Keywords

The Interlude has quoted a few patient voices as a way of introducing Part II, which focuses on the experience of insanity caused by pellagra. Few of the medical investigators who were the subject of Part I were left unmoved by this, the disease’s most shocking effect; indeed, most of them worked in the asylum environment. Here, we shall focus more specifically at how pellagrous insanity was understood, diagnosed and treated by medical investigators and asylum doctors alike, as well as the patient experience of this phase of the disease.

We begin, in this chapter, by introducing pellagrous insanity—how it manifested itself, its place in pellagra’s symptomatology, as well as its impact on society. In chapter 7 we examine the contemporary medical understanding of pellagrous insanity, and the conceptual and diagnostic challenges this posed. We do this by comparing debates surrounding pellagra in Italy with those waged around the same time in the United Kingdom vis-à-vis general paralysis of the insane. The latter disease was eventually linked to syphilis, even if the exact relationship between syphilis and insanity remained ambiguous—much like the body-mind link in pellagra and pellagrous insanity. We compare the two illnesses by examining how doctors classified them, sought to identify their causation and pathogenesis, and how this influenced diagnosis and treatment during the second half of the nineteenth century.

We then shift our gaze more specifically on the asylum experience of pellagra in chapters 8 and 9, where we explore the Venetian insane asylums of San Servolo (for men) and San Clemente (for women). The two chapters are organised around the ‘life cycle’ of male and female sufferers at the two Venetian asylums: from local referral and admission, through to treatment, and ending either with release back into the community or death—inspired by Erving Goffman’s approach (2007). We have focused on the Veneto because this region, now amongst Italy’s richest, was the most struck by pellagra and, by extension, pellagrous insanity.

The advantage offered by patient records in reconstructing the patient experience of insanity is beyond dispute (Risse and Warner 1992). However, to avoid the risk of being overly ‘charmed’ by the qualitative sources and thus producing just a collection of individual stories (Condrau 2007), these will be contextualised quantitatively. Our methodology is thus of the ‘mixed’ variety (Johnson and Onwuegbuzie 2004). The qualitative—here referring to individual patient histories and directors’ reports from the two institutions—will be integrated with the quantitative—based on data culled from the five thousand patient files which make up our Venetian Mental Asylums Database (Priani and Gentilcore 2016). This ensures that the selected examples are able to corroborate and poignantly express significant broader trends—which, if taken alone, risk being dry numbers. In the process, we aim to give a voice to the actors involved—medical practitioners, patients and local authorities—along the lines suggested by Benoît Majerus (2013).

Manifestations, Symptomatology and Impact

But to begin at the beginning: what was pellagrous insanity? (Fig. 6.1).

Fig. 6.1
An illustration of a man who lays on a mattress with his head tilted an an odd angle towards his back. Two men hold down his hands and legs and look on with shocked expressions. A woman standing on the right has her hand on her head. She has one child in her arms and another clings to her legs.

An episode of pellagrous insanity (‘Le sventure d’Italia: Un dramma della pellagra’). From: La Tribuna Illustrata, 3 July 1904

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The following case history provides an answer. On 14 September 1862, Dr Filippini, of the insane asylum of Feltre (province of Belluno), wrote to the asylum of San Servolo to refer a patient suffering from pellagrous insanity. The sufferer, Domenico Gorza, was a forty-year-old married peasant. In the spring of 1861, ‘he had peeling on the backs of his hands, ankles of his feet and top of his chest’. Then, the following autumn ‘he fell into delirium’, as the disease progressed. On 23 March 1862, ‘because he tried to flee from his family and tended towards acts dangerous to his own existence, he was brought and admitted into this asylum’. Domenico was observed to have ‘desperate unceasing clamorous delirium’, wrote Filippini: ‘he thinks he is irredeemably damned, he beats himself angrily with his fists and would like to take his own life’. The cause, according to Filippini, was ‘the disease of poverty, endemic pellagra’. Indeed, as Filippini wrote by way of diagnosis: ‘The characteristic form of the illness leaves no doubt at all in establishing it: pellagra with frenzied delirium and tendency towards suicide by demonomania [possession by demons]’. In the Feltre asylum, Domenico was treated for ‘light gastric complications’ (i.e. diarrhoea) that accompanied pellagra and fed a ‘restorative diet’ to combat the patient’s underlying cachexia (wasting syndrome). However, given that it was impossible to provide the necessary and appropriate ‘secure detention’ for the patient, Filippini was requesting Domenico’s transferral to the San Servolo asylum in Venice.

