Rough Skin: An Introduction

Abstract

We begin this chapter, and the book, with the tragic story of Mattio Lovat (1806), to introduce the then fairly new and little-understood disease, known in Italy as pellagra—literally, ‘rough skin’, after its primary manifestation. But dermatitis was only the first of the infamous ‘four Ds’, to which we can add diarrhoea, dementia and death. Italy and the United States would be the countries most affected by the disease, but pellagra was either epidemic, endemic or occasional in many other areas where maize cultivation and consumption was widespread. We suggest that what must have seemed like a positive agricultural development—the introduction of the Central American plant maize, with its prodigious yields and its ability to feed so many—had some unintended consequences in Italy over the course of the long nineteenth century. If it became a celebrated part of local culture and diet, because of its very success, maize cultivation altered longstanding landholding patterns and adversely affected peasant conditions and livelihoods. A combination of poverty and meagre diet resulted in endemic pellagra, with an estimated 100,000 sufferers in Italy by the late 1870s. We conclude this chapter by outlining the aims and structure of the book.

In March 1814, a London-based quarterly periodical called The Pamphleteer published the ‘Narrative of the Crucifixion of Matthew Lovat, Executed by his Own Hands at Venice’ (Ruggieri 1814a). The anthology’s publisher, the classical scholar A. J. Valpy, had an eye for the learned and the unusual, but this particular pamphlet was truly startling. It took the form of a medical case history of religious mania, as written by a Venetian surgeon named Cesare Ruggieri. Its protagonist, Matthew Lovat, was a pious young shoemaker in small village of Pieve di Zoldo in the Dolomite Mountains around Belluno (now more famous for its ski resorts). Lovat’s wishes to become a priest had been thwarted because of the family’s wretched condition. He became ill, ‘subject in the spring to giddiness in his head, and eruptions of a leprous appearance showed themselves on his face and hands’. The first sign of insanity came in July 1802, when Lovat, perhaps feeling the ‘stirrings of the flesh against the spirit’, ‘performed upon himself the most complete general amputation’—a castration—throwing ‘the parts of which he had deprived himself from his window into the street’.

Lovat managed to survive the self-inflicted operation, but could not bear the village gossip that resulted, and so migrated to Venice, like many of his countrymen, including his own brother, in search of a better living. Here Lovat was able to practise his trade, but became obsessed with the idea of crucifying himself. He realised his grisly objective in July 1805. The article describes at length the materials and mechanisms Lovat used, which included nailing one of his hands and both his feet to the cross, with which he then managed to launch himself out of a window, and hang suspended there in agony, until he was let down by several passers-by (Fig. 1.1).

Fig. 1.1

The crucifixion of Mattio Lovat. From ‘Narrative of the crucifixion of Matthew Lovat, executed by his own hands, at Venice, in the month of July 1805 … now first translated into English’, The Pamphleteer, 1814

One of these was the surgeon Ruggieri, who treated Lovat’s wounds and had him taken ‘to the hospital of St Luke and St John’ (actually Santi Giovanni e Paolo). When Ruggieri asked him why he had done it, Lovat replied: ‘The pride of man must be mortified, it must expire on the cross’. To account for his motivations and to ensure that no one else was incriminated for his actions, Lovat ‘committed his ideas to a slip of paper’. He felt no pain as he recovered, his state of religious insanity blocking the ‘fluid’ in his nerves, Ruggieri explained. In August 1805, Lovat was transferred to ‘the lunatic asylum of San Servolo’, where he ‘became taciturn, and refused every species of meat [food] and drink’. Six months later ‘there appeared some symptoms of consumption’, including faint pulse, weakness and cough. Lovat would ‘remain immoveable’ for long periods and in February 1806 the skin of his face and lower extremities peeled off. On 8 April, his breathing having become laboured, Lovat died.

