Medical Reactions to a New Disease (The Eighteenth Century)

Abstract

In this chapter, we explore reactions to pellagra as a new disease and the character of the medical debates that ensued. If pellagra in Italy can be characterised as a disease of the long nineteenth century, this history can be subdivided into three different phases. This chapter will examine the earliest of these, from 1770 to 1815. This phase is characterised by investigations aimed at constructing the new disease’s clinical history, through to the considering the disease as nosological ‘problem’—the question of its nature and how to classify it—and culminating in polemics over its causation. Two things are worth noting here. First of all, during this first phase of investigation, the focus was on the skin—manifestations on the body’s surface—as a key to understanding the new disease. And, secondly, this is far from a history of linear progression, there being as much diversity of opinion in 1815 as there had been a generation earlier.

In 1789, a twenty-five-year-old student doctor at Padua’s San Francesco Grande hospital reported on his first encounter with a new disease.

I came across it quite by chance in the hospital, having resumed my customary practice of going there, as the real and only source of medical observations. It so happened that one day I was present when a young sick woman was admitted. The attending physician was asking her different questions as usual, to which she replied haltingly, evidently in a daze. I happened to gaze at her hands, and saw that they were of a blackish colour, as was also part of her arms. I proceeded to examine her more carefully, and I noticed that the cuticle there was dried and rough, and that here and there it was starting to peel off, whilst the skin underneath remained white and shiny. In addition, the [woman’s] mother related how an extreme weakness, particularly in her legs, had reduced the poor young woman to a state where she was incapable of performing her farm labours, and how these complaints had afflicted her the past two years, at the start of the spring season. Pausing to think about the three observed phenomena, that is her dizziness, extreme weakness and especially the morbid alteration of the cuticle, I was immediately reminded of pellagra, a disease pervasive in the territory of Milan, and I believed there was a very great similarity to it. The attending physician, seeing me particularly attentive in the examination of this sick woman, told me that for the last few years, but especially this year, similar patients had been coming to the hospital, about whom only general ideas had been reached hitherto. (Fanzago 1815, pp. 48-9)

At the time he was writing, Francesco Fanzago—the name of our young doctor—had just returned from two years’ training at the hospital in Pavia, at what was Lombardy’s university. Here, he had studied under Johann Peter Frank, the noted German scholar of hygiene and legal medicine and proponent of public health reforms. Fanzago (1764–1836) returned to his native Veneto, to Padua where he had taken his degree, full of curiosity and crusading zeal. His committed and methodical examination of hospital cases, and his undogmatic presentation of his findings, was also consistent with the approach outlined by the Scottish Enlightenment physician John Gregory, whose work on medical ethics Fanzago had just translated into Italian. From the start, Fanzago’s interests in pellagra were as much social as nosological, and he would spend the next twenty-five years of his life studying and writing about the disease. More than anyone else in the Veneto, he was the physician who put his name to pellagra; not that there were no other claimants to the title, as we shall see.

Most of Fanzago’s 1789 Memoria on the subject consists of a description of sixteen pellagra case histories observed in Padua’s San Francesco Grande hospital. The hospital setting allowed Fanzago to follow the course of the disease and observe the effects of treatments more systematically and in greater detail than previously, in addition to carrying out autopsies on patients who died there. His observations meant that he was the first to be able to identify pellarina (‘peeling-off’) in the Veneto and pellagra (‘rough skin’) in Lombardy as one and the same disease. As Fanzago put it, both names were ‘derived from the affliction observed in the epidermis’ that constitutes one of pellagra’s ‘most evident signs’ (Fanzago 1815, p. 75).

