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

By Giuliano Franco

Doctor at the court and academic of the Modena and Padua Universities, Bernardino Ramazzini (1633-1714) lived in the second half of the seventeenth century. Without renouncing to his vocation as a doctor, he visited the craft workshops to identify the threats to health, examined the diseases of workers and proposed a variety of preventive measures. Aware of the need to avoid extremes of all kinds, he recommended moderation in all types of behaviour. The expression «prevention is far better than cure» summarises his precept. Through the description of the context in which he lived and the analysis of his observations and proposals, the essay explores Ramazzini’s main works by revisiting his thinking in a contemporary way, highlighting the modernity of his anticipatory reflections and focusing on his visionary ideas.

• Language: English
• Publisher: Youcanprint
• Release date: Apr 10, 2020
• ISBN: 9788831663021

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Contents

Preface

Overview

1 - Introduction

2 - An all-around doctor and scientist

3 - The historical context

4 - Territory and demographic structure of the Duchy of Modena and Reggio

5 - Culture in Modena Capital

6 - Economy, techniques & technology of production in the seventeenth century

7 - Work and health:an epistemological relationship

8 - Work and health in Ramazzini’s thought

9 - Medicine and doctors in the second half of the seventeenth century

10 - The commitment to the health of peasants and artisans

11 - The Diatriba about workers’ diseases

12 - The Commentatio on princes’ disorders

13 - A semantic readingof the Diatriba

14 – Quam artem exerceas? What is your job?

15 - The epidemiological approach

16 - Residential proximityto environmental hazards:a paradigmatic case

17 - Health risks from exposureto metals

18 - Work-related lung disorders

19 - An eponymousof a work-related syndrome:the hypersensitivity pneumonitis

20 - Physical effort, poor posture and fatigue: the epidemicsof musculoskeletal disorders

21 - Stress on mind and body

22 - Health problems associated to nightwork and long hours of work

23 - Occupation and voice disorders

24 - Environmental noise and health

25 - Health problems from exposure to radiations, workplace heat and external climate

26 - Medications and risks to health

27 - Odours, headache, and hypersusceptibility

28 - Eye fatigue

29 - Work-related cancer

30 - Discovering the link between environmental hazard & risk to health

31 - Risk communication

32 - Old and new preventive approaches: hazard identification, risk assessment, and health protection measures

33 - Personal protective measures

34 - The theme of moderation in the Diatriba and the Commentatio

35 - Workers well-being and workplaces health promotion

36 - Sedentary job and physical activity

37 - Food intake

38 - Alcohol drinking

39 - Exposure to tobacco

40 - Inequalities and vulnerabilities: then and now

41 - Gender inequality and vulnerability

42 - Inequalities and vulnerabilities: ethnic minority workers

43 - Ethical issues in health protection of workers: a framework

44 - Principles and ethical virtues of the Diatriba

45 - First, do no harm and pursue the good

46 - An empathic attitude toward individual and people

47 - Serving the interest of the people and ignoring external pressures

48 - Love for study, willingness to improve, humanitarian attitude

49 - Fostering the integration of practical medicine (Medicina practica) and experimental research (Medicina theorica)

50 - Prevention is far better than cure

51 – On the development of risk prevention and workers health protection

52 - Occupational health & whole-person health

53 - The lesson of Ramazzini

54 - Afterwords. The legacy of the pioneering work of the Magister

Biographical notes, relevant historical events and other facts

Relevant quotations

Bibliography - 1. Ramazzini’s works and writings

Bibliography - 2. References

Figures & Table

Giuliano Franco

Prevention is far better than cure

Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini

(1633-1714) in public health.

Cover: Portrait of Bernardino Ramazzini, Philosopher and Physician of Carpi. Work by Anthony Stones based on the engraving by. G. Seiller (Geneva, 1716). From: Glass B, Stones A, Franco G. Diseases of Workers by Bernardino Ramazzini. A Tribute. Wellington: Department of Labour. 2000 (by courtesy of Anthony Stones).