The tragic story of Mattio Lovat, to give him his Italian name, has been the subject of a bestselling historical novel by Sebastiano Vassalli, alas never translated into English (Vassalli 1992). And Ruggieri’s narrative is known to historians of psychiatry as one of the first detailed case histories of mental illness, here presented as an example of ‘religious mania’ (Galzigna 1992; Böhmer 2018). It appeared in Italian in 1806 and was republished in 1814 (Ruggieri 1814b), prompting translations in French, German and the English version from which we have quoted. What is less well-known is that Ruggieri was also using his pamphlet to identify a singular underlying feature of Lovat’s insanity: a relatively new and still little-understood disease, known in Italy as pellagra—from the words pelle agra, literally ‘rough skin’, after its primary manifestation. This point is completely lost in the English translation, which refers to Lovat’s peeling of the skin as ‘leprosy’. Valpy was not to blame for the confusion. In fact the term ‘pellagra’, as well as knowledge about its devastating effects, would not become known in England until three years later, when the well-travelled London doctor Henry Holland published ‘On the pellagra, a disease prevailing in Lombardy’ (Holland 1817).

For medicine today, pellagra is a severe wasting illness caused by a deficiency of vitamin B3 (nicotinic acid, or niacin) in the diet, or its amino acid precursor, tryptophan. This is usually due to a reliance on maize flour (corn meal) as the staple foodstuff, which although it contains niacin, it is in a form that cannot be assimilated by the body. Its signs and symptoms form the ‘four Ds’: dermatitis, diarrhoea, dementia and death. Its incidence today is quite rare because of increased awareness and strategies such as vitamin fortification. If you have ever wondered why there is niacin in your flour, processed bread or morning cereal, now you know!

In the period covered by this book, Italy and the United States were the countries most affected by the disease, but pellagra was either epidemic, endemic or occasional in many other areas where maize cultivation and consumption was widespread, and were in some sense involved in the debates (and tragic effects) explored in this book. This included parts of France (Traimond 1992), Portugal (Monteiro et al. 1946), Spain (García Guerra and Álvarez Antuña 1993), Romania (Scrob 2020), Egypt (Ellinger et al. 1937) and South Africa (Viljoen et al. 2021). Today, sporadic cases may occur in people with socio-economic difficulties, inadequate diets, alcoholism and other diseases that block the absorption of niacin. That said, pellagra has occasionally re-appeared in more widespread form during emergency situations, such as famines brought on by war—for instance during the Spanish civil war of the 1930s (del Cura and R. Huertas 2007) or, in times closer to our own, in war-torn Angola in 1999 (WHO 2000).

The exact causes of pellagra would not be known until the 1930s. For the state of knowledge at the start of the nineteenth century, we need to return to Henry Holland. And this is necessary if we are to understand why the people in this book acted and suffered as they did. Holland’s article was the result of several trips to Lombardy and, he says, extensive reading of the Italian literature on the subject. He noted how pellagra was ‘confined almost exclusively to the lower classes of people, and chiefly to the peasants’; how the symptoms appear first during spring, only to disappear come late summer; how the disease would recur every spring, the symptoms getting worse each year; and how ‘the constitutional malady shews itself under a variety of forms’. Other doctors would be intrigued, indeed bewildered, by the range of symptoms sufferers exhibited, which appeared to vary from place to place and from person to person, even to point of appearing contradictory.

The insanity that pellagra caused was its most disturbing feature. ‘In the hospitals appropriated to the reception of such cases’, Holland remarked, ‘the Pellagrosi afford a melancholy spectacle of physical and moral suffering, such as I have rarely had occasion to witness elsewhere’. When he visited the lunatic asylum in Milan, of the 500 patients of both sexes confined there more than one-third were pellagra victims. Worse still was the fact that the public hospitals were incapable of dealing with ‘the vast numbers’ of sufferers, so that most ‘perish in their own habitations, or linger there a wretched spectacle of fatuity and decay’ (Holland 1817).

