ARTICLE IN PRESS

Applied Ergonomics 35 (2004) 67–70

Bernardino Ramazzini’s early observations of the link between

musculoskeletal disorders and ergonomic factors
Giuliano Franco*, Leonardo Fusetti
Department of Internal Medicine and Medical Specialties, The School of Medicine and the School of Occupational Medicine,
Chair of Occupational Health, University of Modena, Largo del Pozzo 71, Modena 41100, Italy
Received 9 January 2003; accepted 30 August 2003

Abstract

Bernardino Ramazzini (1633–1714) systematically studied the relationship between work and diseases. He realized that it was not
possible to ascribe all workers’ diseases to chemicals or physical agents and foresaw that other factors were involved. He observed
that common diseases could originate following the maintenance either of prolonged stationary postures or of unnatural postures
(e.g. bakers, workers who stand, sedentary worker, scribes, weavers) or following activities requiring heavy muscular performance
(e.g. porters and woodworkers). Furthermore, Ramazzini recognized the need to undertake measures to prevent disorders from
repetitive motions and manual lifting and anticipated the now accepted advice of moderation and recommendations of reduction of
work duration for a number of hard jobs requiring a standing position or severe muscular effort. From his early writings therefore it
is evident that Ramazzini realized the importance of assessing the ergonomic factors associated with the occurrence of work-related
musculoskeletal disorders.
r 2003 Elsevier Ltd. All rights reserved.

Keywords: Occupational health; History of ergonomics; Work-related musculoskeletal disorders

1. Introduction Although as a formal branch ergonomics has a

Not specific to any type of job, work-related
musculoskeletal disorders (WMSDs) affect workers in
a wide variety of occupations, usually take months or
even years to develop and are a major cause of lost time
from work, workers’ disability, compensation claims
and health care costs (Hagberg et al., 1995; Institute of
Medicine, 2001). Since the 1970s, occupational factors
involved in the appearance of WMSDs have been
studied and since then researchers have pointed out
the relationship between WMSDs and ergonomic
factors in the workplace (NIOSH, 1997). Following
the observation of the increasing number of WMSDs,
defined as the ‘‘occupational epidemic of the 1990s’’
(Herington and Morse, 1995), among workers employed
in apparently safe tasks, the need to establish an
ergonomic approach in adapting work to man has
become a major concern.
*Corresponding author. Fax: +39-059-270866.
E-mail address: franco@unimo.it (G. Franco).
history of about 50 years (Wilson, 2000), observations
about the interaction between working individuals and
working environment dates back several centuries
(Marmaras et al., 1999). Among the authors who
foresaw the role of ergonomic factors in workers’
health, the contribution of Bernardino Ramazzini
(1633–1714) is worthy of being remembered (see
Fig. 1). He went beyond the usual doctor’s practice of
his time (which involved dealing with basic health
problems such as typhoid, smallpox and plague) and
began to investigate the role of work in determining
diseases (Franco, 2000). Ramazzini systematized the
then existing knowledge and gave a wide personal
contribution to the field by collecting his observations in
the ‘‘De Morbis Artificum Diatriba’’ (Diseases of
Workers) (Franco, 1999). The first edition of this work
was printed in Modena in 1700 (Ramazzini, 1700), while
the second one appeared in Padua in 1713 (Ramazzini
1713, 1983), where he moved at the beginning of the
century and where he died 1 year later. For his work in
describing clinical conditions associated with a variety

0003-6870/$ - see front matter r 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.apergo.2003.08.001
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68 G. Franco, L. Fusetti / Applied Ergonomics 35 (2004) 67–70

of occupations (Table 1), he is the worldwide recognized of the ‘‘De Morbis Artificum Diatriba’’), where ergo-
‘‘Father of Occupational Medicine’’ (Rosen, 1993). nomic factors and related clinical observations are dealt
This contribution aims at exploring the 112 points with, and it provides brief descriptions of the out-
Ramazzini reported throughout 29 chapters (out of 55 standing ones.

2. The observation of musculoskeletal disorders

Ramazzini realized that it was not possible to ascribe

the whole spectrum of workers’ diseases to the
characteristics of the working environment (chemicals
or physical agents) and foresaw that other factors were
involved in causing particular clinical pictures, above all
WMSDs. In fact, he observed that a variety of common
diseases could originate following irregular motions and
prolonged postures of the worker’s body. Ramazzini
described in several occupations (which are reported in
Table 1) clinical pictures which are usually included
among the WMSDs: sciatica, gibbus, valgoid condition,
hernia, pain in different parts of the body, fatigue,
arthritis, paralysis, lameness, shoulder dislocation and
muscular tension.