© 2020 Giuliano Franco

This book is based on the Italian version Meglio prevenire che curare. Il pensiero di Bernardino Ramazzini, medico sociale e scienziato visionario published in 2015 (222 pages). The book has been thoroughly reviewed and enriched by illustrations of the Diatriba (1713 edition) and other writings. The text and notes have been reviewed and updated in the light of most recent scientific literature. This edition includes some biographical notes, a timeline of relevant historical events and other facts, the most relevant quotations of the Diatriba and other works, and a bibliography including both Ramazzini’s works (quoted in the text) and consistent scientific and scholarly references.

Title | Prevention is far better than cure - Revisiting the past to strengthen the present: the lesson of Bernardino Ramazzini (1633-1714) in public health.

Author | Giuliano Franco

ISBN | 9788831663021

© 2020. All rights reserved to the author

This work is published directly by the Author through the Youcanprint self-publishing platform and the Author holds all rights thereof exclusively. No part of this book can therefore be reproduced without the prior consent of the author.

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Preface

Busy occupational and public health practitioners who do not have the time to keep up with the burgeoning specialist literature may find it easier to ignore history completely. The result is an increasing distance between historians and practitioners, a situation that results in the impoverishment of a public health robbed of his historical perspective: the origins of disciplines, the scientists who contributed to their development, the research on which the practice is based¹. This essay proposes to the doctors, especially to the young doctors, but also to those who in different ways are involved in occupational and public health, a reading of Bernardino Ramazzini work (Figure 1).

The self-congratulatory and sometimes even iconoclastic impetus occasionally ascribed to Ramazzini’s works prompted me to reconsider the way how to treat the subject. This essay has neither the purpose nor the ambition to analyse the matter in the guise of a biographer or a historian, who I am not. It does not aspire to be included among the high quality and highly valued writings of several distinguished scholars, mainly historians, who wrote quite extensively about the Carpigian. Rather than a critical or a historical analysis of his writings to be compared with the works of most eminent scientists and philosophers of the recent and less recent past, it wants to be a simple educational and straightforward proposal for a modern rereading and revisitation of Ramazzini’s words. For this reason, that is to bypass some trivial or biased interpretations of his thought and to avoid the discussion of other analyses, Ramazzini’s own words have been widely reported². By limiting the historical references to those that could not be actually omitted, the essay endeavours to distil his lesson through the current experiences, thus removing disputable and ambiguous hypotheses, inconsistent judgments, questionable interpretations, and vested-interest statements. Therefore, this essay tries to let the Magister talk as far as possible and aims, through his words, to make comprehending the original and innovative character of the De Morbis Artificum Diatriba³ and other writings in the context of current advances in the field of occupational health. In Ramazzini’s words, readers will be able to discern his ancient, but ever vital contribute within the current trends and future challenges for both research and prevention in the field of occupational health and public health⁴. In such way, it is possible to appreciate that several, if not all, preventive and promotion interventions in workplaces find their ideal origins in the past as evidenced by the visionary words of an eminent doctor and social scientist⁵.

Overview

Although work-related disorders represent today a challenging issue from the economic, social and health point of view⁶, in the second half of the seventeenth century, the health of workers was not a priority for the states. Therefore, it may be surprising that a scholar paid attention to workers health conditions in a period characterised by a deep economic and cultural recession. Doctor at the Este court and academic at the School of Medicine of Modena, Bernardino Ramazzini was a brilliant clinician, a doctor who cared about humble’s health, a scientist who inquired into unusual realities⁷. He systematically analysed the relationship between the environment and disease by observing working techniques, describing work-related disorders and proposing preventive measures⁸. For his main work, the Diatriba, he is acknowledged as the founder of occupational medicine⁹.

In working environments, he identified the hazards that could harm health and caused specific disorders in individuals and in groups of workers who carried out the same activity. He classified diseases according to the type of job performed and described, in addition to several morbid forms of historical interest, still widespread pictures (bronchopulmonary pictures such as asthma in millers and hypersensitivity pneumonitis in those who sifted the cereals¹⁰, musculoskeletal disorders¹¹, psychosocial problems¹², noise damage¹³, breast cancer in nuns¹⁴), of which he suspected and sometimes understood the pathophysiological mechanisms.

Although a long scientific and regulatory journey has been made by introducing and refining methods and tools for the recognition of diseases, the diagnosis of work-related illness is mostly based on information gathered by the patient through work history. It was Ramazzini who first invited his colleagues to be rational¹⁵ and to always inquire as to a patient’s occupation since health is profoundly affected by the kind of work¹⁶.