Clear to everyone was how ‘the evil is augmenting at this moment in a very alarming degree’, such that ‘there are districts in the Milanese territory, where the proportion of pellagrosi is one out of five or six in the whole population’. But how was it spread? Holland singled out the hereditary factor, how ‘the disease continues in families, with an evident predisposition derived from parents who have suffered under it’. The wretchedness of peasant living conditions and the meagre diet, despite being ‘in one of the more fertile portions of Europe’, is believed to be ‘the principal cause’ of the disease ‘by all those with whom I have conversed on the subject, and almost all the writers on the pellagra’. In the previous fifty years, the condition of the peasantry had worsened significantly. This was the result of wars, ‘changes of political state’ and the variable systems of government and taxation that resulted, ‘a decaying state of commerce, and a faulty system of arrangement between the landlords and the cultivators of the soil’. In particular, this ‘squalid wretchedness and emaciation of the peasantry’, ‘appears to have increased in a tenfold ratio during the last two years’, the result of several successive bad harvests, wars and political changes. Holland notes how several Italian investigators have singled out ‘the increasing use of maize as an article of food’ as a possible factor ‘in the extension of pellagra in this part of Italy’. He is sceptical, however, noting the areas where maize is a staple but where pellagra has not been identified—yet.

Finally, on the issue of medical treatment, Holland expressed what the core issue was—and which would remain so throughout the years covered by this book. ‘The truth is’, he wrote, ‘that in a malady, thus extensively prevalent among the lower classes, and depending chiefly, as it would seem, on their diet and mode of life, no ordinary methods of cure can be adopted with a reasonable prospect of success; the evil requiring those more general preventive means, which it is out of the power of medicine to afford’. Their poverty precluded any changes in diet or medical treatment in the home. In any case, medical treatments were limited to responding to the symptoms, like the skin peeling and the diarrhoea. Provision had been made for supporting a certain number of sufferers in insane asylums but this ‘has done little in mitigating the evil’. Holland realised that it was ‘not a light task to remove causes which affect a whole community of people’ (Holland 1817).

Maize and Its Effects

If we have summarised Holland’s perceptive article at length, it is because it provides a useful introduction to some of the key issues we explore in this book. We aim to provide an exploration, firstly, of the medical responses to a new disease epidemic and attempts to understand and treat it; and, secondly, of the patient experience of that disease, as it ravaged through society during the course of what has been termed the ‘long nineteenth century’. Eric Hobsbawn famously used this label in a trilogy of works to characterise a unitary period of Western history going from the English industrial and French revolutions (1789) through to the start of World War I (1914): modernity, with all its contradictions, its notions of progress and its darker side (Schlimm 2019). The label encapsulates the approximate start and end dates for pellagra as it became endemic in Italy.

What must have seemed like a positive agricultural development—the introduction of the Central American plant maize, with its prodigious yields and its ability to feed so many—had some unintended implications in Italy over the course of the long nineteenth century. On the one hand, the ‘glory of maize’ (Messedaglia 2008) became a celebrated part of local culture and maize polenta a welcome addition to the local diet. On the other hand, because of its very success, maize became ‘the despot of our countryside’ (Balardini 1882, p. 4). Its cultivation and consumption altered longstanding landholding patterns and adversely affected peasant conditions and livelihoods.

Italy, like the rest of Europe, owes a lot to what the environmental historian Alfred Crosby first called the ‘Columbian exchange’ (Crosby 1972). Columbus inadvertently set in train the biological unification of the planet, bringing together two agricultural systems that had evolved separately hitherto. The result was an exchange of the fruits of the earth that continues to this day; an exchange not just of agricultural products, but of foodways too; the exchange began between Europe and the Americas, but quickly extended to Africa and Asia. As a result of this process, Europe acquired maize, tomatoes, potatoes and most types of beans. For their part, the Americas would acquire wheat, rice, bananas, citrus fruits, coffee and cane sugar. Asia got bananas, papayas, potatoes and chillies, whilst Africa acquired maize, manioc and potatoes. In Italy, as elsewhere, each of these foodstuffs—tomatoes, potatoes, peppers, maize—has its own historical trajectory (Sentieri and Zazzu 1992).

Because maize is such a prodigious food source, it has been called a ‘coloniser’, in particular in Europe and Africa. It has been blamed for nourishing the slave trade (Warman 2003) and causing a transformation in Africa’s ecology (McCann 2005). The arrival and spread of maize into many parts of the northern Italy was no less dramatic: a ‘revolutionary irruption’, in the words of the economic historian Giovanni Levi (Levi 2014). Unlike the reception of other New World plants in Italy, such as the tomato and potato, which was slow and problematic (Gentilcore 2010, 2012), that of maize was quite relatively quick. Maize was the first new world plant to be represented in Italian art, within a few years of the Europeans’ initial encounter with it (Janick and Caneva 2005). It was the first to be cultivated as a curiosity in botanic and pleasure gardens, as an ‘exotic’. And it was the first to be widely cultivated, especially in northern Italy (Cazzola 1991; Finzi 2009).