In this chapter, we focus on the exploration of pellagra as a new disease and the character of the medical debates that ensued. If pellagra in Italy can be characterised as a disease of the long nineteenth century, this chapter will examine its first phase, roughly from 1770 to 1815. This phase is characterised by investigations aimed at constructing the new disease’s clinical history, through to considering the disease as nosological ‘problem’—the question of its nature and how to classify it—and culminating in polemics over its causation. Two things are worth noting here. First of all, during this first phase of investigation, the focus was on the skin—manifestations on the body’s surface—as a key to understanding the new disease. And, secondly, this is far from a history of linear progression, there being as much diversity of opinion in 1815 as there had been a generation earlier.

Early Clinical Descriptions of Pellagra

When it came to understanding the ‘new’ in medicine, Fanzago’s 1789 investigations into pellagra typify the clinical history focus, with its emphasis on direct experience over doctrine, the observation of hospital patients and detailed description of case histories. Fanzago republished his 1789 investigations into pellagra in 1815, together with all the work he had published on the subject in the intervening years (Fanzago 1815). But the collection began with the first known work on the disease published in the Veneto, by Jacopo Odoardi (1776). Fanzago was staking a claim for the study of pellagra in the Veneto, beginning with an implicit presentation of himself as the direct heir to Odoardi, offered as a pioneer of the clinical history phase.

The earliest notions of the new disease, even the names given to it, are related to its nature as an affliction of the skin. This is what particularly struck those who first came across it, the peasants of the Veneto, who called it pellarina. According to Odoardi, ‘first physician’ in the town of Belluno, the disease appeared first as a roundish mark (macchia) on the back of the hands in March or April, accompanied by mild itching. Sufferers said they had been sunburnt. The next year it was worse, itchier, and the skin did not return to its previous colour, but peeled off. In addition, in women, their already scarce menses would stop altogether. During the third and fourth years, the feet and shins suffered like the hands, the skin there peeling off; in consecutive years, the scabs on the hands and feet became so large as to resemble the scabs of lepers. For Odoardi, the new disease was thus a ‘particular kind of scurvy’, although it differed in some important details (in Fanzago 1815, pp. 8–9).

Odoardi’s accurate and detailed clinical description of the disease, evidently based on direct observation in and around his native Belluno, became the standard and his work was always referred to by successive investigators. His concerns about the origins, nature (nosology) and cure of the disease would become standard approaches. Debates centred on how to classify pellagra, as reflected in decisions over what to call it. Much depended on determining whether it was a form of scurvy or leprosy (the earliest candidates). Odoardi noted that the name first assigned to the disease in the Veneto, ‘Alpine scurvy’ (scorbuto alpino), was something of a misnomer. He did not object to the adjective ‘Alpine’, because he was convinced that the disease was indeed a regional one, affecting ‘this our wide valley [Belluno] and our Alps’. Rather, Odoardi was not convinced by the label ‘scurvy’, since scurvy did not affect the brain, whilst pellagra did.

For Odoardi, what happened on the surface of the body was a reflection of what was happening inside it. Late eighteenth-century medicine had not completely jettisoned its Galenic underpinnings. If scurvy was then seen (at least by Odoardi) as a kind of food poisoning that affected the blood, caused by a subsistence on floury foods, a peasant diet based largely on unsalted maize polenta, combined with the forced inactivity of the winter months and close living conditions, led to the formation of a ‘scorbutic sluggishness’ in the blood.                                     

The Nosological Question

In addition to republishing his 1789 Memoria and Odoardi’s pioneering 1776 study, Fanzago also included a more extensive essay of his, the Paralleli tra la pellagra ed alcune malattie che più le rassomigliano (Parallels between pellagra and several diseases most resembling it), first printed in 1792. Here he took the comparative approach ushered in by Odoardi to its logical conclusion, comparing pellagra to other known diseases (Fanzago 1815). With this publication, Fanzago took the social construction of pellagra in the Veneto into a new phase, the nosological, where the concerns of classification shaped investigation and debate. Curiously, the same ‘nosological problem’ was being posed in Spain, but with little point of contact (García Guerra and Álvarez Antuña 1993).