3. Linkage of the clinical picture with the ergonomic

factor

Fig. 1. Bernardino Ramazzini. Sculpture, main hall of the School of Although Ramazzini did not develop a detailed
Medicine, University of Modena. approach for the assessment of the factors associated
with WMSDs, he understood the relationship between
posture, repetition of movements, weight lifting, mus-
Table 1
cular load and certain disorders (Franco and Franco,
Syllabus of workers whose diseases are covered in the ‘‘De Morbis
Artificum Diatriba’’ (bold character identifies occupations associated 2001), allowing him not only to describe the anatomical
with the occurrence of musculoskeletal disorders) localization of the disorder, but also to identify intensity
and duration of the risk factor. The analysis of his work
Apothecaries Athletes Bakers and millers
Bathmen Blacksmiths Brick-makers allows, in 59 passages, the identification of specific
Carpenters Cheese-makers Chemists ergonomic factors which are associated with different
Cleaners of cesspits Confectioners Coppersmiths clinical pictures.
Corn-sifters and Corpse-workers Farmers The responsibility of biomechanical overload and
measurers awkward postures is identified and recognized as the
Fishermen Fullers Gilders
Glass-makers Healers by inunction Hemp flax, and silk-
cause of diseases affecting miners ‘‘I ascribe to certain
workers violent and irregular motions and unnatural postures of
Horsemen Hunters Laundresses the body, by reason of which the natural structure of the
Lutestring-makers Midwives Miners vital machine is so impaired that serious diseases
Nurses Oilmen Painters
gradually develop therefrom’’.
Plasterers and lime- Porters Potters
workers A prolonged stationary posture is held responsible for
Printers Razor and lancet Runners disorders in workers who stand ‘‘It is worth while
grinders discussing why standing, even for a short time, proves so
Sailors and rowers Salt-workers Sedentary workers exhausting when compared with walking and running
Soap-makers Soldiers Starch-makers for a long time. It is generally supposed that this is
Stone-cutters Sulphur-workers Tanners
The learned Tinsmiths Tobacco-workers because of the tonic movement of all the antagonist
Vintners and brewers Voice-trainers and Weavers muscles, both extensors and flexors, which have to be
Singers continually in action to enable a man to keep standing
Well-diggers Workers on minutes Workers who stand straight’’.
objects Unnatural postures are considered to be the cause of
Writers and notaries
disease among cobblers and tailors ‘‘Tailors are often
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G. Franco, L. Fusetti / Applied Ergonomics 35 (2004) 67–70
subject to numbness of the legs, lameness, and sciatica,
because while they are sewing garments they are, out of
necessity, obliged to keep one of the legs back against
the thigh’’, and other sedentary workers ‘‘who sit while
they work at their job, become bent, hump-backed, and
hold their heads down like people looking for something
on the groundy’’, including scholarly men, who y
‘‘physically inactive in proportion to the activity of their
minds and brains, suffer the drawbacks of a sedentary
life’’. Furthermore, ‘‘coppersmiths become humpbacked
besides, from that continual stooping over the work’’
and the same occurs to ‘‘goldsmiths who hammer gold
into the finest possible leaf’’.
The responsibility of musculoskeletal overload is
detected 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’’ and in porters who
‘‘become in time round-shouldered, because the dorsal
vertebrae are constantly bent forward and become set in
that position’’.
Fatigue as a consequence of heavy and prolonged
muscular performance is recognized in farmers ‘‘ythey
have to wrestle with unending toil and the direst poverty
on another man’s estate’’, in soap-makers ‘‘Any harm
that comes to these workmen from their work is caused
solely by excessive toil day and nighty’’, in weavers
‘‘This kind of work is certainly very fatiguing, for the
whole body is tasked, both hands, arms, feet, and back,
so that every part of the body at once shares in the
work’’, whose job is recognized as particularly danger-
ous for females ‘‘Now an occupation so fatiguingy
especially for women, for if pregnant they easily
miscarry and expel the fetus prematurelyy’’). Fatigue
is also reported in writers and notaries ‘‘First, constant
sitting, secondly the incessant movement of the hand
and always in the same directiony’’, among whom the
muscular overload of the arm and the progressive
impairment of the function are observed ‘‘yincessant
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’’.
4. Recommendations and suggestions for preventative
measures
Ramazzini did not only investigate workers’ WMSD,
but also emphasized the need for studying the working
process and identifying ergonomic hazards. In addition,
he observed that preventative measures should have
been adopted to eliminate hazards linked with discom-
forted posture and biomechanical overload. He re-
marked upon the responsibility of nobles in assuring
healthy working conditions, and formulated advice on
69
postural change (6 times), recommendations on the use
of specific individual devises (4 times), hygienic propo-
sals (11 times) and advice on lifestyle (9 times). The
approach could seem rough and incomplete but it
correctly interprets modern strategies for preventing the
occurrence of WMSDs. Such strategies involve pointing
out stakeholders’ responsibilities in the protection of
workers’ health, stressing workers’ responsibilities in
their own health protection and intervening on factors
within the work organization (for example by reducing
the exposure) (Buckle and Devereux, 2002).
The periodic interruption of the working activity and
the reduction of its duration is recommended for a
number of hard jobs requiring a standing position ‘‘It
follows that whenever occasion offers, we must advise
men employed in the standing trades to interrupt when
they can that too prolonged posture by sitting and
walking about or exercising the body in some way or
other’’ or a severe muscular effort. If on the one hand
Ramazzini suggests moderation to the workers involved
above all in hard jobs ‘‘I have no precautions to suggest
except this: They should be moderate and not overwork,
y’’, on the other hand he suggests physical exercise to
sedentary workers ‘‘They should be advised to take
physical exercise, at any rate on holidays. Let them
make the best use they can of some one day, and so to
some extent counteract the harm done by many days of
sedentary life’’ and ‘‘First of all, to repair the damage
that a sedentary life may bring on, physical exercise will
be beneficial, but in moderationy’’.
In foreseeing the importance of instruments aimed at
the prevention of WMSDs, Ramazzini’s pioneering view
is remarkable in the light of modern ergonomic
interventions, including health and safety programs
emphasizing primary prevention strategies aiming at
reducing the prevalence of WMSDs.
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