Ramazzini’s interest went well beyond the description of clinical aspects of diseases. Sceptical about overuse and effectiveness of treatments of his time¹⁷, he was more concerned with prevention—prevention is far better than cure was his precept¹⁸. Ramazzini assumed that every preventive measure depended from the knowledge of risk¹⁹. He firstly identified and assessed the work-related risk and secondly, he suggested preventive measures. The risk assessment started from the observation of a morbid event not only in the single individual but also in the group of workers exposed to the same risk. In this way, he anticipated the modern epidemiological tool for the analysis of health status alterations both in working and in living environments²⁰.

As for preventive measures, he foreshadowed a variety of actions that are well established today. As for what today is called engineering measures, he suggested removing the polluted air emitted from the minerals and advised too that the best way to contain dust pollution was to carry the work in a spacious place and not in confined quarters²¹. As for what today is called organisational and administrative control, such as reducing the working time to limit the exposure to a risk factor, he recommended men employed in the standing trades to interrupt the too prolonged posture and suggested to women widely involved in hard jobs, «nothing in excess»²². This advice is often found in other pages, indicating the need to be moderate²³. The effectiveness of the suggested measures could be currently challenged; however, one should mention that his conceptual approach (firstly, identification of the hazard; secondly, mitigate the risk; thirdly, protect the individual) is consistent with preventive interventions now wholly established²⁴.

In addition to health problems directly linked to occupational risk factors, Ramazzini was attentive to those related to lifestyle and proposed measures to limit the risk by suggesting healthier behaviours²⁵. As to the sedentariness, he considered that the best thing was exercising the body and prescribed it first of all²⁶. As to obesity, although the second half of the seventeenth century was the time of severe famines, and that manual workers had resources just sufficient to obtain a frugal livelihood, Ramazzini reminded that those who live longer and who are less suffering from diseases are the same ones who lead a sober and simple life—a well-known truth²⁷. As to tobacco smoking that he defined an incurable and bad habit, Ramazzini was somewhat prophetic life— the vice will always be condemned and always maintained²⁸. As to wine consumption, Ramazzini claimed that nothing is more hostile, either openly or subtly than the unreasonable intake of wine, and drew the attention on the damages, not only physical, that its abuse could provoke²⁹. The set of indications in the works of Ramazzini shows how he anticipated the idea of considering the workplace as a privileged site to involve workers in health promotion programmes that aim to improve their well-being³⁰.

While current relationships between patient and doctors are based on the assumption that physician’s first and primary duty is to the patient and are founded on deontological codes originated from the ethical principles, in the second half of the seventeenth century it was not the time for a doctor-relationship strictly based on these values. Ramazzini regularly showed an empathic attitude towards his patients or workers. He also displayed effective communication skills when he explained to the workers what was necessary to do to protect health from occupational hazards³¹. The expressions manifested a paternalistic attitude typical of the doctor of that time towards the patient; they aimed to instruct the subject to take appropriate behaviour to avoid or limit exposure to hazards³². His messages always revealed his commitment to the patient’s welfare and his effort in helping patients to cope with illness but did not recognise any autonomy to individuals, who were mainly passive subjects³³. Although sometimes his frankness went beyond the political correctness boundary of our time³⁴, Ramazzini remained in sharp focus and respectful of any humble or vulnerable individual³⁵ and revealed an honest paternalism based primarily on the language of moderation³⁶. Although one can speculate on a certain grade of independence from the powers of the Church and the civil authorities³⁷, it could be asserted that the Diatriba, which is primarily inspired to the Hippocrates precept (first, do no harm), offers a view unquestionably aimed to protect and improve workers’ health³⁸. It is easy and perhaps even surprising to find some of these elements (beneficience, autonomy and justice) in current codes of ethics for health professionals, which guide and assist the ethical behaviour towards the various stakeholders: workers and their representatives, company, other public and private bodies, and colleagues³⁹.