As we saw in Part I, pellagra was then understood to be a disease associated with a subsistence diet of maize polenta, possibly spoilt, extreme poverty and hard labour, which in its later, more chronic stages caused insanity, often violent. Whilst the exact aetiology of pellagra remained unclear, the effects of the disease could not have been clearer: asylums in the maize-growing areas of northern Italy were filled with cases of the disease. It was precisely in order to contain patients affected by pellagra and the mentally disturbed that the Italian government intensified the construction of new asylums in the latter decades of the nineteenth century (Canosa 1979). Smaller, town hospitals were unable to cope with cases of pellagrous insanity and so they were referred to the larger, better equipped regional asylums. The main asylums for the Veneto—which included the eight provinces of Belluno, Padua, Rovigo, Treviso, Venice, Verona, Vicenza and Udine—were on the island of San Servolo, for men, with a sister asylum for women on the neighbouring island of San Clemente (Willms 1993; Salviato 2002; Priani and Botti 2009) (Fig. 6.2 and 6.3).

Fig. 6.2
A monochrome photograph of San Servolo asylum surrounded by water. The structure of the asylum is large and stretches horizontally.

View of San Servolo asylum, c. 1880. San Servolo Servizi Metropolitani di Venezia

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Fig. 6.3
A photograph of San Clemente asylum. It is surrounded by water. The structure of the asylum stretches horizontally. There are boats in the water.

View of San Clemente asylum. From: Cesare Vigna, Il manicomio centrale femminile di San Clemente: memoria, 1887

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Male and female patients were thus confined in separate institutions—an untypical practice not only in the rest of Italy, but in Europe, where segregation into male and female wards at the same institution was more the norm. In the case of Venice, this division by gender was mainly due to the logistical difficulties of housing both male and female inmates on the same small island institution of San Servolo. Venice’s female asylum remained within the former hospice of San Lazzaro, part of the city’s main hospital, before it was eventually relocated to the lagoon island of San Clemente in 1873. It was to the asylum of San Servolo that Filippini referred Domenico, and he was duly admitted two days later, on 16 September 1862.

Domenico’s patient record at San Servolo records his condition month by month: his willingness to take the medicines offered—iron and valerian—but his refusal to eat, so that he had to be spoon-fed; how his initial aggression and bouts of blaspheming, necessitating occasional use of a straightjacket, turned to total apathy, with Domenico ‘curled up in a corner’. By February 1863, Domenico’s condition seemed improved, with him doing domestic chores, sleeping soundly and eating well, although he was still taciturn. By March, San Servolo’s doctors were trying to have Domenico work on the asylum’s vegetable plots, as part of his therapy, but he was still too weak and unwilling to move much. In May, Domenico was struck down by cold and fever ‘so intense he seemed sick with cholera’. The attacks of cold recurred over the following months and Domenico became taciturn, lethargic and melancholic. By now, his relations were concerned about his condition and pressed for his release. But Domenico’s confinement ended on this sad note: ‘Died of gastro-hepatitis on 9 February 1865, at one o’clock in the afternoon, after two years, four months, 24 days’ stay in hospital’.

In addition to introducing us to pellagrous insanity, Domenico’s sad case suggests many of the themes we shall explore in Part II: the conflicted medical aspect of diagnosis and treatment (including work therapy); the three phases of referral, stay and discharge (or death); the close relationship between the life cycle of male and female pellagra patients and their own biological life cycles; the economic conditions and geographical origins of sufferers; and the place and function of the asylums within the wider community.

As we observed in Part I, pellagra had devastating effects in Italy over the long nineteenth century. It was a recurrent disease, where a reliance on maize polenta followed the ups and downs in diet which came with the seasons, as well as shifts in wheat prices. It was also a progressive disease, leading to a downward spiral if dietary conditions did not improve—there being no treatment as such. The case of Lucia Pontel is typical. According to her patient file, we learn that Lucia was the daughter of pellagrous parents, subsisted entirely on a diet of polenta, and was referred to the San Clemente asylum from the municipal hospital of Udine in 1874. According to her patient file: ‘Every spring since she was a girl she has been subject to pellagrous erythema. At the age of 40 she was admitted to the Udine hospital with melancholy. Over the years that followed she was admitted a further six times, each time being discharged cured after some four months’.

If the number of reported pellagrins was close to 100,000 in 1879, the number of pellagrins suffering from pellagrous insanity is more difficult to determine. Contemporary estimates put the percentage of the pellagrous insane out of overall pellagrins at 1.7% in 1880–1, 3.2% in 1899 and 4.6% in 1908–10—the number of chronic cases climbing even as pellagra rates declined (Porisini 1975). Of course, the number of pellagrous insane who were actually committed to Italian asylums was probably only a minority of those who suffered pellagrous insanity, perhaps only a third according to a contemporary estimate (Guarnieri 1988).

During the last quarter of the nineteenth century, when the pellagra epidemic was at its worst in Italy, pellagra-sufferers overwhelmed hospitals in the Veneto (not unlike the situation caused by the peaks of COVID-19 as we write this). The number of pellagrins (of all stages) admitted to general hospitals in the Veneto region each year more than doubled during the 1870s, reaching 3,995 in 1879 (Morpurgo 1882, p. 176). If we look at insane asylums in the Veneto in particular, the proportion of the pellagrous insane to the general insane was something like five to eight. For instance, in 1885, of the 1,415 male insane being treated at general hospitals throughout the Veneto region, 954 of these were pellagrous (or 67%). Of the 1,182 women, 707 were pellagrous (or 60%). By the 1890s, rising numbers meant that the costs of caring for the pellagrous insane was the top item of expenditure in the annual budget of the province of Treviso (Gregorj 1893, pp. 11, 13). This was in a context where the annual costs to Italian provinces for hospitalising the insane poor went up by an estimated 199% between 1871 and 1897 (Canosa 1979).