It was not going to rival wheat in favour and esteem, but it would rival and eventually replace many of the so-called ‘inferior’ cereals, like millet and buckwheat. A map from 1549 shows part of an estate near Vigonza, in the flat countryside around Padua (Gasparini 2002). The field is planted with maize, perhaps the earliest Italian representation of a maize field. That said, this was not yet an established cultivation, but an occasional one. It was something suited for marginal lands and in emergency situations, such as famine, not a part of the normal cycle of production and crop rotation. But that would come: by the end of the nineteenth century two million hectares were given over to maize cultivation, producing two million tonnes, feeding a per capita consumption of 35 kilos per year.

Its agricultural success was due to several reasons. The first was yield. Although maize yields were never as astounding as some European proponents made out, estate accounts do suggest that in the Italian maize heartland, the Veneto, during the eighteenth century, the ratio of maize to wheat yield was in the range of 6:1. The second reason was its growing cycle: both wheat and maize could be grown in the same year, one after another, so that if the wheat harvest failed, there might still be time to get a maize crop in. For landowners, it was fast becoming an important cash crop, rivalling wheat. For farm labourers and smallholders, maize had other, secondary uses. The pruned tops of the plant could be used as livestock forage; the stalks, once macerated, could supply bedding for the animals; stalks and cores made good kindling, once dried; the leaves were used as bedding material, the stuffing inside mattresses; and, of course, the kernels provided abundant and filling animal feed.

Its usefulness as famine food was soon apparent. With every harvest failure—and they came frequently—maize cultivation expanded further; maize was more productive than other inferior cereals and more tolerant to the extremes of the Mediterranean climate. From famine food, it became everyday food. The assimilation of maize was so unproblematic that local terms for it tended to associate maize with plants already known. In this way, the new word for maize replaced the previous plant, in people’s vocabulary just as it was doing in their fields and on their plates. In the Veneto they called maize formentón, the word previously used to indicate buckwheat. Polenta went from being grey (buckwheat) to yellow (maize), as the plant became naturalised in the region, an established part of local cultivation and consumption.

By the eighteenth century, maize was being grown on a large scale in estates of Italy’s Po valley, where it had become part of the crop rotation and a staple element of the local peasant diet. Its quick assimilation was due to the way it could be easily accommodated into established food habits. Like other wheat substitutes, attempts were made to use maize in bread-making, but the results were not especially encouraging. In parts of central and southern Italy, it was made into a flatbread, along the lines of modern focaccia. But the greatest success of all was obtained by using the maize flour in another, traditional manner—polenta.

The well-off developed their own more sophisticated preparation methods, with rich seasonings and accompaniments. As a 1775 agricultural treatise said of polenta: ‘this rustic foodstuff is eaten by the upper classes, rendered more refined by the use of the usual seasonings’ (Pilati 1775). The poor had to be content with the simple addition of water to their maize flour, with little or nothing to go with it. Maize polenta was cheap and filling and so quickly became a staple of the peasant diet in areas where it was grown. Its consumption—in its unadorned monotony—became associated with the peasant condition (Bernardi 1991, pp. 335–336). In Parma, a traditional folk rhyme sang of a newlywed peasant woman who had dreams above her station: ‘she wants only to sleep in freshly laundered bedlinen/she won’t eat polenta if there’s no cheese served with it/she doesn’t want to do the housework…’ (Petrolini 1975, p. 286). She will be in for a rude awakening, the rhyme seems to imply.

The production and consumption of this new-found staple had two unforeseen costs, on the economy and on health. By the 1870s, maize was the number one crop in six provinces of the newly united Italy, in terms of land area (MAIC 1879). In the northern regions of Piedmont, Lombardy, Veneto, Emilia and Romagna, the product of maize fields represented 41% of total production, against 33% for wheat and 25% for rice. The increased cultivation of maize brought with it a structural shift in the Italian countryside, every bit as significant as the agricultural revolution in eighteenth-century England. It was good for landowners and millers and certainly good in terms of production and yield; but not so good for the farm labourers themselves. Peasant working conditions declined, as peasants were transformed from the tenant farmers of the traditional tenant-farmer (or mezzadria) system to renters (in cash); or else they became field hands, working for a wage rather than for a part of the production (Monti 1998). All of this at a time when increasing numbers of people were chasing too few agricultural jobs and too little land (Zamagni 1993).