In Ramazzini’s work, we find the elements that characterise current regulations to safeguard the health of those who work. He anticipated the well-established points and the current trends of occupational health: (i) understanding the association between environment and health, (ii) suspecting the working and environmental origin of every disease, (iii) suggesting interventions aiming at protecting workers health, (iv) promoting workers health issues by addressing sedentariness, lack of exercise, food intake, and any abuse⁴⁰. He proved far-sighted and prescient when he paid attention to the behaviour of individuals, to whom he recommended following a balanced lifestyle—advice more and more valued because life does not consist of simple living, but in being well⁴¹. His lesson remains alive and offers as a model of behaviour for every doctor, for the community of occupational health professionals, for those who practice in companies and the public health field⁴².

1 - Introduction

On 5 November 1714, Bernardino Ramazzini passed. His figure, work, ideas, message, virtues have been the subject of some celebratory events that have outlined his profile as a doctor, scientist, innovator, nonconformist spirit, enlightened genius, who lived in a period like that of the second half of the seventeenth century, characterised by a profound socio-economic and cultural recession that influenced every aspect of human life. Although it is difficult to add anything to the writings of historians⁴³ and the publications of scholars of the Magister⁴⁴ from Carpi, the commemorative events of the third century of his death represented an opportunity, not only repetitive and not only ritual, to focus on his thought⁴⁵.

It is worth mentioning, on the one hand, his innovative drive, which still today surprises in the light of the evolution of the protection regulations and on the other his curiosity towards natural phenomena that have made possible observations and discoveries in the meteorological and geological field documenting his vocation of a complete scientist. As regards the contribution in the medical field, it has been emphasised the modernity of teaching which, ignored for many decades and understood in its entirety only in the last century, is still utterly relevant today. Ramazzini’s lesson provides topical elements both for the medical practice in general and for the health protection of those who work. It cannot fail to amaze how Ramazzini, who lived in a period in which medicine is often practised by health professionals who sometimes took the form of the Commedia dell’Arte masks properly described by Molière in The Imaginary Invalid, stood as a critic, sometimes with lashing and mocking words, of the useless if not harmful practices of colleagues⁴⁶. He strongly recalled the importance of the practical medicine of which he claimed a role equal to that of theoretical medicine. He manifested his doubts about the efficacy of many popular treatments and censored the colleagues used to repeat prescriptions of drugs. On the other hand, he was a supporter of a simple medicine based on correct nutrition, rest and cleanliness. Such orientations were somewhat unusual and even daring at that time; some suggestions, regardless of the existence of the Inquisition, were in contrast with the influence of the Church regarding the cleaning of the body and the burial outside the churches.

Many are the innovative elements of his thought that could be exercised in the current medical profession. The understanding of the association between environment and health, the suspicion of an environmental origin of any pathology, the need to collect the working history of all patients are universal teachings that today constitute mandatory educational goals for medical students. Some other proposals are also popular: the prudent suggestions in undertaking therapy, advice aimed at adopting useful professional practices and the recommendations to show a compassionate attitude towards patients. The lesson for the occupational physician is also modern. Ramazzini proved visionary when, abandoning his vocation as a doctor who cared for the patient, proposed to visit workplaces to identify dangers and investigate the damage that the work environment produced on those who work. He used an approach that today we would call epidemiological. The procedure was based on the observation of the group of workers, on assessing the risk and on proposing some measures that today we would define risk prevention, health protection, and risk information. His precept, expressed in his Oratio xiii given in 1711 by the expression «longe præstantius est præservare quam curare» (prevention is far better than cure), still proves the preventive vocation of the Magister⁴⁷. Ramazzini also turned his attention to the behaviour of individuals. Aware of the need to avoid extremes of all kinds, he was inspired by the doctrine of classical philosophy when he recommended moderation in every sort of behaviour. Therefore, he advised «ne quid nimis» (nothing in excess), an indication expressing the need to follow a regular and balanced lifestyle. He also suggested healthy lifestyles (refraining from smoking, drinking wine moderately, controlling the passions of the soul) and recommended regular physical exercise for those who carried out a sedentary occupation and ventured to counsel temperance in the «venereorum usus» (sexual intercourse). All these indications demonstrate how Ramazzini anticipated the idea of considering the workplace as a privileged site to involve workers in health promotion programs that try to improve their lifestyle and well-being in a perspective that recognises health as a value⁴⁸. The ethical aspects of the work, which take on the characteristics of the virtues aiming at the good of the people and counteract inequalities, should not be neglected. His ethical attitude is demonstrated not only by his choice to begin medical practice away from the cities but also by the attention to the living conditions of people. Hence, Ramazzini showed those universal values that today are revived in a different form both in the deontological code of the medical profession and in the codes of conduct to which occupational physicians, in compliance with the law, must abide in the exercise of their function⁴⁹. The ethical and deontological aspects of Ramazzini thought are exposed and commented in chapters 43-47.