Fanzago took the opportunity to elaborate on his assertion that pellagra was a new disease, since the few previous Italian authors on the subject had not gone so far. Its novelty was evident in the fact that only ‘in the last few years’ had it made itself felt and caused significant harm. How does the investigator approach and explore novelty? For Fanzago, it was essentially a nosological question. He defers to the ancient Roman physician Celsus that when an unknown disease is first encountered, it should be reduced to a disease already known and described. To which pre-existing illness should pellagra be compared? The candidates were scurvy, leprosy, hypochondriasis or, perhaps, even a ‘distinct disease’.

The question was a serious one, Fanzago argued, for the answer would determine the kind of treatment most appropriate. If pellagra was a form of scurvy, then ‘it will be necessary to choose those antiscorbutic medicines which can be best adapted to the specific degeneration of the humours’. If pellagra was leprosy, then one had to treat it as a disease of the skin, ‘as the most obstinate and essential symptom’. If hypochondria, then one had to treat ‘the system of the nerves’. Finally, if we were to consider it as ‘a disease of a distinct type, then the measures we take must be likewise distinctive’ (Fanzago 1815, p. 113). The problem was that every investigator saw something different when looking at the description of a disease, particularly in the case of pellagra, because of the diversity of its symptomatology. Fanzago’s solution was to explore each of the parallels in turn, comparing how closely each analogy fit. The fact that Fanzago stressed the discontinuities between the three different parallels over the similarities leaves us to little doubt as to where his sympathies lay—that is, with the distinctiveness of pellagra.

The first and longest discussion is the ‘parallel’ between pellagra and scurvy. As Fanzago noted, for some investigators the two seemed one and the same, to the extent that they considered it mistaken to see a difference. The attraction of scurvy as a possibility lay in its open-endedness: despite the many recent English studies into the disease, there were many different ‘kinds’ of scurvy and a resulting confusion and contradictions about its causes. Pellagra seemed to have many symptoms in common with scurvy, beginning with its effects on the skin. Although these might look similar, those of pellagra are actually quite different in appearance and distinct in the seasonal nature of their appearance, Fanzago noted. Moreover, in pellagra, the sun’s rays appeared to exacerbate the problem, whereas they had no effect in scurvy. When it came to the teeth and gums, affected in both, these turned out to be primary symptoms in scurvy, inseparable from it, but only ‘secondary or non-essential symptoms’ in pellagra. And, then, pellagra went on to affect the nervous system and the brain, which was not the case in scurvy. At most, scurvy led to languor, sadness and despondency, as in any long-lasting illness. But the madness associated with pellagra was quite different, as Fanzago had observed first hand:

The sight of those miserable wretches when they are overcome by madness truly moves one to pity. They mostly flee from their domestic abodes; they seek out solitary places; they eat earth, grass, and every kind of refuse; they scream, sing and when they are taken by fury they threateningly shout abuse at passers-by; and they often try to throw themselves into water when they can and drown themselves in it. (Fanzago 1815, p. 144)

Fanzago thus offered an early description of the complexities posed by the insanity associated with pellagra, which would exercise doctors throughout the century, as we shall see further in chapter six. In any case, other, intermediate symptoms were shared by both scurvy and pellagra: diarrhoea, dysentery, consumption, dropsy, paralysis and contractions. But, then, these were common to many diseases. Whereas scurvy was amenable to treatment, provided the correct remedies are administered, these same medicines appeared to have little or no effect in treating pellagra. Fanzago gives the example of lemons. Unlike scurvy, pellagra ‘observes a periodic order, following the cycle of the seasons; affects women much more than men; is based more prevalently amongst country inhabitants, although on some rare occasions striking city dwellers’ (Fanzago 1815, p. 151).

