, DC: National Academy Press; 2001.
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