2 - An all-around doctor and scientist

In a considerable extent, Ramazzini owes his fame to his Diatriba⁵⁰ and historians and scholars have valued the figure above all for this contribution (Figure 2-2). However, at that time his fame was established for scientific merits for other works. During his stay in Modena, in the last decade of the seventeenth century, he carried out an intense activity of practical doctor, scholar and academic. His professionalism and courteous manners were appreciated by all⁵¹ so that it was the same Duke Francis II to summon him to court from time to time «for up an hour, to discourse and converse with edifying readings, discussion on literary matters, having felt the pulse»⁵². However, his observations of natural phenomena stimulated him and inspired his research activities. In addition to dealing with the investigation of mercury movement in the Torricelli tube, he described the surface of the territory of Modena and the geological structure of the land, of which he represented the hydrogeological section graphically⁵³.

Inspired by the Hippocratic lesson, Ramazzini devoted himself to the study of the relationship between climatic factors and the onset of diseases. He then published a series of geophysical writings that laid the foundations for studying the association between climate and disease⁵⁴ (Figure 3-2). The ingenuity and brilliance of the observations did not go unnoticed. The studies on the sanitary and climatological conditions of the territory were appreciated by European scholars and were worth the admission to the prestigious Caesareo-Leopoldina Academia Naturae Curiosorum⁵⁵. Similarly to other geniuses of the time who studied natural phenomena even outside the spheres of their profession, he proved himself a worthy researcher, endowed with a great depth of intellect and breadth of vision. The Diatriba is the work that made his figure immortal. In his work he gathered the observations made as a doctor and as an investigator of the territory, combining clinical remarks of the patient-worker with the description and analysis of working conditions, the environment, work techniques and related risks. In this way, he anticipated those researches on the diseases of the workers and those trends in the preventive field that will emerge after many years. He proved to be an acute observer of the working realities and nonetheless regularly showed an empathic attitude towards his patient, also displaying excellent skills as an experienced communicator when he explained to the workers (in reality, the doctors who read the Diatriba) what was necessary to do to protect health from occupational hazards. Some questions, perhaps rhetorical, could be formulated on the meaning of this work and the figure of the Magister. Is he a precursor of new ideas in the medical field? Is he an innovator in the social sphere? Is he the founder of a new discipline? Can he be considered an illuminist? Many historians analysed the work, discussed the context in which it was written, explored the contents, magnified the originality, thus helping to focus on the figure of Magister. His work is that of an exponent of the neo-Hippocratism who valued the practice of ancient medicine and represented a concrete medical-social conquest of the century⁵⁶. By addressing some of the so-called social determinants of health⁵⁷, he anticipated the future social medicine⁵⁸. Indeed, one cannot help but remember his aptitude for paying attention to the humble and disadvantaged conditions of the people’s life, as evidenced both by his choice to start medical practice far from the cities and by his thinking about behaviour and responses to the therapies of common people and wealthy nobles⁵⁹. Historians of the late nineteenth century recognised the value of the work⁶⁰. However, doctors took on the role of protagonists in assessing and appreciating more fully the value of the Diatriba. It was Maggiora who expressed himself in this way about the aims and contents of the work: «In foreseeing the real task of hygiene and convinced that the doctor’s office is not only to cure the sick but also to prevent diseases and to promote a general improvement in health, [Ramazzini] conformed to these concepts a good part of his wise and beautiful scientific work [...] the hygienic work almost all the result of very accurate original observations [...] still today worthy of consideration»⁶¹. And among those who claimed his figure as a «tutelary deity», it was mainly the occupational physicians, thanks to the studies of Luigi Devoto, to pay more attention to his personality and his works⁶². At the same time, other scholars expressed their admiration for the Diatriba, which was recognised as the first treatise on occupational medicine and an original text of preventive medicine⁶³. Ramazzini was acknowledged as the founder and father of occupational medicine⁶⁴ and other disciplines⁶⁵ and defined as an all-around scientist⁶⁶ for his curiosity for natural phenomena, his cultural polymorphism and his multifaceted scientific activity⁶⁷. To fully understand the manifestations of admiration and appreciation that have accompanied the history of the Diatriba it is necessary to place the work in the historical and socio-economic contexts that characterised the places where Ramazzini lived.