By the early nineteenth century, maize became part of the cash economy in parts of northern Italy. Landowners speculated on what to grow, what to sell. They expanded the land area devoted to maize cultivation, at the expense of fallow and meadow land. Peasants ended up working for a wage, rather than for a part of the production; worse still, they increasingly had to pay in cash to rent their land. The relationship between landlord and tenant changed as a result. What the peasant was able to produce for himself was often owed to the landlord to pay off loans given or to help pay the rent. In a downward spiral, the tenant got further into debt and became further dependent on maize production. The best he could hope for was a ‘good year’, a bountiful maize crop, which allowed him to pay off some of his debts.

Peasants became ‘trapped’ in an economic system from which the only means of escape was emigration (Sori 1979; Bevilacqua 2001). This was mass emigration, beginning one of the largest voluntary movements of people in world history (Cohen and Federico 2001). By the end of the nineteenth century, one-third of Italy’s emigrants come from the Veneto; almost two million people left the Veneto in the last twenty-five years of the century.

This was the economic cost; there was also a health cost. Maize played a part in that nineteenth-century paradox well-known to demographers: a deterioration in the ‘biological’ standard of living hidden by economic growth and population increase (Livi Bacci 1990). Maize polenta became more than a filling staple; it became virtually the only food consumed during winter and spring by large sectors of the agricultural population. Its effects were not confined to maize-producing areas. Thus in Romagna, pellagra was first encountered amongst the labourers in the rice paddies, who fed themselves largely with polenta rather than with the fruit of their own labours because it was much cheaper (Cerasoli 2020).

The native populations of central and north America, where maize comes from, prepared it by soaking the kernels in ash, laboriously turning it into what in Nahuatl is known as nixtamal—a pottage which could either be consumed as it was or transformed into tortillas (Pilcher 2017). Hence the modern-day label of ‘nixtamalisation’ for this process, by means of which the chemical compounds niacin and tryptophan are made bio-available. Alas, this preparation method did not follow maize across the Atlantic. Instead Europeans—with their constant worries about famine and the cultural centrality of bread and flour—sought to treat maize like a cereal. They dried the cobs, separated the kernels and milled them into flour. As lovely as the polenta made from this flour undeniably was (and is), its key nutrients could not be assimilated by the body.

Pellagra was the result.

Pellagra and the Medical Response

If pellagra was unknown in early nineteenth-century England, it had been a fact of life in north-eastern Italy since at least the mid-eighteenth century. Peasant names for the disease suggest it was already widely known amongst the peasantry before Italian physicians ‘discovered’ it in the late 1760s—evidently unaware that a Spanish physician had already described the new disease in the 1730s (García Guerra and Álvarez Antuña 1993). Medical investigators soon adopted the popular label for the disease, pellagra. This conditioned explanations of, and investigations into the disease for some time to come. At the same time, contemporaries were struck by how the appearance and spread of the pellagra epidemic coincided with the start and spread of maize cultivation and consumption there. That said, the precise link between maize and pellagra, its nature as a deficiency disease, and an effective treatment for the terrible scourge, all eluded medicine until the 1930s. And whilst debate continued over the exact causation, the number of sufferers grew, reaching epidemic proportions in the late nineteenth century and early twentieth centuries (De Bernardi 1984a, 1984b; Giannaio 2010, 2011; Cerasoli 2020).