The final 25 years of the nineteenth century witnessed a vast increase in both the number of asylums in Italy and the numbers committed to those asylums. A Foucauldian approach would put this down to the nascent psychiatric profession flexing its custodial muscles, linking internment to cure (Gillio 2009). But worsening social conditions in the new country had a significant part to play: steady increases in the numbers of insane poor were the result of the impoverishment of the Italian rural and urban poor. The elimination of trade barriers following Unification in 1861–70 and the liberalisation of the Italian economy, combined with a widespread move away from shared tenancies (mezzadria) by landowners, forced large numbers of peasants to become day labourers—when there was work—in a wage-based economy. Poor sanitation, habitation and diet did the rest. Behind abstract medical labels like ‘cretinism’, ‘alcoholism’, ‘imbecility’ and ‘pellagrous insanity’ applied to asylum inmates lay the spectre of dire poverty and social deprivation. This was particularly so with pellagrous insanity, where there existed a ‘tight link between the structural transformations of Italian society and the devastating spread of mental illness’ (De Bernardi 1982, p. 17).

The result was that San Servolo and San Clemente, like other asylums in regions of Italy where pellagra was endemic, were shaped by the disease. Between its founding, in 1873, and 1887, of the 4,755 admittances into San Clemente, 2,070 were pellagrins (44%) (Vigna 1887, pp. 95–6). In 1877, almost half of the admissions into both institutions were pellagrins (48%). In total, considering the period 1842–1912 for San Servolo and 1873–1912 for San Clemente, and based on a census of one year in five, our VMAD database records 5,709 admissions. Of these, 1,587 were pellagrous insane (28%). This divides into 31% at San Clemente (757 out of 2,466 admissions) and 26% at San Servolo (830 out of 3,241 admissions) (Priani and Gentilcore 2016). This is even higher than other asylums located elsewhere in Italy where pellagra was endemic, such as the San Lazzaro asylum in Reggio Emilia, where the pellagrous insane amounted to 27% (women) and 20% (men) of admissions between 1871 and 1899 (Ferrari 1985, p. 209).

The general hospitals of the Veneto (provincial and municipal) were the source of most of the pellagrous insane patients admitted to San Servolo and San Clemente. This was a sign of the patients’ poverty, since those committed to asylums direct from home tended to be relatively better-off, a process in which pellagrins were under-represented. That said, we still know precious little about the domestic care of the insane (Guarnieri 2007). Men were more likely to be committed to the asylum direct from home than were women, who were more likely to be referred from another institution, such as a local hospital. The difference may be down to the cultural notion of ‘scandal’, which meant that the female pellagrous insane were more quickly and more routinely institutionalised when their behaviour was affected (Finzi 1982a; Salviato 2003). Such was the case of Lucia Marchesan, admitted to San Clemente in 1876: an elderly widow ‘who wanders around the streets all day committing acts offensive to public morality … she swears at (impreca) all the people she meets’.

The institutions to which these sufferers were headed were intended to provide a new moral order for the insane: less a prison and more a hospice. The first director of San Clemente, Cesare Vigna, had high hopes: ‘the mental hospital [frenocomio] is no longer a prison, no longer a sepulchre for the living, it is no longer even a place of segregation, but an asylum, a [source of] relief, a clinic; it is itself a most effective means of treatment’ (Vigna 1887, p. 54). According to this new ‘moral therapy’, the institution itself, and the sufferer’s presence in it, became part of the cure, in space and in time (De Peri 1979; Tagliavini 1988).

However, in the 1880s there still existed those in Italy, like the socialist Enrico Ferri, who believed the asylum’s primary role was as a ‘place of custody’, performing a function of defence for the rest of society (Guarnieri 1988, p. 105). San Servolo and San Clemente were in practice a bit of both. The statutes of San Clemente make the asylum’s role quite clear: ‘Only insane women needful of detention, dangerous to themselves and to others, and a threat to public morality and order will be admitted into the asylum’ (Statuti 1873, p. 6; emphasis in the original). It was no accident that Italian asylums came under the authority of the Ministry of the Interior (Lonni 1982).

The whole thoroughly documented process of referral, confinement and discharge was governed by notions of social order and public safety. Municipal officials, the police and asylum authorities liaised closely with one another. Even the asylum patient files, with their personal details and mug shot—which we shall discuss further in chapter 8—bear a close resemblance to the criminal records which, from an Italian law of 1888, the police were bound to keep (Fiorino 2002). How asylum doctors kept records of the pellagrous insane in their care was in part determined by how they understood ‘pellagrous mania’ in particular, and mental illness more generally, to which we now turn.