3 - The historical context

Bernardino Ramazzini was born on 4 October 1633 in Carpi⁶⁸, in the Duchy of Modena and Reggio, an independent State in the Northen Italian peninsula⁶⁹ (Figure 4-3). It was the same year in which Cardinal Bellarmino dragged Galileo Galilei before the inquisitors in a process that ended with the condemnation and dismissal of Galileo for Copernican theories. To understand his genius, we must consider the age in which he lived and the place where he worked. The period between the end of the Italian wars that reflected the wider European rivalries and the second decade of the seventeenth century coincided with the moment in which the Italian civilisation exercised its maximum influence on the western ones. Although there were considerable differences between the various territories in terms of development, population and wealth, Italy represented a model of cultural and scientific progress. In the Italy of the cities, there was a frantic development in the technical and commercial fields, goods and services were widely available, efficient governments of the territories limited the feudal rights of the princes⁷⁰. The development of sophisticated financial mechanisms in the economic field, the high quality of manufactured products, the renewal of the techniques of production of goods, the integration of agriculture with cattle breeding, the introduction of valid administrative tools guaranteed prosperity. This phase of growth continued throughout the sixteenth century until the early decades of the seventeenth century. The period from 1600 to 1618 represented the culmination of mercantile and manufacturing prosperity. Towards the twenties of the seventeenth century, the peninsula was hit by wars that contributed to eroding commercial potential and curbing manufacturing activities. It was the Thirty Years’ War in Germany that determined the initial crisis, while the conflict between Spain and Holland made commercial sea routes dangerous. The flourishing system was about to collapse. There was a drop in demand for goods, a decline in manufacturing production, a shortage of food products, and a fall in tax revenues. Pestilence transmitted by belligerent armies hit Italy. The plague epidemics of 1630 and 1656 and the occasional epidemics of typhus, smallpox and malaria involved significant sections of a population that, weakened by malnutrition, lived in precarious hygienic conditions. These conditions marked the commencement of a long period of famine and Italy prepared to face a deep economic recession.

At the same time, also due to the growing oppression of the Church against intellectuals and academics who were not loyal to the orthodoxy, Italy lost its cultural influence⁷¹. Western Europe assumed a role of increasing importance in the economic and cultural fields and witnessed the birth of the scientific method that opposed dogmatism. Thanks to research in the areas of mathematics (the analytical geometry started by Descartes, the infinitesimal calculus presented by Newton), of physics (Newton’s universal gravity theory, Boyle’s gas laws, Huygens’ wave theory of light) and the inventions in the field of technology (the adding machine of Pascal, the calculating machine of Leibniz) started the modern science. In the areas of biology and medicine, several scholars and doctors emerged (Harvey, van Leeuwenhoek, Redi, Boerhaave) whose contributions offered some of the basis on which modern medicine is grounded. The cultural and economic centre of gravity, therefore, shifted from Naples-Rome-Florence-Venice to Paris-Amsterdam-London. Italy thus ceased to represent the model of cultural development and technical innovation⁷².

The period was characterised by a deep recession affecting every aspect of life also in the territory of the Duchy of Modena. The social problem was alarming. The testimonies provided a dramatic picture of the situation⁷³. In this historical context marked by famine, epidemics and wars, the Magister conducted his studies, which led him in 1690 to hold the course De Morbis Artificum in the University of Modena and finally to publish the editio princeps of the Diatriba in 1700.