Fanzago dedicated another substantial discussion to the second parallel, that is, between pellagra and leprosy (or elephantiasis). Leprosy was classed amongst the ‘cutaneous diseases’ and, more broadly, amongst the ‘affections’ that ‘concern the exterior surface of the body’, to the extent that it actually resided in the skin. In pellagra, however, the skin was only affected periodically: ‘the skin affliction appears, goes away, comes back and then disappears altogether’. Moreover, in its later stages, the effects of leprosy were absolutely horrendous, whereas, at the latter stages of pellagra, the skin was often unblemished. Fortunately, at least pellagra would not appear to be ‘spread by contagion’, Fanzago noted, unlike leprosy which had been seen to be so from the time of ancients (Fanzago 1815, p. 164).

Thus, when it came to ‘their characteristic signs’, the differences between pellagra and leprosy outweighed the similarities. What about causation? Poor diet would seem to be a factor behind both diseases. Increased poverty, with its deleterious effects on ‘healthy and strict nutrition’, had to be acknowledged as the main ‘remote’ or indirect cause of pellagra. In this, pellagra was similar to leprosy, which was likewise a disease of poverty, although the same could be said of many other diseases too, as is evident every time there is a famine, Fanzago suggested.

A limitation in identifying pellagra with leprosy was that the latter was a disease of the past, at least in Italy. But the most striking and convincing argument for diversity of leprosy and pellagra lay in their treatments, Fanzago notes. When it came to leprosy, ancient physicians recommended frequent and abundant bloodletting, drastic purges, scarification, unguents and medicated baths—if one can call a bath in a mixture of sulphur, nitro and alum ‘medicated’. When it came to pellagra, however, bloodletting and purges were positively harmful, and because the skin affection goes away by itself, no scarification or corrosive plasters were necessary.

Fanzago’s third ‘parallel’, that between pellagra and hypochondriasis, meant a departure from considering pellagra as ‘a simple skin affliction’ and seeing it instead as ‘an affliction mainly of the nervous system’. Fanzago did not realise how close he was in identifying the nerves as a component of pellagra. However, for the medicine of Fanzago’s day, the ‘highly-strung feeling’ and ‘frailty and sensitivity’ of hypochondriacs bore little resemblance to the insanity of pellagra sufferers; not to mention the fact that most hypochondriacs were ‘well-off and well-nourished men’, whereas it was precisely ‘abundant and nutritious food’ that turns out to be an ‘excellent remedy’ for pellagra (Fanzago 1815, pp. 184, 180, 190).

Fanzago was fairly certain in having identified the causes and symptoms of pellagra, as well as its treatment. At the same time, he was quite aware that implementing this cure was far from easy. Peasants, especially the hired farm hands, had no choice but to work hard, were conservative in their habits and had little regard for their health, ‘taking a thousand times more care over the health of their animals than their own’ (Fanzago 1815, p. 197).

Indeed, diet was a central concern in Fanzago’s next major foray into pellagra, Sulle cause della pellagra (On the causes of pellagra), a lengthy paper delivered before Padua’s Academy of Sciences, Letters and Arts in 1807 and published two years later (in Fanzago 1815). By this time, Fanzago had been professor of practical medicine at the University of Padua and, following university reforms, was now professor of both pathology and legal medicine there. Fanzago’s paper focused on pellagra’s causes and would attract the fire of another illustrious physician active in the Veneto, Giambattista Marzari (1755–1827). It also takes us into the next element of early explorations of pellagra, the aetiological, where questions about causation predominated. Pellagra’s aetiology would prove an even harder nut to crack than its nosology.

Pellagra’s First Priority Dispute

The two men had much in common. Marzari, nine years older than Fanzago, had, like him, taken his degree at Padua, and had gone on to become professor of physic and eventually regent of Treviso’s Real Liceo, later the Ateneo, founded by Napoleon in 1810. Marzari’s reforming zeal found expression in Treviso’s first newspaper, Il Monitor di Treviso, which he founded in 1807, and in his own medical practice, assisting the sick poor free of charge, including pellagra sufferers—apparently cured as a result of Marzari’s contribution to understanding the disease’s causes (Chiades 1982). Marzari published his ‘medico-political essay’ on pellagra in 1810 (Marzari 1810), as well as two other works on the subject several years later.