In Lombardy in 1830, an estimated 14 per 1,000 inhabitants in maize-growing areas were pellagra sufferers. By 1879, there were 97,855 documented pellagrins (pellagra sufferers). More than a third (29,836) of these were in the Veneto region, which is the main focus of our book. In affected areas of the country—to put it another way—16 out of every 1,000 people over the age of 15 engaged in agriculture was a sufferer. The figure in the Veneto was twice that (MAIC 1879, pp. 324–5). And these were only the officially documented cases; actual morbidity was estimated at twice the official numbers (Morpurgo 1882, p. 173). Moreover, the epidemic seemed to be spreading, appearing further south, into Tuscany and the Marche, even down to the gates of Rome, only recently made the capital of a newly united Italy (Fig. 1.2). The disease became entrenched in society, endemic. In addition to causing debility and insanity, pellagra killed. Pellagra-related morbidity and mortality peaked in the 1880s and 1890s. In the Veneto region, pellagra was responsible for 1,238 registered deaths in 1890. In Italy, at the end of the century, almost half of all deaths due to pellagra occurred in the Veneto (Gregorj 1893, p. 20; Porisini 1979, p. 13).

Fig. 1.2

Number of pellagrins per 1,000 farm workers, men and women over 15 years of age, 1881. From: Giuseppe Antonini, Pellagra: storia, eziologia, patogenesi, profilassi, 1902

Pellagra was not just a disease of peasants; it was a disease of poor peasants, with day labourers and landless peasants the worst off, as contemporaries observed. But it attacked even tenant farmers, or mezzadri (Porisini 1979). As a chronic and debilitating disease, pellagra became a fact of life, destroying families. It exacerbated the negative effects of maize cultivation, by rendering peasants unfit for work. There was also a gendering of the disease; women suffered from it more than men and were more often institutionalised in asylums, as we shall see in Part II. The disease overwhelmed hospitals and insane asylums. At a time when increasing socio-economic marginalisation was a leading factor behind insanity and institutionalisation, the proportion of inmates diagnosed with ‘pellagrous mania’ rose to 15% nationally (Giudice 2009); but of course the figure was significantly higher in maize-consuming areas.

People—peasants in particular—lived in fear of contracting the disease, with the dire effects it would have on them and their families, in particular since there was no cure. A pellagrin admitted to the Forlì insane asylum, Raffaele Calandrini, according to his patient record, ‘shows himself very worried about the epidermic desquamation on his hand, and of its terrible significance, well known even amongst the general public’ (Cerasoli 2020, p. 105). We can certainly appreciate this; we have all learned to recognise and dread the varied symptoms of COVID-19.

The Italian government was effective in gathering evidence about the pellagra problem, if perilously slow to act on it (MAIC 1879; Jacini 1881–1886). Social solutions, which might have enabled the poor to eat other more nourishing foods, were deemed at the very least disruptive and at the most revolutionary. It was time of agrarian crisis, price instability and widespread social unrest (De Bernardi 1984b, pp. 25–32; Crainz 1994, pp. 75–78). A short-lived radical newssheet of the day even called itself Il Pellagroso (The Pellagrin) (Fig. 1.3). Its masthead depicted an angry peasant, holding a slice of polenta and a bowl of water, surrounded by the tools of his trade like so many weapons. The newspaper’s editor (Tito Melesi) threatened: ‘The title of this periodical may get up some people’s noses. … But is it honest to hide this shameful sore? It is time to end the lies. We aim to sow discord between labour and capital, to eliminate forever from our society the inhumane market of the worker’s toil’.

Fig. 1.3

Masthead of Il Pellagroso: giornale popolare-amministrativo-politico, a short-lived radical newssheet, published at Castel d’Aria (Mantua) in the mid-1880s

The elites, medical and otherwise, did not want to fan the flames. Whilst working towards the social good, medical solutions tended to be palliative—if not downright harmful, given the medical theories of the time. Take, for example, a cheap pamphlet published in Milan in 1869, entitled Curing pellagra (La pellagra si cura) (Lombroso 1869). It was one of two dialogues its author wrote for a broad readership.

The dialogue is between a physician and a poor peasant woman, Tonia. It starts brusquely, with the doctor informing Tonia that her husband’s case is incurable, diagnosed with ‘what we call pellagric typhus’. He tells Tonia that had Pietro’s condition been diagnosed earlier ‘he would still be hoeing in the fields, one of the village’s strongest workers’; but delivering the sad message also allows the doctor to stress the importance of treating the disease early, since both Tonia and her infant son are also pellagra sufferers. Tonia makes light of her troubles: what is a bit of indigestion, itching along her back and burns on her hands and feet? To which the doctor replies that that was exactly Pietro’s reaction to his own glassy vision, dizzy spells, diarrhoea and peeling skin; and now his condition is too far advanced to be treated. Tonia complains that she can’t even consider treatment for her and her son: ‘do you think that salamis are raining down from our granary and that Barbera and Chianti wines are flowing in our ditch? … Would you have me beg for charity from the few better-off people in the village, who only give it out once a year, while we suffer from the disease all year round?’.