4 - Territory and demographic structure of the Duchy of Modena and Reggio

Due to the delegitimisation of the Este descent and the consequent devolution of the territory of Ferrara to the Papal States, Modena hosted Cesare d’Este, expelled from Ferrara by Pope Clement VIII and became the State capital on 29 January 1598⁷⁴. The status of the Este Duchy was strongly influenced by the relocation of the Court from Ferrara. Government and bureaucratic structure were transferred en bloc to the city, along with officials, staff and archives. Modena assumed the role of capital of the Duchy, but «in Modena the Court had to start from scratch, having arrived in tatters, an army of poor people without families and a future, led by a couple of bastards laden with children and debts, persecuted, or at best abandoned by the relatives»⁷⁵. Like other Italian cities, whose economy depended above all on agriculture and artisan processing, the territory of the Duchy was also involved in the decline of the peninsula. There was a decrease in population, stagnating prices, reduced trade, the crisis of many manufacturing activities, the contraction of agricultural production and cultivated area. If at the beginning of the seventeenth century the Italian population amounted to just under 14 million people, in the period between 1600 and 1660 epidemics caused a reduction estimated between 10 and 15%⁷⁶. At the same time, the population of Modena, which reached about 18,000 around the year 1620⁷⁷, decreased both due to the general demographic reversal and the effect of the plague⁷⁸. During the plague epidemics of the years 1630-31 and 1656-57 the mortality, even if lower than the values around 40% observed in neighbouring cities (Brescia, Verona, Padua), reduced the population of Modena to ten thousand inhabitants⁷⁹. Only after 1680, there was a slow but constant resumption of births and an increase in the number of inhabitants reaching 20,000 in the eighteenth century⁸⁰. The average population density was around sixty people per square kilometre, reaching about one hundred in the low plain. The urbanisation rate of the ducal territory was in line with the Italian one: 15% of people lived in the cities of the Duchy, while most of them lived in rustic houses and scattered villages in the countryside and the Apennines⁸¹. The economic decay of the period, which determined the progressive urbanisation of the peasants, accompanied by the lack of labour demand, made life in the city increasingly critical. The concern and intolerance of the citizens who feared the invasion of miserable crowds to threaten the order and public health led to the issuing of tenders against urbanisation, against all «crippled, full of sores, vagabond, gypsy and rascal» and to strengthen the guard at the gates of the walls to protect the city⁸². The establishment of the Opera dei Mendicanti with the charitable function of offering help to the poor and with that of the magistracy responsible for the census and control of beggars dated back to that time⁸³.

City structure and characteristics remained unchanged compared to the previous centuries. Modena had narrow streets, low arcades, poor hygienic conditions: «At that time the inhabitants of the city were allowed to keep all sorts of animals in their homes, including pigs. They threw excrement, bones, waste, debris and any other kind of rubbish in public streets and squares. Missing from paving, flooded by frequent floods and without any special commissioner or local staff in charge of cleaning, streets and squares always were cluttered with dust or mud, from trash, manure and all sorts of rubbish. It is easy to imagine the damage of aesthetics, hygiene and smell»⁸⁴. The disposal of sewage and the purging of the 42 sewers took place in the days dedicated to rest when work activities were suspended. In this regard, it is well known the episode described in the xiv chapter of the Diatriba that stimulated Ramazzini’s interest in exploring a topic overlooked. Not as well known is the appeal to the authorities of his colleague of Studio Francesco Torti about the necessity to provide for the coverage of the open-air canal facing the hospital because of the «stench that offends not only the sick [...] and beyond indecency makes the wall and beds very damp»⁸⁵.

5 - Culture in Modena Capital

In the European context, the economic and military importance of the Duchy was somewhat limited, and the events of the community were of little interest. Thanks to the protection accorded to letters and music, the figures of the Este Court are nevertheless worthy of attention⁸⁶. Like the sovereigns of other Italian States, the Este family was committed to preserving authority and legitimising its power through the organisation of celebrations, ceremonies, parties, games and shows⁸⁷. Festivals tended to support social cohesion through greater integration between the Court, aristocracy, personalities, and the people of Modena⁸⁸. They represented an opportunity for employment for artists and favoured some distribution of wealth deriving from the production of goods and services⁸⁹. The impulse given to culture, above all to music characterised that period⁹⁰. The cantatas, which together with other vocal works, represented the most widely cultivated genres, consisted of arias and recitatives produced on didactic and moralising themes within the framework of the Accademia dei Dissonanti⁹¹. Duke Francesco II also gave impetus to the theatrical movement even through the construction of new theatres, which he controlled both as regards the choice of performances, instrumentalists and singers. Among the singers, a prominent place occupied the young Margherita Scevina Salicoli, a virtuoso at