Despite their geographical proximity, their shared reforming outlook, their shared approaches to medical investigation, and, as we shall see, their shared conclusions, the close contemporaries Marzari and Fanzago are conspicuous by their absence from one another’s works. In fact, what we have is a classic a priority dispute—common in the history of science—just the first of a series in what would become the field of pellagrology.

Marzari claimed to have written his Saggio a year before Fanzago presented his 1807 paper, which ‘unforeseeable circumstances’ had prevented him from publishing until 1810. What these circumstances were, Marzari did not reveal. (In fact, Marzari had been arrested by the Napoleonic government for comments made in the December 1807 issues of Il Monitor.) ‘I think that for these reasons I can maintain a priority right on this aspect of the pathological doctrine [of pellagra]’, Marzari wrote regarding his own theory of pellagra’s causes (Marzari 1810, p. 106; the emphasis is his). Fanzago did not let this go unanswered. In his 1815 re-edition of all of his own pellagra studies, Fanzago affirmed that his earlier publication date (1807) gave him evident priority over Marzari, not to mention the fact that he had been lecturing on the subject since 1803 from his chair in practical medicine, a fact to which his many students from Treviso, Marzari’s home town, could testify.

Priority aside, what was the source of dispute between the two medics? Let us begin with what they disagreed on. These areas turn out to be minor points. Fanzago was quite satisfied with the now well-established term ‘pellagra’, whilst Marzari would have preferred to go on using Pujati’s label of ‘Italic scurvy’ (scorbuto italico), given that pellagra was not only a disease of the skin and worse symptoms followed, as in scurvy. They also disagreed on the number of pellagra’s stages and, whilst agreeing that the symptoms and manifestations of the disease could vary widely from sufferer to sufferer, Marzari believed that this variety was a reflection of individual temperament, sex and age, as well as climate. Climate, especially sunshine, was important for Fanzago too, but none of the other factors were.

However, Fanzago and Marzari agreed that pellagra was a disease of the countryside, limited to the poor peasantry; that the disease in Italy was less than fifty years old; that it started as seasonal; that it progressed by degree; that it was not hereditary, contagious or transmissible by touch; that there were more women pellagrins than men; and that, given its cause, further investigations would turn up cases in other parts of Italy and Europe. More than anything else, they both believed they had pinpointed the disease’s cause, which lay in the diet of the affected peasants. Marzari was adamant that their maize diet ‘constitutes the true and certain cause of pellagra’ (1810, p. 38), whereas Fanzago was slightly more circumspect. But it was a difference of degree and approach.

Fanzago and Marzari both noted how the diet of peasants in the Veneto had changed during the previous century, a result of the worsening of economic conditions and the introduction of maize. They identified poverty as the predisposing or indirect cause, the direct cause being a maize-based diet, consumed in the form of polenta. And, if a maize-based diet was the cause, in particular during winter months when little else is available, then prevention was straightforward: better food. They also shared the idea that a publicity campaign would be necessary in order to spread the message. Marzari proposed a ‘work of popular education, written by order of the government by an author who is both well known and well versed in this subject, and who, with clarity and vigour, knows how to make himself understood everywhere, right down to the most rustic of huts’ (Marzari 1810, p. 59). Who could Marzari possibly have had in mind? After all, only he had the journalistic panache required. It must have piqued him that this honour would eventually go to Fanzago, who published his Istruzione catechistica sulla pellagra in 1816 at the government’s behest—and with the same printer Marzari used (Fanzago 1816). In this manual in question-and-answer form, Fanzago characterised as a ‘hornets’ nest’ the ‘many debates [that] have arisen amongst those authors who have written on pellagra’. The irony is that today, in general historical surveys of pellagra, Marzari is credited with being the first to espouse the deficiency theory (Carpenter 1981).