The doctor replies that he is aware of her condition and informs her that, as the result of trials carried out ‘in Turin, Perugia, Florence and Brescia’, his colleagues have found another way to cure pellagra. The method ‘is much cheaper and better suited to your poverty’, since it does not involve food it will not hurt her purse. Tonia’s curiosity aroused, the doctor tells her that, for her infant son, all she need to do is towel-rub his back, chest, stomach and underarms two or three times a day with a salt-water solution. For herself, as an adult, the treatment is different; it involves a small amount of arsenious acid, a powder which she is to dissolve in some boiled water and wine spirit, and swallow three spoonfuls of the solution a day. Tonia asks the doctor if it would work on her husband, but he replies that it is too late for that; for Pietro, we would need a miracle and miracles ‘do not happen and have never happened in medicine’, he instructs her. So Tonia asks whether the powder would help her poor, elderly neighbour Paola, ‘who shakes all over and suffers sharp pains in her legs, arms and back’. The doctor replies that in Paola’s case age is a factor and she would need to take another, inexpensive remedy: lead (acetate) dissolved in water, but its effects are not as sure or as fast.

Finally, Tonia remembers to ask about the treatment for her diarrhoea, and the doctor recommends that she ‘put the polenta to one side and buy four ounces of beef, pound it and cut it fine, sweeten it with sugar, and eat twice a day’. But then he notes that Tonia doesn’t have enough money for this treatment and suggests that she goes to the pharmacy and buys a grain of calomel [mercurous chloride], has the pharmacist divide it into five, and takes this every two hours until the flow stops. And there the doctor’s visit ends.

Aside from the patronising tone of the dialogue, it may have been just as well that most pellagra sufferers and their families would have been too poor to afford the (harmful) remedies the doctor prescribed! And, of course, pellagra treatment was nowhere near so straightforward as Lombroso made out. Even contemporaries were aware of that. As one nineteenth-century reader wrote in a copy of the dialogue now in the Marciana Library, Venice: ‘It would seem so easy to get better from pellagra! But the facts speak with an inexorable language of their own, very different’.

Then, without contemporaries quite understanding why, deaths due to pellagra began to decline. In the period 1908–1910, average yearly deaths were half what they had been ten years earlier (Cohen and Federico 2001; Helstosky 2004).

About This Book

The historical study of pellagra in English has tended to focus on the US experience of the disease, which has explored pellagra as an American problem, in search of an American solution (Etheridge 1972; Roe 1973; Bollet 1992). In addition to determining the geographical focus, this has meant a limited chronological one: that is, the first three decades of the twentieth century, when pellagra was epidemic in the parts of the southern United States, culminating in the experimental work of Joseph Goldberger to identify its causation and treatment during the 1920s, which lay the basis for eventual success in defeating the disease. Similarly, Italian historiography (almost exclusively in Italian) has focused on the Italian experience of pellagra, mainly during the nineteenth century. It has tended to do so from a social history and demographic perspective, within the context of explorations of agricultural change and the marginalisation and impoverishment of the Italian peasantry (De Bernardi 1984a; Finzi 2009; Giannaio 2010, 2011). If the medical history of pellagra in the United States has been well served (Leslie 2002; Marks 2003), this has been much less the case for Italy (De Bernardi 1984b; Cerasoli 2020). The asylum experience of pellagrous insanity has been the subject of a handful of important case studies (Finzi 1982; Ferrari 1984, 1985; Salviato 2002), but we lack detailed comparative analysis of the two Venetian asylums, San Servolo and San Clemente. The medical history of pellagrous insanity—contemporary attempts to understand its causes and manifestations, in the context of mental diseases more broadly—has hardly been explored. These are the gaps this books aim to fill.