Back to the Surface: Pellagra’s Exterior Signs

Despite their mutual animosity, Fanzago and Marzari were both on the right track, although it would be another hundred years before the solution to pellagra’s aetiological puzzle began at last to emerge. In the meantime, physicians continued to investigate and write about the subject as if they were amongst the very first to do so. The medical representatives of every Italian State where pellagra appeared—in this period before Italian Unification—had to re-invent the wheel. Thus the first Tuscan to write about pellagra, the Florentine physician Vincenzo Chiarugi in 1814, went through all the same phases—clinical histories, nosology, aetiology—as the three investigators surveyed above, Odoardi, Fanzago and Marzari. Chiarugi reformulated the same arguments and evidence as previous authors in his attempt to account for, classify, identify causation and propose cure and prevention. He devoted a long section to positing a maize-based diet as the most likely cause, evidently unaware that both Fanzago and Marzari had just done so, and more convincingly, only a few years earlier (Chiarugi 1814).

Chiarugi (1759–1820) was a contemporary of Fanzago and Marzari, although all his academic formation and medical experience were within the Tuscan grand-duchy. Two features are new and specific in Chiarugi’s pellagra essay. The first is the focus on Tuscany, as pellagra spread southwards with the spread of maize cultivation and consumption. Second, Chiarugi devoted more space to the cutaneous symptoms of pellagra than any other author before him. This would seem strange, since, by Chiarugi’s time, the skin rash and desquamation associated with pellagra was seen by all observers as but the primary stage of the disease. Chiarugi’s interest in the surface aspect of pellagra is easily explained, for he was the author of an early treatise on skin diseases, based on cases he had observed whilst director of Florence’s Bonifazio hospital, a purpose-built asylum for the insane. Here, Chiarugi had done away with chains as a means of restraint and had instituted the regular keeping of patient files, procedures that would later be identified with the kind of moral therapy we shall re-visit in chapter seven.

When it came to classifying pellagra, the skin symptoms were the most characteristic and fundamental elements of the disease, according to Chiarugi. His representation of pellagra as essentially cutaneous may appear to take us back to the earliest reactions to it, as reflected in its very name, but it did so by taking observations to an entirely new level of detail. Chiarugi devoted a tenth of his pellagra study to a detailed and vivid discussion of the skin rashes: their appearance, nature and location, the periodic desquamation and reappearance, and how they could vary over the often very long course of the disease. The rash could even disappear entirely for several years: ‘So pellagra, right from the very start of its invasion, undermines [the body] with a hidden and deceptive progression, leading towards its destruction’ (Chiarugi 1814, p. 22). Chiarugi’s descriptions are accompanied by frequent references to the plates at the back of the book, which illustrate different phases of desquamation on the hands, feet and chest (Fig. 2.1).

Fig. 2.1

Pellagrous desquamation. From: Vincenzo Chiarugi, Saggio di ricerche sulla pellagra, 1814

When it comes to classification, Chiarugi put the emphasis on the exterior signs of the disease because they were enough to diagnose pellagra, whereas the gastric and nervous ones could easily be confused with other forms of illness. Most other investigators into pellagra, including Fanzago and Marzari, had reversed the emphasis, devoting more attention and placing more (or at least equal) importance on the gastric and nervous symptoms, which after all ran the gamut from diarrhoea and dizziness to dementia. Chiarugi’s solution to the pellagra problem, his ‘big idea’ that concludes the book, was that the authorities encourage landowners and peasants to plant white maize instead of yellow (Chiarugi 1814, pp. 121–123).

His proposal was not taken up (it would not have made any difference anyway); nor was his theory that the key to understanding pellagra lay in the skin. Nevertheless, studies and proposals like Chiarugi’s serve as a sign that the disease was being taken seriously, in all its social and economic implications, even whilst its classification and causation remained matters for dispute. By the early nineteenth-century Italian investigators largely agreed on the clinical picture of pellagra, even whilst they continued to debate its nosology, which was much more problematic. As for its aetiology, this would prove the most difficult, continuing to exercise what would become the field of pellagrology well into the twentieth century.