We have divided our exploration into two parts. Part I focuses on how the Italian medical community responded to pellagra. Given that the disease came to be considered a ‘social question’, a ‘disease of poverty’, was Italian medical science committed to it? How does it compare to the campaign to rid Italy of malaria (Snowden 2006), conducted at much the same time, but with much more fanfare and greater success? What inroads did medicine make in understanding and treating the disease?

We approach the shifting medical and scientific discourse on pellagra by focusing on three separate scholarly disputes, which together cover the entire history of the illness in Italy over the long nineteenth century: significant episodes in the ongoing and often heated and personalised debate on the subject, but which had little effect on the number and suffering of pellagrins. The three disputes will be used as microhistories, to illustrate the engagement of developing medical science to the illness, and will be compared to the more practical role of the asylum physicians and local district doctors, who had most face-to-face contact with sufferers.

If left untreated, pellagra leads to forms of insanity, often violent. In Italy, as we shall see in Part II of this book, local psychiatric hospitals were the only concrete form of treatment offered to pellagrins by the authorities. But before they would even treat it, asylum doctors were faced with a quandary: how to classify, explain and diagnose pellagrous insanity, at a time when pellagra itself was not fully understood? We examine this question in chapter six, by means of a comparison with responses to general paralysis of the insane in the United Kingdom, at roughly the same time. Although the asylums’ function was primarily custodial, the somewhat better diet they provided to inmates was sometimes enough to affect an improvement—at least whilst sufferers remained institutionalised. In chapters seven and eight, we offer a systematic overview of how these institutions treated pellagrous insanity. The running of these asylums was left up to local authorities; and it was they, too, who undertook what little official response was offered to the pellagra epidemic: the setting up of provincial pellagrological commissions, the provision of public maize desiccating plants, health stations and soup kitchens for sufferers, education and other limited forms of relief.

For the research underpinning this book, we have consulted a wide range of printed and archival sources: (1) the writings of Italian medical investigators into the causes, classification, diagnosis and treatment of both pellagra and pellagrous insanity; this includes medical treatises, asylum reports, articles and correspondence; (2) the proceedings of the Italian Pellagrological Congress, which met between 1899–1922, and the main scientific journal in the field, the Rivista pellagrologica italiana, published 1900–1921; (3) newspapers, like L’Eco di Bergamo, which frequently reported pellagra-related stories; (4) the archival records, and in particular the thousands of patient files, of the two main psychiatric hospitals of Italy’s Veneto region, San Clemente (for women) and San Servolo (for men). Located on two small islands in the Venetian lagoon, the institutions served as the regional insane asylums for men and women, respectively, from their founding in the nineteenth century until their closure in 1978. This resulted in the creation of a data set, deposited at the UK Data Service: VMAD: The Venetian Mental Asylums Database (Priani and Gentilcore 2016). It covers the period 1842–1912 for San Servolo and 1873–1912 for San Clemente, sampling one year in five, and is based on a total of 5,709 patient files—of which 1,587 relating to the pellagrous insane, 830 men and 757 women.

That said, our approach is a mixture of the quantitative and the qualitative. This book brings together the different methods and approaches of a range of disciplines—economic and social history, agrarian history, environmental history, history of medicine and science, the history of psychiatry and mental illness—in order to reconstruct the impact of a single food plant (maize) and a single disease (pellagra) over the long nineteenth century. Our aims in this book are various: to set pellagra and pellagrous insanity in a wider context of man-made or societal diseases, related to poverty and diet; to contribute to recent efforts to trans-nationalise Italian history; to explore how medical and scientific research was carried out during the long nineteenth century and the uncertainties this engendered, in terms of classification, explanation, diagnosis and treatment; to explore the experience of pellagrous insanity from the sufferer’s point of view and its social and economic ramifications for peasant families; to add to our knowledge of the history of mental illness and its treatment in Italy.

After careful consideration, we have decided to report patient names in full, in an attempt to restore some sense of dignity to them, even if only posthumously. We appreciate that records of mental illness are potentially sensitive and need to be approached carefully. Our findings are based exclusively on records in the public domain, housed in publicly accessible archives, with a closure period that has well since passed.

All translations are our own, unless stated otherwise.